Imaging of the Patient with Thoracic Outlet Syndrome

MR Imaging of the Brachial Plexus: A Practical Review

The brachial plexus is a network of nerves responsible for the motor and sensory innervation of the upper extremity and upper chest. Pathologies affecting this structure can lead to significant morbidity, ranging from pain and sensory deficits to profound motor impairment. MR imaging is the modality of choice for imaging the brachial plexus. This review provides an overview of brachial plexus imaging, emphasizing practical aspects, anatomic landmarks, and imaging protocols, as well as a wide range of pathologies ranging from traumatic injury to inflammatory, idiopathic, hypertrophic, and neoplastic conditions.

Magnetic resonance neurography in the diagnosis of neurological subtypes of thoracic outlet syndrome

Neurological thoracic outlet syndrome (TOS) can be challenging to diagnose, particularly given its described subtypes of neurogenic TOS (NTOS) and disputed TOS (DTOS) that exhibit variable clinical presentations and etiologies. The diagnostic workup of TOS often includes magnetic resonance neurography (MRN) of the brachial plexus. Specific MRN imaging modifications for TOS evaluation are required to maximize spatial and contrast resolution to increase the conspicuity of nerve segments and their relationships to surrounding osseous structures. Dynamic assessment with arm positioning is used to evaluate outlet narrowing and compression of the plexus. Individual nerve segments are interrogated for their longitudinal and cross-sectional morphologies and signal characteristics. In patients with NTOS, MRN may reveal focal impingement of the C8/T1 nerve roots and/or lower trunk with accompanying abnormal T2-weighted signal hyperintensity. Predisposing anatomical entities include cervical ribs, rib synostoses, hypertrophic callous following clavicular fracture, remnant first thoracic rib from prior incomplete resection, and variable perineural scarring. In comparison, DTOS patients frequently demonstrate signal hyperintensity and enlargement of the mid plexus (trunk and division level), with narrowing of the costoclavicular interval. Following comprehensive diagnostic workup that frequently includes electrodiagnostic testing, patients are directed to different management pathways. Nonsurgical management is considered for all cases of DTOS; all patients with NTOS or DTOS who fail conservative treatment warrant referral for a surgical opinion. If surgery is pursued, MRN can be helpful in preoperative planning.

Under pressure: a head-to-toe review of vascular compression syndromes

Vascular compression syndromes are a group of conditions resulting from mechanical compression of blood vessels by adjacent structures leading to compromised blood flow and various associated symptoms. They frequently affect young, otherwise healthy individuals and are often underdiagnosed due to their rarity and vague clinical manifestations. Achieving an accurate diagnosis depends on the integration of clinical presentation and imaging findings. Imaging modalities including color doppler ultrasound, computed tomography angiography, magnetic resonance angiography, and catheter-directed digital subtraction angiography are essential for diagnosis and management. Dynamic imaging is crucial in eliciting findings due to the positional nature of many of these syndromes. In this paper, we will present a "head-to-toe" overview of vascular compression syndromes including Vascular Eagle Syndrome, Vascular Thoracic Outlet Syndrome, Quadrilateral Space Syndrome, Hypothenar Hammer Syndrome, Median Arcuate Ligament Syndrome, Renal Artery Entrapment Syndrome, Left Renal Vein Compression/Nutcracker Syndrome, May-Thurner Syndrome, Adductor Canal Syndrome, and Popliteal Artery Entrapment Syndrome. Treatment is variable but typically involves a combination of conservative and surgical management. Surgical approaches focus on decompression of affected neurovascular structures. Endovascular treatment alone is rarely recommended. We aim to equip general radiologists with the knowledge needed to accurately diagnose patients with vascular compression syndromes, allowing for timely treatment.

Diagnostic and Therapeutic Approach to Thoracic Outlet Syndrome

Thoracic outlet syndrome (TOS) is a group of symptoms caused by the compression of neurovascular structures of the superior thoracic outlet. The knowledge of its clinical presentation with specific symptoms, as well as proper imaging examinations, ranging from plain radiographs to ultrasound, computed tomography and magnetic resonance imaging, may help achieve a precise diagnosis. Once TOS is recognized, proper treatment may comprise a conservative or a surgical approach.

Current Clinical Concepts: Rehabilitation of Thoracic Outlet Syndrome

Thoracic outlet syndrome (TOS) involves inconsistent symptoms, presenting a challenge for medical providers to diagnose and treat. Thoracic outlet syndrome is defined as a compression injury to the brachial plexus, subclavian artery or vein, or axillary artery or vein occurring between the cervical spine and upper extremity. Three common subcategories are now used for clinical diagnosis: neurogenic, arterial, and venous. Postural position and repetitive motions such as throwing, weightlifting, and manual labor can lead to symptoms. Generally, TOS is considered a diagnosis of exclusion for athletes due to the poor accuracy of clinical testing, including sensitivity and specificity. Thus, determining a definitive diagnosis and reporting injury is difficult. Current literature suggests there is not a gold standard diagnostic test. Rehabilitation has been shown to be a vital component in the recovery process for neurogenic TOS and for arterial TOS and venous TOS in postoperative situations.

A rare case of overlapping thoracic outlet syndrome attributed to an anatomical variation in the anterior scalene muscle: Diagnostic challenges and treatment approaches

Mixed thoracic outlet syndrome, which compresses arteries and nerves, is a rare disorder. Mixed thoracic outlet syndrome due to anatomical abnormalities of the anterior scalene muscle is even more sporadic. We report a case of mixed thoracic outlet syndrome in a patient with no history of trauma or vigorous exercise. We reviewed the medical literature, emphasizing the clinical role and the role of diagnostic imaging methods in a sequential approach to this syndrome.

Compressive lesions of the head and neck: Common and uncommon must-know entities

There are many lesions that cause compression of nerves and vessels in the head and neck, and they can often be overlooked in the absence of adequate history or if not suspected by the radiologist. Many of these lesions require a high index of suspicion and optimal positioning for imaging. While a multimodality approach is critical in the evaluation of compressive lesions, an MRI utilizing high-resolution (heavily weighted) T2-weighted sequence is extremely useful as a starting point. In this review, we aim to discuss the radiological features of the common and uncommon compressive lesions of the head and neck which are broadly categorized into vascular, osseous, and miscellaneous etiologies.

