A case of venous thoracic outlet syndrome recognized by arm swelling

Most cases of thoracic outlet syndrome are detected by neulogical symptoms, and most of the other symptoms are caused by arterial stenosis. It is rare for the syndrome to be recognized by venous symptoms. We report a 56-year-old woman with thoracic outlet syndrome recognized by arm swelling. She was admitted for radiation therapy of a recurrent tumor of lung cancer at the left apex. Her right arm gradually became swollen. We performed venography from the right median cubital vein because of suspected venous thrombosis. Venography revealed stenosis of the right subclavian vein at the costoclavicular space, and this finding was confirmed by helical CT. These findings strongly support our diagnosis of thoracic outlet syndrome.     

Thoracic outlet syndrome in aquatic athletes

Thoracic outlet syndrome is a well-recognized group of symptoms resulting from compression of the subclavian artery and vein, as well as the brachial plexus, within the thoracic outlet. Symptoms are related directly to the structure that is compressed. Diagnosis is difficult because there is no single objective, reliable test; therefore, diagnoses of thoracic outlet syndrome is based primarily on a set of historical and physical findings, supported and corroborated by a host of standard tests. Because aquatic athletes are primarily "overhead" athletes, one may expect a higher incidence of thoracic outlet syndrome in this population. The differential between TOS and "swimmer's shoulder" (multidirectional instability and subacromial impingement) may be difficult. Nonsurgical treatment methods can be helpful in relieving symptoms; in certain recalcitrant cases, however, surgical intervention can provide lasting relief and a return to aquatic athletics.     

Thoracic outlet syndrome

Thoracic outlet syndrome remains a clinical diagnosis dependent almost exclusively on one's history and physical examination. Shoulder girdle depression, which may be present as a result of postural abnormalities or trauma (athletic or otherwise) has become recognized as an important cause of thoracic outlet compression. Management of this syndrome is entirely dependent on making an accurate diagnosis and defining the cause of neurovascular compression. Although thoracic outlet syndrome occurs infrequently, if the physician fails to consider this diagnosis, patients may suffer unnecessary and prolonged disability that may not only preclude optimal participation in athletics, but also interfere with certain activities of daily living.     

Round Table: Charting the Factors of Fatness

Thoracic outlet syndrome is a brief commonly missed cause of upper-extremity pain and musculoskeletal symptoms. Understanding the anatomy of the cervicoaxillary canal and proximal limb, etiology of the syndrome, evaluation of clinical symptoms, and differential diagnosis of thoracic outlet pain can lead to proper rehabilitation of the disorder.     

Thoracic outlet syndrome: evaluation with CT

Diagnosis of the thoracic outlet syndrome is often difficult, particularly in patients without osseous abnormalities on plain radiographs. The radiographic and computed tomographic (CT) findings were reviewed from 27 patients with thoracic outlet syndrome and 21 normal subjects. The plain radiographs and CT scans were assessed by two independent observers without awareness of the clinical history. Fifteen patients with thoracic outlet syndrome had osseous abnormalities (anomalous cervical ribs; abnormally long, drooping C-7 transverse processes) identifiable on plain radiographs. CT did not provide further diagnostic information in the patients with abnormal radiographs. Eight of 12 patients (66%) with normal plain radiographs had abnormal findings on CT scans, consisting of impingement of the C-7 transverse process on the scalene triangle or anteromedial aspect of the middle scalene muscle. Only two of 21 control patients (9.5%) displayed this CT abnormality (P less than .01). CT may be useful in patients with symptoms suggestive of thoracic outlet syndrome and no osseous abnormalities on plain radiographs.     

"Effort" thrombosis of the subclavian vein in a competitive swimmer

"Effort" thrombosis is a unique form of subclavian and axillary vein thrombosis because it is the result of an unusual variant of the thoracic outlet syndrome. Another cause of subclavian vein thrombosis is local compression from trauma, tumor, or development anomalies; a third is intimal damage from indwelling central venous catheters. This is a case report of "effort" thrombosis of the subclavian vein in a competitive swimmer. A recently developed technique of local infusion of low-dose streptokinase therapy is used for clot lysis. Early diagnosis is essential for effective thrombus dissolution with streptokinase. The rationale, risk, and method of streptokinase administration are discussed. Since "effort" thrombosis is secondary to thoracic outlet syndrome (TOS), decompression of the thoracic outlet by removal of the first rib after clot lysis is recommended.     

An unusual case of thoracic outlet syndrome associated with long distance running

An amateur marathon runner presented with symptoms of thoracic outlet syndrome after long distance running. He complained of numbness on the C8 and T1 dermatome bilaterally. There were also symptoms of heaviness and discomfort of both upper limbs and shoulder girdles. These symptoms could be relieved temporarily by supporting both upper limbs on a rail or shrugging his shoulders. The symptoms and signs would subside spontaneously on resting. An exercise provocative test and instant relief manoeuvre, which are the main diagnostic tests for this unusual case of "dynamic" thoracic outlet syndrome, were introduced.     

