A 62-year-old patient presented with persistent cognitive deficits 3 months after a right temporal ischemic stroke due to ipsilateral carotid occlusion. Work-up disclosed hemodynamically significant contralateral carotid artery stenosis and left subclavian steal phenomenon. Brain SPECT imaging revealed bihemispheric chronic brain hypoperfusion that substantially improved on repeat imaging when the subclavian steal was temporarily diminished by inflating a cuff around the left arm. Carotid endarterectomy of the asymptomatic carotid stenosis substantially ameliorated bihemispheric brain perfusion and reversed cognitive impairment. This case highlights that multi-vessel, extracranial atherosclerotic disease may cause chronic diffuse brain hypoperfusion that can be associated with cognitive impairment.

2nd Department of Neurology University of Athens School of Medicine Attikon University Hospital Athens Greece

2nd Department of Neurology University of Athens School of Medicine Attikon University Hospital Athens Greece International Clinical Research Center St Anne's University Hospital in Brno Czech Republic

3rd Department of Surgery School of Medicine University of Athens Athens Greece

Nuclear Medicine Department Brugmann University Hospital Brussels Belgium

Stroke Unit Department of Neurology Brugmann University Hospital Brussels Belgium

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