Neurogenic thoracic outlet syndrome and controversies in diagnosis and management

Compression of the neurovascular structures at the level of the scalene triangle and pectoralis minor space is rare, but increasing awareness and understanding is allowing for the treatment of more individuals than in the past. We outlined the recognition, preoperative evaluation, and treatment of patients with neurogenic thoracic outlet syndrome. Recent work has illustrated the role of imaging and centrality of the physical examination on the diagnosis. However, a fuller understanding of the spatial biomechanics of the shoulder, scalene triangle, and pectoralis minor musculotendinous complex has shown that, although physical therapy is a mainstay of treatment, a poor response to physical therapy with a sound diagnosis should not preclude decompression. Modes of failure of surgical decompression stress the importance of full resection of the anterior scalene muscle and all posterior rib impinging elements to minimize the risk of recurrence of symptoms. Neurogenic thoracic outlet syndrome is a rare but critical cause of disability of the upper extremity. Modern understanding of the pathophysiology and evaluation have led to a sounder diagnosis. Although physical therapy is a mainstay, surgical decompression remains the gold standard to preserve and recover function of the upper extremity. Understanding these principles will be central to further developments in the treatment of this patient population.

Thoracic outlet syndrome in women

Thoracic outlet syndrome (TOS) is observed more frequently in women, although the exact causes of this sex disparity remain unclear. By investigating the three types of TOS-arterial, neurogenic, and venous-regarding symptoms, diagnosis, and treatment, this article aims to shed light on the current understanding of TOS, focusing on its variations in women.

Validity of Ultrasound for the Diagnosis of Arterial Thoracic Outlet Syndrome

Objective

Thoracic outlet syndrome (TOS) is a rare disorder mostly seen in younger individuals. Although patient wellbeing is relevantly impaired, it often takes a long time before the diagnosis is made. Digital subtraction angiography (DSA) is routinely used despite its radiation exposure, which is a major concern in this young patient population. Moreover, DSA offers limited opportunities for functional assessment. By contrast, ultrasonography is widely accessible without causing radiation exposure and allows for flexible functional assessment. The main goal of the study was to investigate whether ultrasound (US) was a viable alternative to DSA in diagnosing arterial TOS (aTOS).

Methods

Patients, referred to a tertiary centre for evaluation of suspected TOS, were recruited into the study. DSA was routinely performed with the patient's arms both in the raised (abducted) and neutral (adducted) position. Two vascular surgeons and two radiologists assessed the resulting images for the presence of aTOS. Additionally, two examiners performed US according to a standardised protocol. The reference for presence of aTOS was the DSA based interdisciplinary vascular conference consensus. Inter-rater agreement and latent class analysis (LCA) were performed between assessors and diagnostic methods.

Results

Fifty one consecutive patients (two thirds female) aged 39.3 ± 13.0 years were included within 11 months. US agreement was excellent at 0.94 (0.841-0.980), DSA agreement for vascular surgeons was good at 0.779 (0.479-1.000), whereas it was moderate at 0.546 (0.046-1.000) for radiologists. Results suggest that DSA is untenable as the gold standard for aTOS diagnosis. In LCA, US was shown to be a reliable diagnostic tool for the detection of aTOS.

Conclusion

US examination is a valid test for the detection of haemodynamically relevant compression of arteries in the diagnostic work up of aTOS using a standardised protocol. The role of DSA as the gold standard should be reviewed and needs to be reconsidered.

A Literature Review of Methods of Perioperative Pain Management in Thoracic Outlet Decompression

OBJECTIVES

Post-operative pain control in thoracic outlet decompression (TOD) is difficult due to the complex innervation of the anatomical region. Poor post-operative pain control has been associated with worse patient experiences and prolonged inpatient stays. This study aims to identify evidence-based peri-operative analgesic strategies for thoracic outlet decompression.

METHODS

MEDLINE and Embase searches were performed to identify literature assessing peri-operative pain control methods in patients undergoing TOD. Studies were limited to the English language and within 10 years of publication. Abstracts were screened for relevance by two reviewers and identified review articles on thoracic outlet decompression were also included for critical appraisal.

RESULTS

The primary literature search yielded 124 studies whose abstracts were screened resulting in a total of 16 studies being included for full review and critical appraisal. This included 1 randomised control trial, 7 retrospective cohort studies, 1 case series study, 2 case report study and 5 review articles. Studies utilised a baseline of multimodal oral analgesics with their main investigative focus centred on the use of different methods of peripheral nerve blockade.

CONCLUSION

There is only 1 published randomised controlled trial study investigating postoperative analgesic modalities in thoracic outlet decompression. This deficit of evidence was reflected in the high variation of pain management strategies employed in the published literature. Evidence should be sought to assess the relative efficacy of the various pain management strategies.

Magnetic resonance imaging for diagnosis of suspected neurogenic thoracic outlet syndrome-a systematic scoping review

Background: Neurogenic Thoracic Outlet Syndrome (nTOS) is a rare pathology caused by dynamic conditions or compression of neurovascular structures in the thoracic outlet region. nTOS can be difficult to diagnose due to nonspecific symptoms and magnetic resonance imaging (MRI) techniques are increasingly used to aid the diagnosis and surgical planning. This scoping systematic review explores how MRI is used for diagnosing nTOS and summarizes details of published MRI protocols. Methods: A systematic screening of PubMed, Cochrane, Web of Science, and CINAHL databases using PRISMA-IPD guidelines was conducted in September 2022 to include full-text English papers on MRI and nTOS. Inclusion criteria involved studies describing MRI protocols for the diagnosis of TOS, with a focus on the imaging sequences and protocols. Results: 6289 papers were screened to include 28 papers containing details of MRI protocols. The details of MRI protocols in the analyzed articles were incomplete in all studies. Most authors used 1.5T systems and included T1 and T2-weighted sequences. Most studies applied fat suppression, mainly with STIR. Positioning of the arm differed between studies, including neutral, hyperabducted and abducted and externally rotated positions. Conclusion: Our review highlights a prevalent lack of detailed MRI protocol documentation for brachial plexus. Authors primarily rely on conventional 1.5T systems, employing standard T1 and T2-weighted sequences. The adoption of novel MRI sequences is notably lacking, and fat suppression techniques predominantly adhere to older methods as STIR. There is a clear imperative for authors to provide more comprehensive reporting of the MRI protocols utilized in their studies, ultimately enhancing comparability and clinical applicability. Establishing clear protocol reporting guidelines is crucial to allow for comparison between studies.

Arterial thoracic outlet syndrome by a commonly overlooked anomaly, the cervical rib: A case report

Thoracic outlet syndrome (TOS) is a constellation of symptoms that occur due to the compression of neurovascular structures traversing the thoracic outlet. TOS manifests in 3 distinct forms: neurogenic, venous, and arterial. Among these, arterial TOS is the rarest. A 32-year-old man presenting with severe right arm pain was referred for CT angiography. The imaging revealed bilateral cervical ribs, with the right side showing more pronounced development and fusion with the first thoracic rib. At the fusion site of the right cervical rib and the first thoracic rib, a pseudoaneurysm of the right subclavian artery was detected. Additionally, there was evidence of acute thromboembolism in the right brachial artery at the mid-humerus. Arterial thoracic outlet syndrome is a rare form of TOS that can have detrimental consequences due to associated complications. Cross-sectional imaging, such as CT scans and MRI, is the preferred method for diagnosing TOS and identifying its specific form. Physicians are expected to be familiar with the various forms of TOS, the lesions mimicking TOS, and the imaging tools utilized for diagnosis.

