Essentials of thoracic outlet syndrome: A narrative review

Arterial Thoracic Outlet Syndrome-A Case Study of a 23-Year-Old Female Patient Diagnosed Using a Thermal Imaging Camera

We present the case of a 23-year-old woman who reported weakness in the left upper limb, decreased warmth, numbness in the fingers, pain in the clavicular region, and a severe cold sensation in the limb. A thermal imaging camera examination was performed for diagnostic purposes, which guided further diagnostic and therapeutic management towards arterial thoracic outlet syndrome (aTOS). Following surgery and rehabilitation procedures, significant remission of symptoms was achieved and the patient's condition improved. This is the first report on the diagnosis of aTOS using thermal imaging, paving the way for further clinical research into this effective, rapid, and radiation-free method of diagnostic imaging. Conclusion: Thermal imaging is one of the most effective, readily available, and patient-safe methods for diagnosing vascular disease associated with flow disruption.

Current concepts in clinical features and diagnosis of thoracic outlet syndrome

The diagnosis and clinical features of thoracic outlet syndrome have long confounded clinicians, owing to heterogeneity in symptom presentation and many overlapping competing diagnoses that are "more common." Despite the advent and prevalence of high-resolution imaging, along with the increasing awareness of the syndrome itself, misdiagnoses and untimely diagnoses can result in significant patient morbidity. The authors aimed to summarize the current concepts in the clinical features and diagnosis of thoracic outlet syndrome.

Giant Interpectoral Lipoma Causing Venous Thoracic Outlet Syndrome: A Rare Case Presentation

Lipomas are the most prevalent type of benign soft tissue tumors, primarily composed of adipocytes, and typically remain asymptomatic unless they reach a significant size. Although giant lipomas are infrequent, their occurrence on the chest wall, particularly in the interpectoral region, is exceedingly rare. We present a unique case of a 48-year-old man with a massive interpectoral lipoma measuring 19.4 × 12.9 × 9.4 cm, which resulted in venous thoracic outlet syndrome by compressing the subclavian vein. This case highlights the clinical challenges in diagnosing deep-seated chest wall lipomas and underscores the necessity of considering thoracic outlet syndrome as a potential complication, even in the absence of direct neural or arterial compression. The presentation of thoracic outlet syndrome can vary, and a comprehensive evaluation is imperative for accurate diagnosis and management.

Case report on the diagnosis of vascular thoracic outlet syndrome followed by mechanical thrombectomy

INTRODUCTION AND IMPORTANCE

The thoracic outlet syndrome is characterized by compression of the brachial plexus or subclavian vessels due to anatomical alterations of the thoracic cavity. Vascular presentation is rare and includes thromboembolism and edema in the upper limb, and the diagnosis is often elusive due to its rarity. In this case, we describe a vascular thoracic outlet syndrome presentation whose diagnosis through angiography was achieved after a mechanical thrombectomy.

CASE PRESENTATION

We report a 43-year-old female patient with pain in the right upper limb, accompanied by edema and mild violet discoloration, without risk factors for hypercoagulability, with D-dimer levels within normal values. Mechanical thrombectomy with AngioJET was performed via an endovascular approach, with the extraction of multiple clots, confirming the presence of thoracic outlet syndrome as the underlying cause of the current condition.

CLINICAL DISCUSSION AND CONCLUSIONS

Venous thoracic outlet syndrome is a challenging entity to diagnose; however, it should be considered in cases of deep vein thrombosis of the subclavian vein and confirmed by angiography after a thrombectomy.

Diagnosis of thoracic outlet syndrome with the lower trunk compression of brachial plexus by high-frequency ultrasonography

BACKGROUND

Thoracic outlet syndrome (TOS) with the lower trunk compression of brachial plexus (BP) is difficult to diagnosis. This study aimed to summarize the features of thoracic outlet syndrome (TOS) with the lower trunk compression of brachial plexus observed on high-frequency ultrasonography (HFUS).

METHODS

The ultrasound data of 27 patients who had TOS with the lower trunk compression of brachial plexus were collected and eventually confirmed by surgery. The imaging data were compared, and the pathogenesis of TOS was analyzed on the basis of surgical data.