Thoracic outlet: anatomic correlation with MR imaging

OBJECTIVE: The purpose of this report is to describe the normal MR anatomy of the thoracic outlet and its modification after postural maneuvers using an anatomic-MR imaging correlation. CONCLUSION: MR imaging appears to be a useful technique to study the thoracic outlet and its contents because of its excellent soft-tissue depiction and its multiplanar capabilities. T1-weighted images obtained in the sagittal plane clearly depicted the different compartments of the cervicothoracic-brachial junction. Hyperabduction maneuvers may have potential applications in the assessment of the thoracic outlet syndrome by showing the location of compression.     

Functional imaging of the thoracic outlet syndrome in an open MR scanner

Symptoms due to thoracic outlet syndrome may present only in abduction, a position that cannot be investigated in conventional MR scanners. Therefore, this study was initiated to test MRI in an open magnet as a method for diagnosis of thoracic outlet syndrome. Ten volunteers and 7 patients with a clinical suspicion of thoracic outlet syndrome were investigated at 0.5 T in an open MR scanner. Sagittal 3D SPGR acquisitions were made in 0 and 90 ° abduction. In the patients, a similar data set was also obtained in maximal abduction. To assess compression, the minimum distance between the first rib and the clavicle, measured in a sagittal plane, was determined. In the neutral position, no significant difference was found between patients and controls. In 90 ° abduction, the patients had significantly smaller distance between rib and clavicle than the controls (14 vs 29 mm; p < 0.01). On coronal reformatted images, the compression of the brachial plexus could often be visualised in abduction. Functional MR examination seems to be a useful diagnostic tool in thoracic outlet syndrome. Examination in abduction, which is feasible in an open scanner, is essential for the diagnosis. Received: 22 February 1999; Revised: 15 June 1999; Accepted: 30 June 1999     

房室不一致右室双出口心血管造影诊断：附10例报告

本文报道了１０例经心血管造影证实的房室不一致右室双出口病例。患者均为男性，年龄２～１１岁，平均４．３岁。全部病例室间隔缺损位于肺动脉瓣下，且都有肺动脉狭窄。其中５例为单发右位心，４例存在双侧上腔静脉。可能为一畸形综合征。     

Diagnosis of vascular compression at the thoracic outlet using gadolinium-enhanced high-resolution ultrafast MR angiography in abduction and adduction

Gadolinium-enhanced magnetic resonance angiography allows rapid evaluation of the vascular structures of the thoracic outlet both in the neutral position and in abduction during one examination within FDA-approved dose limitations for contrast agents. The technique appears to be a good screening one for patients suspected of having vascular thoracic outlet syndrome.     

Thoracic outlet syndrome in a throwing athlete diagnosed with MRI and MRA

Thoracic outlet syndrome comprises the clinical manifestations in the arm caused by compression of the neuro-vascular bundle as it leaves the thoracic inlet. The neuro-vascular bundle is composed of the subclavian artery, the subclavian vein, and the bra-chial plexus. The symptoms of thoracic outlet or inlet syndrome are most often caused by compression of the nerves of the brachial plexus, which is involved in up to 98% of cases; the remainder are due to vascular compression. MRI with MRA demonstrates well the anatomy of the brachial plexus as well as any vascular compression or occlusion. The relationship of the axillary and subclavian vein to the first rib and subclavius muscle also can be demonstrated. We present a college baseball player who presented with numbness in the fingers of his throwing hand when throwing a baseball. Evaluation with spin-echo and two-dimensional time-of-flight MR angiographic (MRA) imaging of the thoracic outlet region revealed obstruction of the subclavian vein with the arm abducted. To our knowledge, no such cases have been diagnosed previously with MRI.     

Thoracic outlet syndrome: evaluation of the subclavian vessels by color duplex sonography.

Changes in flow in the subclavian artery and vein resulting from the use of a hyperabduction maneuver during Doppler sonography in 20 volunteers were compared with retrospective findings in 16 patients clinically suspected of having thoracic outlet syndrome. Significant compression of the subclavian artery showed in the Doppler waveform as at least a doubling of peak systolic velocity or complete cessation of flow with hyperabduction; significant compression of the subclavian vein was diagnosed by complete cessation of blood flow or loss of atrial and respiratory dynamics in the waveform of the subclavian vein with hyperabduction. In volunteers, asymptomatic compression of the subclavian vein with arm abduction was seen in two (10%) and asymptomatic compression of the subclavian artery was seen in four (20%). Of the 16 patients, thrombosis of the subclavian vein was found in seven, compression of the subclavian vein with hyperabduction was found in six, and diagnoses other than thoracic outlet syndrome were established as the cause of pain in three. When duplex sonography was compared with venography, which was performed in 10 patients, one false-negative case was found because a subclavian vein thrombus had not been detected. The subclavian artery was examined in five of the six patients with positional compression of the subclavian vein; compression of the subclavian artery was found in three. The clinical significance of compression of the subclavian artery cannot be determined from our data because of the small number of patients involved. When the sonographic criteria of subclavian vein clot or compression resulting in a complete loss of normal venous phasicity with arm abduction and the clinical criterion of subsequent improvement in symptoms after curative surgery are used, color Doppler sonography is 92% sensitive and 95% specific for the diagnosis of thoracic outlet syndrome. This preliminary study shows that Doppler sonography has potential in the evaluation of thoracic outlet syndrome.     