Body and Extremity MR Venography: Technique, Clinical Applications, and Advances

Magnetic resonance venography (MRV) represents a distinct imaging approach that may be used to evaluate a wide spectrum of venous pathology. Despite duplex ultrasound and computed tomography venography representing the dominant imaging modalities in investigating suspected venous disease, MRV is increasingly used due to its lack of ionizing radiation, unique ability to be performed without administration of intravenous contrast, and recent technical improvements resulting in improved sensitivity, image quality, and faster acquisition times. In this review, the authors discuss commonly used body and extremity MRV techniques, different clinical applications, and future directions.

General Overview and Diagnostic (Imaging) Techniques for Neurogenic Thoracic Outlet Syndrome

Thoracic outlet syndrome is an uncommon and controversial syndrome. Three different diagnoses can be made based on the compressed structure, arterial TOS, venous TOS, and neurogenic TOS, though combinations do exist as well. Diagnosing NTOS is difficult since no specific objective diagnostic modalities exist. This has resulted in a lot of controversy in recent decades. NTOS remains a clinical diagnosis and is mostly diagnosed based on the exclusion of an extensive list of differential diagnoses. To guide the diagnosis and treatment of TOS, a group of experts published the reporting standards for TOS in 2016. However, a consensus was not reached regarding a blueprint for a daily care pathway in this document. Therefore, we constructed a care pathway based on the reporting standards for both the diagnosis and treatment of NTOS patients. This care pathway includes a multidisciplinary approach in which different diagnostic tests and additional imaging techniques are combined to diagnose NTOS or guide patients in their treatment for differential diagnoses. The aim of the present work is to discuss and explain the diagnostic part of this care pathway.

Brachial Plexus Nerve Injuries and Disorders

Multimodality imaging of the brachial plexus is essential to accurately localize the lesion and characterize the pathology and site of injury. A combination of computed tomography (CT), ultrasound, and MR imaging is useful along with clinical and nerve conduction studies. Ultrasound and MR imaging in combination are effective to accurately localize the pathology in most of the cases. Accurate reporting of the pathology with dedicated MR imaging protocols in conjunction with Doppler ultrasound and dynamic imaging provides practical and useful information to help the referring physicians and surgeons to optimize medical or surgical treatment regimens.

Clinical Significance of Maximum Intensity Projection Method for Diagnostic Imaging of Thoracic Outlet Syndrome

The aim of this study was to use the magnetic resonance imaging maximum-intensity projection (MRI-MIP) method for diagnostic imaging of thoracic outlet syndrome (TOS) and to investigate the stricture ratios of the subclavian artery (SCA), subclavian vein (SCV), and brachial plexus bundle (BP). A total of 113 patients with clinically suspected TOS were evaluated. MRI was performed in a position similar to the Wright test. The stricture was classified into four grades. Then, the stricture ratios of the SCA, SCV, and BP in the sagittal view were calculated by dividing the minimum diameter by the maximum diameter of each structure. Patients were divided into two groups: surgical (n = 22) and conservative (n = 91). Statistical analysis was performed using the Mann-Whitney U test. The stricture level and ratio in the SCV were significantly higher in the surgical group, while the stricture level and the ratio of SCA to BP did not show significant differences between the two groups. The MRI-MIP method may be helpful for both subsidiary and severe diagnoses of TOS.

Description of Clinical Features and Diagnoses of 444 Cases with Neck-Shoulder-Upper Extremity Pain: A Single-Center Retrospective Review

PURPOSE

Neck-shoulder-upper extremity pain (NSUEP) is a frequently occurring clinical constellation of syndromes. However, its etiology is complicated, and the diagnosis is challenging. We aimed to present detailed clinical characteristics and diagnoses of NSUEP from a single center and heighten clinicians' understanding of this condition.

PATIENTS AND METHODS

Prospectively collected databases were used to retrospectively evaluate patients with NSUEP who underwent treatment at the multidisciplinary consultation center for neck, shoulder, and upper extremity pain at the China-Japan Union Hospital of Jilin University between April 2014 and July 2021. We performed descriptive statistics regarding demographic data, symptoms, findings of physical and radiographic examinations, and each patient's diagnosis.

RESULTS

Development of NSUEP was primarily observed in individuals aged between 51 and 60 years (n = 157, 35.4%). Patients were most commonly referred for upper extremity pain (n = 306, 68.9%). Patients with upper extremity pain presented with hypoesthesia (n = 139, 45.4%), muscle weakness (n = 93, 30.4%), muscle atrophy (n = 90, 29.4%), hyperesthesia (n = 39, 12.7%), and turgidity (n = 18, 5.9%). Among the 22 patients with upper extremity swelling, 8 (36.4%) were diagnosed with autoimmune rheumatic diseases. Among the 352 patients with a single diagnosis, 51 (14.5%) presented with thoracic outlet syndrome, 49 (13.9%) with cervical radiculopathy, 16 (4.5%) with carpal tunnel syndrome, and 16 (4.5%) with brachial plexus injury. Further, among the 92 patients with compound diagnosis, 18 patients (19.6%) were diagnosed with cervical radiculopathy.

CONCLUSION

Among the NSUEP patients in this study, older individuals were the largest group. Pain, numbness, weakness, and mobility limitation are common complaints accompanying NSUEP. The common etiologies of NSUEP include cervical spondylosis, thoracic outlet syndrome, carpal tunnel syndrome, and brachial plexus injury. In addition, autoimmune rheumatic diseases should be considered in patients with NSUEP and swelling.

Quantitative analysis of venous outflow with photo-plethysmography in patients with suspected thoracic outlet syndrome

Background

Venous compression is the second most frequent form of thoracic outlet syndrome (TOS). Although venous photo-plethysmography (PPG) has been largely used to estimate the consequences of chronic thromboses (Paget Schroetter syndrome), systematic direct quantitative recording of hemodynamic consequences of positional venous outflow impairment in patients with suspected TOS has never been reported.

Objective

We hypothesized that moving the arms forward (prayer: “Pra” position) while keeping the hands elevated after a surrender/candlestick position (Ca) would allow quantification of 100% upper limb venous emptying (PPGmax) and quantitative evaluation of the emptying observed at the end of the preceding abduction period (End-Ca-PPG), expressed in %PPGmax.

Materials and methods

We measured V-PPG in 424 patients referred for suspected TOS (age 40.9 years old, 68.3% females) and retrieved the results of ultrasound investigation at the venous level. We used receiver operating characteristics curves (ROC) to determine the optimal V-PPG values to be used to predict the presence of a venous compression on ultrasound imaging. Results are reported as a median (25/75 centiles). Statistical significance was based on a two-tailed p < 0.05.

