Case report
Thromboembolic stroke associated with thoracic outlet syndrome

https://doi.org/10.1016/j.jocn.2013.07.030Get rights and content

Abstract

Thoracic outlet syndrome occurs due to compression of the neurovascular structures as they exit the thorax. Subclavian arterial compression is usually due to a cervical rib, and is rarely associated with thromboembolic stroke. The mechanism of cerebral embolisation associated with the thoracic outlet syndrome is poorly understood, but may be due to retrograde propagation of thrombus or transient retrograde flow within the subclavian artery exacerbated by arm abduction. We report an illustrative patient and review the clinical features, imaging findings and management of stroke associated with thoracic outlet syndrome.

Introduction

Thoracic outlet syndrome (TOS) occurs due to compression of the neurovascular structures as they exit the thorax between the scalene muscles, the clavicle and the first rib, and can present with neurological, arterial or venous occlusive symptoms [1], [2]. Subclavian arterial compression is commonly attributed to a cervical rib. This abnormality is present in around 1% of the population, is bilateral in 50% of patients, and is twice as common in women [1].

Subclavian arterial compression leads to claudication, weak pulse and reduced blood pressure in the affected arm, all of which become more pronounced with arm abduction [1], [2]. A subclavian bruit or a pulsatile supraclavicular mass may be present if there is a stenosis and associated post-stenotic aneurysm. If thrombus forms within the aneurysm, this may embolise to the axillary or brachial arteries leading to acute arterial occlusion. Thromboembolic stroke associated with TOS is a rare event first described by Symonds in 1927 [3], although a patient with obliterative arteritis described by Gould in 1884 and updated in 1887 may also represent the association [4], [5]. We report a case of right middle cerebral artery (MCA) territory ischaemic stroke in a teenager with a concurrent diagnosis of cervical rib and subclavian arterial compression.

Section snippets

Illustrative patient

A 16-year-old girl presented with left hemiparesis. Past history included several months of intermittent digital cyanosis, pain and numbness of the right hand only. She was otherwise healthy with no regular medications, had modest alcohol intake, smoked tobacco occasionally, and denied illicit drug use.

Ten days before admission, the patient had an episode of left-sided weakness, which lasted several hours but completely resolved. On the day of presentation the patient awoke with left-sided

Discussion

The mechanism by which TOS-associated cerebral embolisation occurs is poorly understood. Subclavian arterial compression leading to stasis, intimal trauma and thrombus formation is likely the initial event. Retrograde propagation of thrombus to the origin of the vertebral or common carotid arteries may occur next [3]. In some patients with TOS and associated stroke, thrombus extending into the innominate artery has been found on vascular imaging [6], [7], and during surgery [8]. An alternative

Conflicts of Interest/Disclosures

The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication.

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