Ataque cerebrovascular recurrente secundario a síndrome del opérculo torácico arterial causado por sinostosis de la primera y la segunda costillas torácicas: reporte de caso / Recurrent Stroke Secondary to Arterial Thoracic Outlet Syndrome Caused by First and Second Ribs Synostosis: Case Report

El ataque cerebrovascular recurrente (ACV) es una complicación rara del síndrome del opérculo torácico arterial. Presentamos un paciente de 24 años con isquemia del miembro superior derecho y ACV recurrente en territorio vertebro basilar secundario a estenosis y aneurisma de la arteria subclavia, causado por sinostosis de la primera y segunda costillas torácicas. El paciente fue tratado quirúrgicamente con costocondrectomía y escalenectomía bilateral, resección de aneurisma de la arteria subclavia derecha y anastomosis primaria. Se analizó el caso y se revisó la literatura pertinente sobre ACV y síndrome de opérculo torácico arterial.

Stroke is a rare complication of arterial thoracic outlet syndrome. We present a 24-year old man with right arm ischemia and recurrent vertebrobasilar stroke caused by synostosis of the first and second thoracic ribs. The patien was treated with supraclavicular resection of both first ribs and bilateral scalenectomy, aneurysmal resection and primary anastomosis of the right subclavian artery. We analize this case and review the pertinent literature on stroke and arterial thoracic outlet syndrome.

Thoracic outlet syndrome due to compression of subclavian artery at first rib.

Thoracic Outlet Syndrome (TOS) refers to a constellation of signs and symptoms that arise from compression of the neurovascular bundle within the confined space of the thoracic outlet. Neurogenic (nTOS) from brachial plexus compression (95%), venous (vTOS) from subclavian vein compression (3%), & arterial (aTOS) from subclavian artery compression (1%). Most common clinical presentation of aTOS patients is distal upper extremity arterial emboli in otherwise healthy patient. Presenting a case report of arterial thoracic outlet syndrome.

Surgical Experiences of Arterial Thoracic Outlet Syndrome (TOS)

PURPOSE: We wanted to investigate the clinical features and treatment results of arterial type thoracic outlet syndrome (a-TOS). METHODS: We retrospectively reviewed the surgical treatments (n=9) of a-TOS for 6 patients (4 primary, 2 secondary, males: 100%, mean age: 39.6 years). For achieving thoracic outlet decompression, we performed cervical rib resection (n=6) and scalenectomy (n=7) through a supraclavicular incision. Among the primary TOS patients, 4 patients required subclavian artery (SCA) reconstruction. Arterial bypass were performed using saphenous vein grafts for 2 patients with secondary a-TOS. RESULTS: As an underlying cause of primary a-TOS, all the patients revealed bilateral cervical ribs whereas the secondary a-TOS were caused by malunion of clavicular fractures. All the patients presented with hand ischemia: resting pain in 4, cyanosis in 4, tingling sense in 4, pallor in 2 and finger tip gangrene in 2. After surgical treatment, the ischemic symptoms improved in all patients, but not to a satisfactory levels in the patients with distal arterial emboli. We experienced pneumothorax, transient phrenic nerve palsy and winged scapula as the operative complications. CONCLUSION: To achieve better treatment outcomes, we recommend early surgical treatment before the occurrence of distal arterial embolization even in the asymptomatic patients who reveal subclavian artery abnormalities. For surgical treatment of a-TOS, the supraclavicular approach combined with infraclavicular incisions offers good exposure for achieving thoracic outlet decompression and SCA reconstructions.

Diagnosis and Management of Arterial Thoracic Outlet Syndrome (TOS)

PURPOSE: Arterial TOS is a rare condition caused by compression of the subclavian artery at the thoracic outlet area, which is composed of the anterior and middle scalene muscles, the first rib and the clavicle. We have experienced four cases of arterial TOS and we reviewed them to determine the appropriate management of arterial TOS. METHOD: We reviewed the medical records of 26 patients who were diagnosed and managed for TOS at Seoul National University Hospital from 1985 to 2004. We reviewed the clinical manifestations, diagnostic tools, mode of management and the outcomes. RESULT: The four patients with arterial TOS, 3 males and 1 female, had an average age of 41.3 years (range: 30~53 years). They complained of a tingling sense, coldness, weakness, and cyanosis of affected limb, and a gangrenous finger. They were diagnosed with CT angiography, conventional angiography and Doppler US. The findings were stenotic artery segments, post- stenotic dilatation and luminal thrombi of the subclavian artery. Two of them showed multiple peripheral arterial embolic obstructions and numerous collateral vessels. Three patients with arterial TOS underwent surgery. The operation consisted of the excision of the bony abnormality and the scalene muscle, segmental resection of subclavian artery including the aneurismal dilatation, interposition of a saphenous vein graft, and thromboembolectomy. Their symptoms improved after restoration of blood circulation, but the gangrenous finger required amputation. CONCLUSION: Arterial TOS has the definite risk of limb loss. If there is a high clinical suspicion of this lesion, early diagnosis and confirmation by angiogram may be critical to prevent limb loss. Surgical revascularization provides satisfactory results for limb salvage with low operative morbidity.

Arterial Thoracic Outlet Syndrome (TOS) with Multiple Distal Embolization: A case report

Thoracic outlet syndrome (TOS) is an uncommon condition which is caused by compression of subclavian artery, vein or brachial plexus in the region of thoracic outlet area, which is composed by the first rib, clavicle, anterior and middle scalene muscles and other connective tissue. In arterial TOS, chronic arterial compression causes arterial stenosis, poststenotic dilatation, aneurysm formation, intramural thrombus and peripheral arterial embolism. We present herein a case of arterial TOS patient with multiple distal embolization. The patient was 43-year old male with crutch ambulation because of sequelae of polioviral infection in his youth. His chief complaint was discoloration and gangrenous change of five right digits for 1 month. A rudimentary first right rib was found in simple chest X-ray. Angiographic findings were stenosis and poststenotic dilatation of right subclavian artery, multiple peripheral arterial embolic obstructions and numerous collateral vessel formation. Right thoracoscopic sympathectomy (T2), resection of the abnormal first rib and the abnormal axillary arterial segment was performed through the supraclavicular and transaxillary incision, then interpositional graft with saphenous vein was done for arterial reconstruction. A minor lymphatic fluid collection around the area of operation occurred, but it was easily controlled by percutaneous drainage. The gangrenous wounds of digits were improved after restoration of blood circulation.