Results

An End-Ca-PPG value of 87% PPGmax at the end of the “Ca” period is the optimal point to detect an ultrasound-confirmed positional venous compression (area under ROC: 0.589 ± 0.024; p < 0.001). This threshold results in 60.9% sensitivity, 47.6% specificity, 27.3% positive predictive value, 79.0% negative predictive value, and 50.8% overall accuracy.

Conclusion

V-PPG is not aimed at detecting the presence of a venous compression due to collateral veins potentially normalizing outflow despite subclavicular vein compression during abduction, but we believe that it could be used to strengthen the responsibility of venous compression in upper limb symptoms in TOS-suspected patients, with the possibility of non-invasive, bilateral, recordable measurements of forearm volume that become quantitative with the Ca-Pra maneuver.

Clinical trial registration

[ClinicalTrials.gov], identifier [NCT04376177].

Presentation, management and outcome of surgically managed pediatric thoracic outlet syndrome

PURPOSE

Thoracic outlet syndrome (TOS) is a rare disorder involving compression of the brachial plexus, subclavian artery, and subclavian vein. There is a paucity of data for this pathology's surgical treatment within pediatrics. The objective of this study is to explore the presentation, management, and outcome of pediatric TOS.

METHODS

A retrospective chart review was conducted for 44 patients at a single institution undergoing surgery for TOS. Data was collected on demographics, pre- and postoperative factors, and outcomes.

RESULTS

Forty-four patients underwent 50 surgeries (8 bilaterally). The average age was 15.5 years with 72% female. The most common symptoms were numbness (72%) and pain (66%), with a normal exam in 58%. The average symptom duration prior to surgery was 35.2 months. A supraclavicular approach was performed in all patients, with anterior scalene section (90%), rib resection (72%), neurolysis (92%), and intraoperative EMG (84%) commonly used. Two patients had a lymphatic leak. All patients reported subjective improvement of preoperative symptoms of numbness (26%), pain (22%), and weakness (6%). Differences between vTOS (n = 9) and nTOS (n = 35) included higher preop swelling (p < 0.012), decreased symptom duration (p < 0.022), higher venogram usage (p < 0.0030), and higher preoperative thrombolytics/angioplasty (p < 0.001) in vTOS compared to nTOS. A comparison of soft tissue and soft tissue with bone decompression did not reveal any outcome differences.

CONCLUSION

Pediatric TOS benefits from a multidisciplinary approach, showing good outcomes in postoperative symptom resolution. In our cohort, a supraclavicular approach provided an effective window for decompression with a low complication rate.

Subclavian Artery: Anatomic Review and Imaging Evaluation of Abnormalities

The subclavian artery is an important structure that may be overlooked at CT of the chest and neck, in part because of its anatomic location at the periphery of the field of view but also because the clinical indication for CT examinations infrequently directs attention specifically to evaluation of the subclavian artery. As with all arteries, the subclavian artery has the potential to be involved in a variety of abnormalities, including pseudoaneurysms, dissections, stenosis or thrombosis, and vasculopathies. In addition, the subclavian artery can be secondarily involved as a collateral pathway because of an abnormality elsewhere. The subclavian artery may also be involved in surgical procedures to supply blood to other sites in the body or as an arterial access site. In these cases, recognizing the postsurgical appearance of the subclavian artery has become increasingly complex because of the use of the artery in an increasing number of procedures. Recognizing expected postoperative changes remains important to avoid mistaking them for abnormalities. The authors describe the imaging appearance of the normal anatomy of the subclavian artery and its anatomic variants, related abnormalities, and important postsurgical considerations. ^©RSNA, 2022.

Thoracic outlet syndrome: a review for the primary care provider

CONTEXT

Thoracic outlet syndrome (TOS) symptoms are prevalent and often confused with other diagnoses. A PubMed search was undertaken to present a comprehensive article addressing the presentation and treatment for TOS.

OBJECTIVES

This article summarizes what is currently published about TOS, its etiologies, common objective findings, and nonsurgical treatment options.

METHODS

The PubMed database was conducted for the range of May 2020 to September 2021 utilizing TOS-related Medical Subject Headings (MeSH) terms. A Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) systematic literature review was conducted to identify the most common etiologies, the most objective findings, and the most effective nonsurgical treatment options for TOS.

RESULTS

The search identified 1,188 articles. The automated merge feature removed duplicate articles. The remaining 1,078 citations were manually reviewed, with articles published prior to 2010 removed (n=771). Of the remaining 307 articles, duplicate citations not removed by automated means were removed manually (n=3). The other exclusion criteria included: non-English language (n=21); no abstracts available (n=56); and case reports of TOS occurring from complications of fractures, medical or surgical procedures, novel surgical approaches, or abnormal anatomy (n=42). Articles over 5 years old pertaining to therapeutic intervention (mostly surgical) were removed (n=18). Articles pertaining specifically to osteopathic manipulative treatment (OMT) were sparse and all were utilized (n=6). A total of 167 articles remained. The authors added a total of 20 articles that fell outside of the search criteria, as they considered them to be historic in nature with regards to TOS (n=8), were related specifically to OMT (n=4), or were considered sentinel articles relating to specific therapeutic interventions (n=8). A total of 187 articles were utilized in the final preparation of this manuscript. A final search was conducted prior to submission for publication to check for updated articles. Symptoms of hemicranial and/or upper-extremity pain and paresthesias should lead a physician to evaluate for musculoskeletal etiologies that may be contributing to the compression of the brachial plexus. The best initial provocative test to screen for TOS is the upper limb tension test (ULTT) because a negative test suggests against brachial plexus compression. A positive ULTT should be followed up with an elevated arm stress test (EAST) to further support the diagnosis. If TOS is suspected, additional diagnostic testing such as ultrasound, electromyography (EMG), or magnetic resonance imaging/magnetic resonance angiography (MRI/MRA) might be utilized to further distinguish the vascular or neurological etiologies of the symptoms. Initial treatment for neurogenic TOS (nTOS) is often conservative. Data are limited, therefore there is no conclusive evidence that any one treatment method or combination is more effective. Surgery in nTOS is considered for refractory cases only. Anticoagulation and surgical decompression remain the treatment of choice for vascular versions of TOS.

CONCLUSIONS

The most common form of TOS is neurogenic. The most common symptoms are pain and paresthesias of the head, neck, and upper extremities. Diagnosis of nTOS is clinical, and the best screening test is the ULTT. There is no conclusive evidence that any one treatment method is more effective for nTOS, given limitations in the published data. Surgical decompression remains the treatment of choice for vascular forms of TOS.

