Download Thrombosis of aberrant right subclavian artery co

Rom J Leg Med [19] 303-305 [2011]
DOI: 10.4323/rjlm.2011.303
© 2011 Romanian Society of Legal Medicine Thrombosis of aberrant right subclavian artery co-existing with infarction
of left cerebellar hemisphere: Case report
Ivan Stojanović1*, Goran Ilić2, Radovan Karadžić3, Aleksandra Antović4, Miroslav Milić5
_________________________________________________________________________________________
Abstract: Anomalies of the aortic arch and its main branches are rare; estimations from autopsy series indicate a
frequency of 3%. The incidence of an aberrant right subclavian artery is up to 0.5% of the population.
A putrefied corpse of 59-year old women was found in her locked apartment seating in armchair. The autopsy as a direct
cause of death revealed chronic heart failure. The autopsy also revealed aberant right subclavian artery occluded by thrombosis
and acute infarction of the left cerebellar hemisphere.
The purpose of this report is to describe an unusual case involving acute ischemia of the right upper extremity due to
extensive thrombosis of a retroesophageal right subclavian artery (RSA) in a 59-year-old woman. In literature was described
clinical presentation left hemiparesis caused by right subclavian artery thrombosis and retrograde embolization of thrombus via
the common carotid artery to the right middle cerebral artery distribution. In our case, right subclavian artery thrombosis was
co-existing with acute encephalomalation of the left cerebellar hemisphere. This may be result of retrograde embolization of
thrombus via the left vertebral artery or hypercoagulability of blood with co-existing thrombosis of this two arteries. At autopsy
we exclude existance of paradoxal thrombosis via atrial or vetricular septal defect or arterio-venous fistula, and also exclude
existance of a thrombosis od left atrial auricula.
Key Words: aberrant right subclavian artery, thrombosis, brain infarction, autopsy
A
nomalies of the aortic arch and its main branches are rare; estimations from autopsy series
indicate a frequency of 3%. One of the most common anomalies of the aortic arch is an
aberrant right subclavian artery (ARSA). The incidence of an ARSA is up to 0.5% of the population
[1]. While presenting different clinical manifestations, 75% of the patients remain asymptomatic
[2]. In 80% of the cases, the ARSA runs between the spinal column and the esophagus, in 15% of
the cases between the esophagus and the trachea, and in 5% of the cases ventrally of the trachea [2,
3, 4, 5, 6]. Compression of the esophagus due to a retroesophageal course of the ARSA may produce
difficulty in swallowing. This phenomenon was termed dysphagia lusus naturae (“dysphagia by
freak of nature”) by David Bayford in 1794 and has since come to be known as dysphagia lusoria [7,
8]. Other simtoms of ARSA are hoarseness, airway (trachea) obstruction, stridor, apnea, cyanosis,
and recurring infection.
1)* Corresponding author: MD, student of post graduate studies on Medical Faculty of Nis; Institute of Forensic
Medicine, Medical Faculty, University of Nis, Serbia, Address: Dr Zorana Đinđića blv. 81, 18000 Nis; Serbia;
Phone: +381-63-8141172 and +381-18-4530824; E-mail: [email protected]
2) Professor, MD, PhD; Institute of Forensic Medicine, Medical Faculty, University of Nis, Serbia
3) Professor, MD, PhD; Institute of Forensic Medicine, Medical Faculty, University of Nis, Serbia
4) Associate Professor, MD, PhD; Institute of Forensic Medicine, Medical Faculty, University of Nis, Serbia
5) MD; Institute of Forensic Medicine, Medical Faculty, University of Nis, Serbia
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Stojanović I et al Thrombosis of aberrant right subclavian artery co-existing with infarction of left cerebellar hemisphere
Case report
In the following we present the forensic investigations and technical examinations in chronological
order.
History: A putrefied corpse of 59-year old women was found in her locked apartment seating in
armchair. Notable in the patient’s history was the fact that she had been previously diagnosed diabetes
mellitus and arterial hypertension were reported. Simptoms as difficulty in swallowing, hoarseness or
stridor was not documented.
Autopsy: The autopsy as a direct cause
of death revealed chronic heart failure (left
ventricular hypertrophy with dilatation of the
heart and cardiac fibrosis). The autopsy also
revealed that a right subclavian artery was run
between the spinal column and the esophagus figure 1 [6], and take retroesophageal course to
the right arm. Aberant right subclavian artery
(ARSA) was occluded by thrombosis. Autopsy
determine that acute thrombosis of aberrant
right subclavian artery - fig. 2 and acute
infaction of the left cerebellar hemisphere was
in a causal relationship with a direct cause of
death. Examination od heart not revealed a
atrial or vetricular septal defect or thrombosis
od left atrial auricula.
Microscopic
findings:
Pathohistology examination confirmed a acute
Figure 1. Schematic drawing of the aortic arch, the ARSA, the trachea encephalomalation of the left cerebellar
and the esophagus with a retroesophageal course of the ARSA.
hemisphere and acute thrombosis of aberrant
right subclavian artery.
Toxicology findings: Determine a
ethyl-alcohol in blood in concentracion of
0,30‰ (6,51 mmol/L).
Figure 1. Acute thrombosis of ARSA - autopsy finding.
Discussion
Thrombosis of a subclavian artery is
an uncommon cause of acute upper extremity
ischemia in the elderly. Malformations of
the aortic arch system are also rare [9]. The
purpose of this report is to describe an unusual
case involving acute ischemia of the right
upper extremity due to extensive thrombosis
of a retroesophageal right subclavian artery (RSA) in a 59-year-old woman, that was in a causal relationship
with a direct cause of death. ARSA was run between the spinal column and the esophagus, as in maioriti
of all cases [2, 3, 4, 5]. In literature was described clinical presentation left hemiparesis caused by right
subclavian artery thrombosis and retrograde embolization of thrombus via the common carotid artery to
the right middle cerebral artery distribution [10]. In our case, right subclavian artery thrombosis was coexisting with acute encephalomalation of the left cerebellar hemisphere. This may be result of retrograde
embolization of thrombus via the left vertebral artery or hypercoagulability of blood [11] with co-existing
thrombosis of this two arteries. In literature, if associated aneurysmal dilation exists of ARSA, it can present
as localized pain in the shoulders, neck, and thorax. Ischemia of the upper left extremity secondary to
thromboembolic events has also been described; this can cause rupture of the diverticulum, with fatal
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Romanian Journal of Legal Medicine Vol. XIX, No 4(2011)
consequences[12]. At autopsy we excluded existance of paradoxal thrombosis via atrial or ventricular septal
defect or arterio-venous fistula. Autopsy also excluded existance of a thrombosis od left atrial auricula as a
posible cause of dissemaned thrombosis of arteries.
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