Blood Pressure Discrepancy: A Diagnostic Clue to Innominate Artery Occlusion in Acute ischemic Stroke

Abstract

Background: Innominate artery occlusion is an uncommon but important cause of cerebral ischemia. A simple bedside clue-inter-arm blood pressure discrepancy-can direct clinicians toward this proximal large-artery pathology.

Case: A 42-year-old man presented with sudden left-sided weakness and right sided gaze preference (NIHSS 9) for more than 12 hours. Initial non-contrast CT showed acute right frontotemporal infarction. CT angiography (CTA) demonstrated non-opacification of the right MCA (M1) and attenuated right ICA; duplex ultrasound revealed reversed vertebral flow. A marked inter-arm blood pressure difference had been noted during examination. Repeat CTA of the head, neck, including aortogram revealed a short-segment occlusion of the innominate artery with distal reconstitution. The patient was treated conservatively with antithrombotic medication and early rehabilitation, with gradual clinical improvement.

Conclusion: Inter-arm blood pressure asymmetry should prompt targeted vascular imaging for proximal lesions including innominate artery disease. Conservative therapy may be reasonable in stable patients when endovascular options are deferred, with rehabilitation playing a key role in recovery