Subclavian Effort Thrombosis: Pathophysiology, Diagnosis, and Management

Subclavian vein (SCV) effort thrombosis, also known as Paget-Schroetter syndrome or venous thoracic outlet syndrome, is an uncommon condition that affects individuals with an irregularly narrow thoracic outlet who engage in repetitive overhead motions of the affected arm. Venous injury arises from microtraumas that occur from the repetitive compression of the SCV between the first rib and the overlying clavicle. Additional sources of extrinsic compression can be due to the anterior scalene muscle, subclavius muscle, and costoclavicular ligament. SCV effort thrombosis is a distinct entity from other forms of deep venous thrombosis and requires unique diagnostic and treatment considerations. Early catheter-directed therapy in the form of pharmacomechanical or catheter-directed thrombolysis combined with prompt surgical thoracic outlet decompression offers patients the best chances for early and durable symptom relief.

Neurogenic thoracic outlet syndrome in the overhead and throwing athlete: A narrative review

Thoracic outlet syndrome is an important cause of shoulder pain and dysfunction due to compression of neurovascular structures as they traverse the thoracic outlet. Symptoms are most commonly due to compression of the brachial plexus called neurogenic thoracic outlet syndrome (nTOS). Throwing athletes are at increased risk of nTOS because of a variety of biomechanical factors. However, because nTOS symptoms are often nonspecific, delayed diagnosis is common. Neurogenic thoracic outlet largely remains a diagnosis of exclusion with advanced imaging ruling out vascular involvement and diagnostic injections gaining favor in helping localize sites of compression. Although rehabilitation alone may improve symptoms in some athletes, many require surgical treatment for long-term relief. This generally entails decompression of the thoracic outlet by some combination of muscle release, brachial plexus neurolysis, and first rib resection. Outcomes tend to be successful in athletes with most achieving resolution of symptoms and return to athletic activity. NTOS is an important cause of shoulder pain and dysfunction in throwing athletes. The history and physical examination should focus on activities that exacerbate symptoms. Treatment of nTOS generally requires surgical intervention and allows throwing athletes to return to sport.

Magnetic resonance imaging of the brachial plexus. Part 1: Anatomical considerations, magnetic resonance techniques, and non-traumatic lesions

For magnetic resonance imaging (MRI) of non-traumatic brachial plexus (BP) lesions, sequences with contrast injection should be considered in the differentiation between tumors, infection, postoperative conditions, and post-radiation changes. The most common non-traumatic inflammatory BP neuropathy is radiation neuropathy. T2-weighted images may help to distinguish neoplastic infiltration showing a high signal from radiation-induced neuropathy with fibrosis presenting a low signal.

MRI findings in inflammatory BP neuropathy are usually absent or discrete. Diffuse edema of the BP localized mainly in the supraclavicular part of BP, with side-to-side differences, and shoulder muscle denervation may be found on MRI.

BP infection is caused by direct infiltration from septic arthritis of the shoulder joint, spondylodiscitis, or lung empyema.

MRI may help to narrow down the list of differential diagnoses of tumors. The most common tumor of BP is metastasis. The most common primary tumor of BP is neurofibroma, which is visible as fusiform thickening of a nerve. In its solitary state, it may be challenging to differentiate from a schwannoma.

The most common MRI finding is a neurogenic variant of thoracic outlet syndrome with an asymmetry of signal and thickness of the BP with edema. In abduction, a loss of fat directly related to the BP may be seen.

Diffusion tensor imaging is a promising novel MRI sequences; however, the small diameter of the nerves contributing to the BP and susceptibility to artifacts may be challenging in obtaining sufficiently high-quality images.

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MRI allows narrowing the list of differential diagnoses of brachial plexus lesions.

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MRI helps to distinguish neoplastic infiltration from radiation neuropathy in T2-weighted images.

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Differentiation between tumors, infection, postoperative conditions and post-radiation changes is possible with contrast.

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MRI helps to determine the extent of the infection.

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Diffusion tensor MRI is a promising method for brachial plexus assessment.

Venous thoracic outlet syndrome and Paget-Schroetter syndrome

Venous thoracic outlet syndrome represents a relatively rare but important diagnosis in the adolescent population with increasing recognition. Compression of the subclavian vein within the costoclavicular space can lead to episodic venous outlet obstruction in the upper extremity, with edema, rubor and functional symptoms. Over time, cumulative injury and compression can lead to thrombosis of the vein, referred to as "effort thrombosis" or the Paget-Schroetter syndrome. This progression can lead to the need for acute management of the venous thromboembolism, requirement for thoracic outlet decompression surgery and the potential for long-term sequelae such as post-thrombotic syndrome. Management is focused on clot minimization, anticoagulation during the period of endothelial injury and inflammation and surgical decompression via first rib resection, anterior scalenectomy and venolysis to remove external compression of the vein. This manuscript reviews the diagnosis, evaluation and treatment of venous thoracic outlet syndrome and Paget-Schroetter syndrome.

Imaging of non-specific complaints of the arm, neck, and/or shoulder (CANS): role of the scalene muscles and piercing variants in neurogenic thoracic outlet syndrome

Complaints of the arm, neck and/or shoulder (CANS) are common in the general population (40%) and workers (30%) and have significant economic impact. Twenty-three conditions have been designated as specific CANS. Cases where no cause is identified are reported as non-specific CANS; these cases make up the majority of CANS. Non-specific CANS presentations overlap with clinical entities including cervicobrachial and scalene myofascial syndromes that are associated with neurogenic thoracic outlet syndrome (NTOS). The scalene muscles have been identified as the commonest site of NTOS, although this has been reported to be functional and in conjunction with cervicothoracic junction variants that compromise the brachial plexus lower trunk. Anatomical variants in relation to both the scalene muscles and brachial plexus are not widely recognised in the clinical and imaging literature; however, pass-through and pass-over (or "piercing") variants of the brachial plexus upper trunk and scalene muscles have been well described in the anatomical and anaesthetic literature. In this review, we demonstrate the presence and describe the imaging of scalene muscle pathology and variant muscle-brachial plexus anatomy affecting the upper trunk that are underdiagnosed causes of non-specific CANS presentations and NTOS.

Acute Thoracic Outlet Syndrome Associated with Congenital Pseudarthrosis of the First Rib: A Case Report

CASE

A 15-year-old right-hand-dominant adolescent girl presented with a nondisplaced first rib fracture and evidence of mesoacromion. She reported radiating numbness, pain, temperature change, and paresthesia in her left arm. An MRI revealed a first rib fracture along with brachial plexus and scalene musculature inflammation. Follow-up radiographs demonstrated bilateral rib anomalies during routine comparison views.

CONCLUSION

Congenital pseudarthrosis of the first rib occurs but is not well documented in the literature. This case report describes a case of congenital bilateral first rib pseudarthrosis with associated thoracic outlet syndrome symptoms in a competitive female softball athlete.