RESULTS

TOS occurred predominantly in females (70.4%). Most cases had unilateral involvement (92.6%), mainly on the right side (66.7%). The HFUS features of TOS can be summarized as follows: (1) Lower trunk compression. HFUS revealed focal thinning that reflected compression at the level of the lower trunk; furthermore, the distal part of the nerve was thickened for edema (Affected side: 0.49 ± 0.12 cm vs. Healthy side: 0.38 ± 0.06, P = 0.009), and the cross-sectional area of brachial plexus cords was markedly greater on the injured side than on the healthy side (0.95 ± 0.08 cm² vs. 0.65 ± 0.11 cm², P = 0.004). (2) Hyperechoic fibromuscular bands behind the compressed nerve (mostly the scalenus minimus muscle). (3) Abnormal bony structures: cervical ribs or elongated transverse processes of the 7th cervical vertebra (C7). Surgical results showed that the etiological factors contributing to TOS were (1) muscle hypertrophy and/or fibrosis (100%) and (2) cervical ribs/elongated C7 transverse processes (20.7%).

CONCLUSION

TOS with the lower trunk compression of brachial plexus can be diagnosed accurately and reliably by high-frequency ultrasound.

Underlying Subclavian Artery Occlusion Initially Misdiagnosed in Weightlifter Using Anabolic Steroids: A Case Report and Review of Literature

Subclavian artery occlusion (SAO) is a rare form of peripheral artery disease, sometimes associated with arterial thoracic outlet syndrome (ATOS). Subclavian arterial and venous occlusions are often misdiagnosed initially, and their clinical presentation can be confusing in bodybuilding athletes with increased vascularity in combination with anabolic steroid use. We present a 63-year-old male weightlifter with a history of hypertensive cardiomyopathy, renal transplant with left upper extremity arteriovenous fistula and subsequent takedown, cervical spinal stenosis, left rotator cuff surgery, and decades of testosterone injections who presented with years of left shoulder and neck pain. After having seen multiple providers and being diagnosed with various common disorders, CT angiography and conventional angiography were eventually performed and confirmed the presence of chronic SAO. The chronic occlusion was not deemed amenable to surgery or endovascular intervention and was treated medically with anticoagulation. Although anabolic steroid use is associated with arterial thrombosis, to our knowledge, this is the first reported case of SAO in a weightlifter. Initial misdiagnosis resulted in a long and costly workup. Although the patient's symptoms were consistent with occlusion (and his increased vascularity could potentially suggest chronic thrombosis of any kind), these key signs were masked given his weightlifting history, anabolic steroid use, and concurrent degenerative musculoskeletal conditions common to the weightlifting population. A thorough history, comprehensive physical examination, appropriate imaging studies, and a high index of suspicion for vascular occlusion in athletes who use steroids are critical for the timely diagnosis and treatment of SAO.

Elective brachial plexus decompression in neurogenic thoracic outlet syndrome

We aimed to evaluate functional outcome following elective brachial plexus decompression by compressive fibrous band resection and limited on-demand bone abnormality resection in patients with neurogenic thoracic outlet syndrome (N-TOS). A retrospective continuous observational study was conducted in 17 patients (15 women and 2 men), with a mean age of 42 years, operated on between 2013 and 2021. Twenty brachial plexus decompressions were performed, for 13 objective and 7 subjective N-TOSs, including 3 recurrent N-TOSs. At last follow-up, outcomes were evaluated in terms of residual pain, paresthesia and hand motor deficit, plus patient-reported assessment and Quick-DASH functional scoring. No postoperative complications occurred. At a median follow-up of 12 months (range 6-48 months), complete pain relief and paresthesia resolution were found in 11/15 and 9/14 cases, respectively. All patients reported that their symptoms had improved. In contrast, hand muscle atrophy persisted in all cases (n = 11). Sensorimotor recovery seemed to be poorer and mean Quick-DASH score better in objective than subjective N-TOS patients. Elective brachial plexus decompression seemed to be a safe procedure, providing constant improvement in subjective symptoms related to lower trunk irritation. However, nerve release did not provide hand muscle recovery in patients with objective N-TOS. LEVEL OF EVIDENCE: IV.