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Vertebral Artery Doppler Waveform Changes Indicating Subclavian Steal Physiology

Mark A. Kliewer1, Barbara S. Hertzberg1, David H. Kim1, James D. Bowie1, Daniel L. Courneya2 and Barbara A. Carroll1

1 Department of Radiology, Duke University Medical Center, Box 3808, Rm. 2526, Blue Zone S., Durham, NC 27710.
2 Present address: 82nd MDSS/SGSAR, 149 Hart St., Ste. 5, Sheppard Air Force Base, TX 76311-3482.



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  		Fig. 1A. —Type 1 waveform in 63-year-old woman with asymptomatic carotid bruit. Doppler waveform shows antegrade flow throughout cardiac cycle. Note transient sharp decline in velocity at mid systole producing notch in Doppler trace (arrow). Notch creates two systolic peaks. First rises to acute angle and second has rounded contour. Velocity at nadir of notch is greater than that of end diastole. Also note diastolic notch (arrowhead).

 


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  		Fig. 1B. —Type 1 waveform in 63-year-old woman with asymptomatic carotid bruit. Drawing shows timing of waveform fluctuations in cardiac cycle.

 


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  		Fig. 2A. —Type 2 waveform in 53-year-old woman with coronary artery disease. In this waveform, more pronounced and deeper cleft is evident between two systolic peaks. Nadir of this cleft reached velocity at or just below that of end diastole. Second systolic peak tends to be smaller and broader than corresponding peak of type 1 waveform.

 


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  		Fig. 2B. —Type 2 waveform in 53-year-old woman with coronary artery disease. Drawing delineates waveform changes in cardiac cycle. Outline resembles body profile of rabbit and is sometimes referred to as "bunny waveform."

 


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  		Fig. 3A. —Type 3 waveform in 54-year-old man with angina. Nadir of mid systolic cleft is at or below baseline, but rapid recovery of forward flow before diastole is shown.

 


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  		Fig. 3B. —Type 3 waveform in 54-year-old man with angina. Drawing shows waveform outline.

 


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  		Fig. 4A. —Type 4 waveform in 81-year-old man with coronary artery disease. Nadir of mid systolic cleft falls well below baseline signifying greater reversal of flow during systole. Forward flow is restored in diastole.

 


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  		Fig. 4B. —Type 4 waveform in 81-year-old man with coronary artery disease. Drawing indicates outline of pulse profile.

 


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  		Fig. 5A. —67-year-old woman with stroke in whom type 2 waveform converted to type 4. Doppler tracing of left vertebral artery shows typical type 2 waveform. Note antegrade flow throughout cardiac cycle.

 


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  		Fig. 5B. —67-year-old woman with stroke in whom type 2 waveform converted to type 4. Doppler tracing obtained after deflation of blood pressure cuff shows transient flow reversal in mid systole.

 


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  		Fig. 6A. —82-year-old woman in whom type 4 waveform converted to full subclavian steal. Doppler waveform shows transient flow reversal of type 4 waveform.

 


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  		Fig. 6B. —82-year-old woman in whom type 4 waveform converted to full subclavian steal. After deflation of blood pressure cuff, retrograde flow throughout cardiac cycle indicates full subclavian steal.

 

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