Anatomy, Imaging, and Pathologic Conditions of the Brachial Plexus

The brachial plexus is an intricate anatomic structure with an important function: providing innervation to the upper extremity, shoulder, and upper chest. Owing to its complex form and longitudinal course, the brachial plexus can be challenging to conceptualize in three dimensions, which complicates evaluations in standard orthogonal imaging planes. The components of the brachial plexus can be determined by using key anatomic landmarks. Applying this anatomic knowledge, a radiologist should then be able to identify pathologic appearances of the brachial plexus by using imaging modalities such as MRI, CT, and US. Brachial plexopathies can be divided into two broad categories that are based on disease origin: traumatic and nontraumatic. In the traumatic plexopathy group, there are distinct imaging findings and management methods for pre- versus postganglionic injuries. For nontraumatic plexopathies, having access to an accurate patient history is often crucial. Knowledge of the timing of radiation therapy is critical to diagnosing post-radiation therapy brachial plexopathy. In acute brachial neuritis, antecedent stressors occur within a specific time frame. Primary and secondary tumors of the brachial plexus are not uncommon, with the most common primary tumors being peripheral nerve sheath tumors. Direct extension and metastasis from primary malignancies such as breast and lung cancer can occur. Although diagnosing a brachial plexus anomaly is potentially perplexing, it can be straightforward if it is based on foundational knowledge of anatomy, imaging findings, and pathologic features. ^©RSNA, 2020.

Surgical treatment of cervical rib-associated arterial thoracic outlet syndrome

The arterial form of thoracic outlet syndrome is rare and is associated with anatomic anomalies, generally a cervical rib. It has a varied range of manifestations. The aim of this article is to describe two cases with different clinical presentations: microembolization and aneurysm. A cervical rib was present in both cases. Diagnosis was made on the basis of history, physical examination, postural maneuvers, and X-rays. Computed tomography angiography provided the anatomic detail necessary to plan surgery. Surgical treatment was performed via supraclavicular access, successfully, in both cases.

Evaluation and Management of Venous Thoracic Outlet Syndrome

Venous thoracic outlet syndrome (TOS) is uncommon but occurs in young, healthy patients, typically presenting as subclavian vein (SCV) effort thrombosis. Venous TOS arises through chronic repetitive compression injury of the SCV in the costoclavicular space with progressive venous scarring, focal stenosis, and eventual thrombosis. Diagnosis is evident on clinical presentation with sudden spontaneous upper extremity swelling and cyanotic discoloration. Initial treatment includes anticoagulation, venography, and pharmacomechanical thrombolysis. Surgical management using paraclavicular decompression can result in relief from arm swelling, freedom from long-term anticoagulation, and a return to unrestricted upper extremity activity in more than 90% of patients.

Reoperation for Persistent or Recurrent Neurogenic Thoracic Outlet Syndrome

Identifying the exact cause for persistent and recurrent neurogenic thoracic outlet syndrome (NTOS) is challenging even with high-resolution imaging of the thoracic outlet. Improvement can be achieved with redo first rib resection, although the posterior first rib remnant is one of several potential points of brachial plexus compression. In approaching reoperative surgery for NTOS, the aim is to provide complete thoracic outlet decompression as guided by the patient's history, physical examination, and adjunctive imaging. This may involve resection of the posterior first rib remnant, scar tissue encasing the brachial plexus, elongated C7 transverse process, cervical rib, and/or pectoralis minor tendon.

Athletic Injuries of the Thoracic Cage

A variety of sports require exposure to high-impact trauma or characteristic repetitive movements that predispose to injuries around the thorax. Appropriate prognostication and timely management are vital, as untreated or undertreated injuries can lead to pain, disability, loss of playing time, or early termination of sports participation. The authors review common athletic injuries of the thoracic cage, encompassing muscular, osseous, and vascular conditions, with an emphasis on mechanism, imaging features, and management. The authors also review pertinent soft-tissue and bony anatomy, along with relevant sports biomechanics. Generalized muscle trauma and more specific injuries involving the pectoralis major, latissimus dorsi, teres major, pectoralis minor, lateral abdominal wall and intercostals, serratus anterior, and rectus abdominis muscles are discussed. Osseous injuries such as stress fractures, sternoclavicular dislocation, costochondral fractures, and scapular fractures are included. Finally, thoracic conditions such as snapping scapula, thoracic outlet syndrome, and Paget-Schroetter syndrome are also described. Specific MRI protocols are highlighted to address imaging challenges such as the variable anatomic orientation of thoracic structures and artifact from breathing motion. Athletes are susceptible to a wide range of musculoskeletal thoracic trauma. An accurate imaging diagnosis of thoracic cage injury and assessment of injury severity allow development of an adequate treatment plan. This can be facilitated by an understanding of functional anatomy, sports biomechanics, and the unique injuries for which athletes are at risk. ^©RSNA, 2021.

Contemporary Management of Arterial Thoracic Outlet Syndrome

BACKGROUND

Arterial thoracic outlet syndrome (aTOS) is characterized by compression of the subclavian artery as it exits the thoracic girdle. Chronic and repetitive compression leads to several degrees of arterial wall damage. The treatment is varied and depends on the presentation severity. This study aimed to describe the contemporary experience in managing arterial thoracic outlet syndrome at a large tertiary hospital.

METHODS

We conducted a single-institution retrospective review of aTOS cases from January 2009 to January 2020. Demographic data, clinical presentation, medical images, operative notes, and outcomes were assessed.

RESULTS

Thirteen aTOS cases were identified. The mean age was 43 ± 10 years, and 11 (85%) were women. Both sides were equally affected: right (7 cases, 54%) and left (6 cases, 46%). The most common clinical presentation was arm claudication (7 cases, 54%). Other presentations were: acute arm ischemia, pulsatile neck mass and distal embolization. Cervical ribs were identified by plain X-rays in most cases. All patients were submitted to surgical decompression through the supraclavicular approach. Patients with early disease stages were not submitted to arterial reconstruction and were followed with duplex scan. Arterial reconstruction was done in advanced disease stages (5 cases, 38%): end-to-end anastomosis, interposition graft, and bypass graft. The mean follow-up duration was 32,6 ± 25 months. In all patients, the subclavian artery/graft was patent, and the vascular symptoms were entirely resolved. There were no deaths or amputations.

CONCLUSIONS

Arterial thoracic outlet syndrome has a varied clinical presentation. Cervical ribs are the most common anatomic abnormalities. The diagnosis was based on history, physical examination, and imaging exams. Surgery consisted of supraclavicular decompression, arterial resection, and vascular reconstruction, according to the disease stage. The outcomes were excellent.