Lower trunk brachial plexus compression neuropathy due to cervical rib in young athletes

Compression by a cervical rib may result in neurologic and/or vascular symptoms. Two patients are reported with thoracic outlet syndrome (TOS) secondary to cervical rib. Both patients had vague shoulder pain as well as neurologic manifestations due to compression neuropathy of the lower trunk of the brachial plexus. One patient was suspected initially to have carpal tunnel syndrome.     

Radiological findings in Bouveret's syndrome

Bouveret's syndrome is a rare form of gastric outlet obstruction occurring from passage of a gallstone through a cholecystoduodenal fistula with impaction at the pylorus. We report a case of a 63-year-old man who presented findings highly suggestive of Bouveret's syndrome on upper gastrointestinal series, abdominal computed tomography, and endoscopy.     

Three-dimensional MR angiography in the evaluation of thoracic outlet syndrome.

OBJECTIVE: The objective is to present our initial experience with the combination of three-dimensional time-resolved contrast-enhanced MR angiography and T1-weighted spin-echo imaging for investigation of vascular compression related to thoracic outlet syndrome. CONCLUSION: In patients with clinical signs of thoracic outlet syndrome suggesting vascular elongation or compression, this technique proves to be robust, and its results are comparable to those of conventional catheter angiography. Our results allow precise identification of the anatomic structure(s) responsible for the clinical symptoms and show the effect of arm hyperabduction on the patency of the subclavian vessels.     

Sonographically guided anesthetic injection of anterior scalene muscle for investigation of neurogenic thoracic outlet syndrome

Objective

To describe the technique and complications of sonographically guided anesthetic injection of the anterior scalene muscle in patients being investigated for neurogenic thoracic outlet syndrome.

Material and methods

Subjects were identified via a retrospective review of medical records. For the procedure a 25-gauge needle was introduced into the anterior scalene muscle under real-time ultrasound guidance followed by injection of local anesthetic. The procedures were evaluated for technical success, which was defined as satisfactory identification of anterior scalene muscle, intramuscular needle placement, and intramuscular delivery of medication. There was a short-term follow-up to determine procedure-related complications and rate of unintended brachial plexus (BP) block, manifested by upper extremity paresthesias and/or weakness.

Results

Twenty-six subjects with suspected neurogenic thoracic outlet syndrome underwent 29 injections (three subjects received bilateral injections). Technical success was achieved in all procedures. The mean duration of the procedure was 30 min, and there were no cases of intravascular needle placement or neurogenic pain during the injection. No major complications occurred. Temporary symptoms of partial BP block occurred after nine injections (9/29, 31%), and a temporary complete BP block occurred after one injection (1/29, 3%).

Conclusion

Sonographically guided anesthetic injection of the anterior scalene muscle is a safe and well-tolerated diagnostic test for patients being investigated for neurogenic thoracic outlet syndrome.     

ACR Appropriateness Criteria Imaging in the Diagnosis of Thoracic Outlet Syndrome

Thoracic outlet syndrome is a clinical entity characterized by compression of the neurovascular bundle, and may be associated with additional findings such as venous thrombosis, arterial stenosis, or neurologic symptoms. The goal of imaging is to localize the site of compression, the compressing structure, and the compressed organ or vessel, while excluding common mimics. A literature review is provided of current indications for diagnostic imaging, with discussion of potential limitations and benefits of the respective modalities.The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. In this document, we provided guidelines for use of various imaging modalities for assessment of thoracic outlet syndrome.     

The silent sinus syndrome: clinical and radiographic findings.

OBJECTIVE. The purpose of this article is to acquaint the reader with the clinical and imaging features of the silent sinus syndrome, which is relatively unknown. Discussion of the presentation, treatment, and theory regarding pathogenesis of the syndrome follows. CONCLUSION. The silent sinus syndrome consists of painless facial asymmetry and enophthalmos caused by chronic maxillary sinus atelectasis. Although the diagnosis is usually suspected clinically, it is confirmed radiologically by characteristic imaging features that include maxillary sinus outlet obstruction, sinus opacification, and sinus volume loss caused by inward retraction of the sinus walls.     

The cervicothoracic junction on chest radiograph

Fractures of the first rib may be detected by indirect signs, including apical extrapleural fluid collection, pneumothorax, and supraclavicular soft tissue mass. Thoracic outlet syndrome represents a complex series of abnormalities that may be clarified utilizing digital subtraction angiography. Major distortions of alignment can produce bony adaptive changes at the cervicothoracic junction simulating intra-spinal canal tumors.