A 53 year old man presents with left sided tinnitus and slight unsteadiness for 1 year. During the same period, he experienced pain in his right arm following muscular exertion, which was completely relieved by rest. He also experienced numbness in the right upper arm. His medical and surgical histories are unremarkable. His family history is significant for coronary artery disease in his father and older brother. He stopped smoking 2 years ago, and has a total smoking history of 10 pack years. He only drinks socially.
There is retrograde flow in the right vertebral artery and right carotid artery during the mid-systolic phase of the cardiac cycle. Anterograde blood flow is seen during the remainder of the cardiac cycle. No other abnormalities are noted.
There is complete occlusion of the proximal right subclavian artery and retrograde flow through the right vertebral artery. The arch of the aorta and great vessels appear normal. No other structural or functional vascular abnormalities are noted.
The coronary vasculature appears pristine.
There are multiple small hypodense lesions in the white matter of both hemispheres, which are suggestive of ischemic lesions.