Subclavian Vessel Compression Assessed by Duplex Scanning in Patients with Neurogenic Thoracic Outlet Syndrome and No Vascular Signs

Neurogenic thoracic outlet syndrome (NTOS) is the most frequent form of TOS. It may affect both sides, but specific complementary exams are lacking. We aimed to evaluate duplex scanning results in a group of patients with unilateral or bilateral NTOS and no clinical vascular signs, referred for rehabilitation. We performed a retrospective observational study in patients with unilateral or bilateral NTOS and no vascular symptoms. Subclavian vessels were assessed by duplex scanning. Compressions were considered in case of >50% of increased or decreased blood flow. A total of 101 patients met NTOS criteria; mean age was 40 +/− 10.2; 79.2% women. Seventy patients had a unilateral NTOS and 31 a bilateral form. Duplex scanning showed that 56.4% of the patients had vessels compression, 55.7% in the unilateral group and 58.1% in the bilateral (p = 0.81). In unilateral NTOS, 21 (30%) patients had bilateral vascular compression, 17 (24.3%) had ipsilateral compression and 1 (1.4%) had contralateral compression. In bilateral NTOS, 15 (48.4%) had bilateral compression and 3 (9.7%) compression on only one side. We found a significant difference of the rate of vascular compressions between symptomatic and non-symptomatic upper-limbs, 54.5% vs. 32.9%, respectively, (p = 0.002) and a significant association between symptomatic upper-limbs and vascular compression (OR = 2.45 [95%IC: 1.33–4.49]; p = 0.002). The sensitivity and the specificity of the duplex scanning were 54.5% and 67%, respectively. The ROC curve area was of 0.608 [95%IC: 0.527–0.690]. Despite a highly significant association between symptomatic upper-limbs and vascular compression, duplex scanning did not help make the diagnosis of NTOS.

Surgical treatment of cervical rib-associated arterial thoracic outlet syndrome

Resumo A forma arterial da síndrome do desfiladeiro torácico é rara e está associada a uma anomalia anatômica, geralmente uma costela cervical. Suas manifestações são muito variadas. Este artigo tem como proposta relatar dois casos de apresentações clínicas distintas: microembolização e aneurisma. Em ambos, uma costela cervical estava presente. O diagnóstico foi realizado através da história, do exame físico, das manobras posturais e das radiografias. A angiotomografia computadorizada proporcionou o detalhe anatômico necessário para o planejamento operatório. O tratamento cirúrgico foi realizado pela abordagem supraclavicular, com sucesso em ambos casos.

Clinico-radiological review of peripheral entrapment neuropathies - Part 1 upper limb

PURPOSE

This article aims to review the pertinent anatomy, etiopathogenesis, current clinical and radiological concepts and principles of management in case of upper limb entrapment neuropathies.

METHODS

The review is based on critical analysis of the existing literature as well as our experience in dealing with entrapment neuropathies.

RESULTS

Entrapment neuropathies of the upper limb peripheral nerves are common conditions that are often misdiagnosed because of their varying clinical presentations and lack of standardized diagnostic methods. Clinical assessment and electrodiagnostic studies have been the mainstay; however, imaging techniques have provided newer insights into the pathophysiology of these entities, leading to a paradigm shift in their diagnosis and management. The current best practice protocols for entrapment syndromes are constantly evolving with increasing emphasis on the role high-resolution ultrasound and magnetic resonance imaging. Many imaging criteria are described and we have tried to present the most validated measurements for diagnosing entrapment neuropathies.

CONCLUSION

It is imperative for a clinical radiologist to be familiar with the etiopathogenesis and clinical features of these conditions, in addition to being thorough with the anatomy and the latest imaging strategies.

REACT - A novel flow-independent non-gated non-contrast MR angiography technique using magnetization-prepared 3D non-balanced dual-echo dixon method: Preliminary clinical experience

Flow-independent relaxation-based non-contrast MR angiography techniques yield good signal-to-noise ratio and high blood-tissue contrast, complementing non-contrast flow-dependent and contrast-enhanced MR angiography techniques in the assessment of vascular disorders. However, these techniques often suffer from imaging artifacts at high magnetic field strengths or across large fields-of-view. Relaxation-Enhanced Angiography without Contrast and Triggering (REACT) is a recently introduced flow-independent non-gated non-contrast three-dimensional MR angiography technique that has been developed to mitigate some of these issues. We present our initial experience with the clinical applications of REACT in imaging disorders of the central and peripheral vascular systems.

Thoracic Outlet Syndrome in the Overhead Athlete: Diagnosis and Treatment Recommendations

PURPOSE OF REVIEW

Neurovascular compression in the upper extremity is rare but can affect even those participating in high-level competitive athletics. To assess optimal approaches to treatment, in this review, we evaluate the current literature on neurovascular compressive syndromes affecting the upper extremity, with a special focus on the thoracic outlet syndrome (TOS).

RECENT FINDINGS

Neurovascular compression at the thoracic outlet can involve the brachial plexus, subclavian artery, or subclavian vein, each with distinct clinical manifestations. Neurogenic TOS is best treated with surgical decompression, if physical therapy has not improved symptoms. Venous TOS results in acute thrombosis superimposed on chronic venous compression. Treatment is best directed at early anticoagulation, catheter-directed thrombolysis, and surgical decompression, with most patients able to discontinue anticoagulation and return to high-level athletic activity. Arterial TOS is related to aneurysmal degeneration of the subclavian artery with distal embolization, leading to limb-threatening ischemia. This should be aggressively treated with surgery. Similar degenerative changes can occur in the axillary artery and its branches, leading to distal embolization. Prompt recognition of these potential sources of limb-threatening ischemia is critical to limb preservation. TOS includes rare but important conditions in the overhead athlete. Recent advances in physical therapy and image-guided diagnostic techniques have facilitated more accurate diagnosis. Surgical treatment remains the gold standard to maximize function or for limb preservation, and future research is needed to clarify optimal pain and physiotherapy regimens, as well as to examine novel approaches to neurovascular decompression.

Magnetic Resonance Angiography of the Thoracic Vasculature: Technique and Applications

Magnetic resonance angiography (MRA) is a powerful clinical tool for evaluation of the thoracic vasculature. MRA can be performed on nearly any magnetic resonance imaging (MRI) scanner, and provides images of high diagnostic quality without the use of ionizing radiation. While computed tomographic angiography (CTA) is preferred in the evaluation of hemodynamically unstable patients, MRA represents an important tool for evaluation of the thoracic vasculature in stable patients. Contrast-enhanced MRA is generally performed unless there is a specific contraindication, as it shortens the duration of the exam and provides images of higher diagnostic quality than noncontrast MRA. However, intravenous contrast is often not required to obtain a diagnostic evaluation for most clinical indications. Indeed, a variety of noncontrast MRA techniques are used for thoracic imaging, often in conjunction with contrast-enhanced MRA, each of which has a differing degree of reliance on flowing blood to produce the desired vascular signal. In this article we review contrast-enhanced MRA, with a focus on contrast agents, methods of bolus timing, and considerations in imaging acquisition. Next, we cover the mechanism of contrast, strengths, and weaknesses of various noncontrast MRA techniques. Finally, we present an approach to protocol development and review representative protocols used at our institution for a variety of thoracic applications. Further attention will be devoted to additional techniques employed to address specific clinical questions, such as delayed contrast-enhanced imaging, provocative maneuvers, electrocardiogram and respiratory gating, and phase-contrast imaging. The purpose of this article is to review basic techniques and methodology in thoracic MRA, discuss an approach to protocol development, and illustrate commonly encountered pathology on thoracic MRA examinations. Level of Evidence 5 Technical Efficacy Stage 3.

Thirty-year experience of transaxillary resection of first rib for thoracic outlet syndrome

BACKGROUND

Thoracic outlet syndrome is an important clinical entity, which usually affects young patients and working cohort, causing disability if unrecognized and untreated. Although treatment is commonly conservative, in patients with more severe disease, surgical treatment is often required for decompression. Purpose of this paper was to evaluate the surgical and clinical outcomes of patients who underwent first rib resection through transaxillary approach for thoracic outlet syndrome (TOS) during a period of 30 years.

METHODS

A retrospective study was conducted on a prospectively compiled, computerized database between January 1988 and December 2018 including patients affected by TOS surgically treated in two Italian centers, by the same surgeon. Patients with neurogenic and vascular TOS were included in the present analysis. The surgical approach for TOS decompression was the first rib resection using the Roos' transaxillary approach, with small variations in technique. Outcome measures considered for analysis were primary technical success, 30-day and mean follow-up re-intervention, pneumothorax, nerve injury and symptoms recurrence rates.

RESULTS

One hundred three patients were treated: 89 (86.4%) women and 14 (13.6%) man; median age was 32.6±10.2 years (range 9-53). Prominent symptoms were neurogenic in 60 patients (58.2%), venous in 32 (31.1%), and arterial in 11 (7.76%) patients. In 49 patients (47.5%) with prominent neurogenic symptoms, concomitant symptoms of vascular TOS were also presents. Thirteen (12.6%) patients had cervical rib and sixteen cases (15.5%) had bilateral TOS. Technical success was achieved in all cases, and no other surgical access or secondary approach was necessary. Three patients (2.9%) presented with hand ischemia and also needed an arm vein bypass after rib resection. One (0.9%) intraoperative arterial injury was reported and nerve injury rate was 1.8%. At 30-day re-intervention rate was 0.9%: one patient experienced hemothorax solved by thoracoscopic drainage. Restrict pneumothorax was reported in 42 patients (40.8%) treated through pleural drainage. At mean follow-up of (93±9 months) partial symptoms recurrence was present in 6 patients (5.8%).

CONCLUSIONS

In our experience first rib resection through the transaxillary approach is a safe and feasible procedure associated with an acceptable rate of peri-operative morbidity and satisfactory long-term relief of symptoms.

An overview of the findings of dynamic upper limbs’ arterial and venous duplex in cases of vascular thoracic outlet syndrome

Background

To describe the findings of the dynamic upper limb arterial and venous duplex in the assessment of vascular compression in cases of VTOS. This study was conducted on 58 patients with VTOS; they were evaluated by dynamic duplex examination.

Results

Vascular compression was subdivided into a venous compression that was detected in (84.4%,n = 49), arterial compression that was seen in (1.7%,n = 1), and combined arterial and venous compression that was present in (13.7%,n = 8); bilateral compression was existing in (94.4%,n = 55), compression at the scalene triangle was seen in (1.7%,n = 1), at the costo-clavicular space was seen in (91.3%,n = 53), and at the retro-pectoral space was depicted in (8.6%,n = 5).

Complicated arterial compression was detected in (1.7%,n = 1), whereas venous complications were seen in (6.8%,n = 4).

Conclusion

Dynamic duplex ultrasound offered a simple, noninvasive, and quick technique that can help in the evaluation of the vascular thoracic outlet syndrome without exposure to ionizing radiation or contrast media administration like that in CT; nevertheless, it is done with the patient in the upright position, thus avoiding the high false-negative results associated with the supine position that is used in the CT and MRI studies.

Vascular magnetic resonance angiography techniques

Magnetic resonance angiography (MRA) denotes a unique option for the evaluation of peripheral vasculature due to its noninvasive nature, lack of ionizing radiation exposure, potential for non-contrast examination, and ability for generating volumetric representations that showcase vascular pathology. The constant evolution of the available MRA techniques, however, makes understanding and determining an optimal imaging protocol difficult. Here we present a brief overview of the major MRA sequence options, their major weaknesses and strengths, and related imaging considerations. Understanding the technical underpinnings of the various MRA methods helps with recognition of common imaging issues and artifacts and rendering clinically relevant interpretations.

Non-aortic vascular findings on chest CT angiogram: including arch vessels and bronchial arteries

CT angiogram (CTA) has become the modality of choice for imaging of thoracic vascular pathologies, involving the aorta and the pulmonary arteries. Apart from showing exquisite details of these large arteries, pathologies and anatomic variants of their branches can also be studied to a great extent. The major branches of aortic arch can be affected by a wide variety of pathologies ranging from atherosclerosis to trauma and vasculitis. Bronchial arteries in spite of supplying only 1% of lung parenchyma can become hypertrophied in various congenital and acquired conditions, becoming an important source of collateral circulation as well as a source for life threatening hemoptysis. CT also plays an important role in diagnosis of vascular compression at the thoracic outlet. With advances in CT technology, the acquisition, interpretation and clinical applications of CT angiography will continue to grow in the years to come.

A Case of Venous Thoracic Outlet Syndrome: Primary Care Review of Physical Exam Provocative Tests and Osteopathic Manipulative Technique Considerations

Thoracic outlet syndrome (TOS) is a condition that results from the compression of the neurovascular bundle of the upper extremities. It has generally been divided into neurogenic and vascular TOS with vascular further being divided into venous and arterial. This case report is of a healthy 24-year-old female who was misdiagnosed initially in an emergency department only to return two days later for reevaluation. Here, the patient's admission and workup are discussed after she presented to the family medicine clinic for a referral for further evaluation by a cardiothoracic surgeon. Physical exam provocative tests which are often overlooked are reviewed, and osteopathic manipulative techniques and principles are mentioned.

Thoracic Outlet Syndrome: A Comprehensive Review of Pathophysiology, Diagnosis, and Treatment

Thoracic outlet syndrome, a group of diverse disorders, is a collection of symptoms in the shoulder and upper extremity area that results in pain, numbness, and tingling. Identification of thoracic outlet syndrome is complex and a thorough clinical examination in addition to appropriate clinical testing can aide in diagnosis. Practitioners must consider the pathology of thoracic outlet syndrome in their differential diagnosis for shoulder and upper extremity pain symptoms so that patients are directed appropriately to timely therapeutic interventions. Patients with a definitive etiology who have failed conservative management are ideal candidates for surgical correction. This manuscript will discuss thoracic outlet syndrome, occurrence, physical presentation, clinical implications, diagnosis, and management.