Ultrasonographic assessment of arterial cross-sectional area in the thoracic outlet on postural maneuvers measured with power Doppler ultrasonography in both asymptomatic and symptomatic populations
The purpose of this study was to evaluate the feasibility and potential usefulness of power Doppler ultrasonography (PDU) in the assessment of changes in arterial cross-sectional area in the thoracic outlet during upper limb elevation.
Forty-four volunteers and 28 patients with a clinical diagnosis of arterial thoracic outlet syndrome were evaluated by B-mode imaging and PDU. Arterial cross-sectional area was assessed in the 3 compartments of the thoracic outlet with the arm alongside the body and at 90 degrees, 130 degrees, and 170 degrees of abduction. The percentage of arterial stenosis was calculated for each of these arm positions. Nineteen of the 28 patients were also assessed by magnetic resonance (MR) imaging.
No significant arterial stenosis was shown in the interscalene triangle and in the retropectoralis minor space of the volunteers and patients. A significant difference (P < .01) in stenosis between volunteers and patients was seen for all degrees of abduction in the costoclavicular space. The 130 degrees hyperabduction maneuver appeared to be the most discriminating postural maneuver. Seven patients assessed with MR imaging did not have any arterial stenosis on MR images, whereas an appreciable degree of arterial stenosis was shown with ultrasonography.
Arterial compression inside the thoracic outlet can be detected and quantified with B-mode imaging in association with PDU.
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- "The caliber of the subclavian artery can also be studied by subclavicular oblique horizontal slices with various degrees of abduction of the shoulder . "
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ABSTRACT: Ultrasound examination of the brachial plexus, although at first sight difficult, is perfectly feasible with fairly rapid practical and theoretical training. The roots are accurately identified due to the shape (a single tubercle) of the transverse process of C7 in the paravertebral space, and the superficial position of C5 in the interscalene groove. The téléphérique technique allows the roots, trunks and cords to be followed easily into the supraclavicular fossa. In just a few years, ultrasound imaging of the plexus has become a routine anesthesia examination for guiding nerve blocks. In trained hands, it also provides information in thoracic outlet syndromes, traumatic conditions (particularly for postganglionic lesions) and tumoral diseases. Even if MRI remains the standard examination in these indications, ultrasound, with its higher definition and dynamic character, is an excellent additional method which is still under-exploited.
Available from: Lee Herrington
- "The proposed mechanisms for compressive trauma of the second and third portions of the axillary artery are a tight or hypertrophied pectoralis minor muscle (Dijkstra & Westra, 1978; Finkelstein & Johnston, 1993) and anterior translation of the humeral head (Dijkstra & Westra, 1978; Durham, Yao, Pearce, Nuber, & McCarthy, 1995; Vlychou et al., 2001) combined with repetitive overhead activity. The hyperaduction manoeuvre (Wright, 1945) is used in conjunction with the clinical presentation and subjective history to aid the diagnosis of compressive injury of the axillary artery (Demondion et al., 2006). It is thought to compressively stress the vessels in the subcoracoid region, especially the second portion of the axillary artery under the pectoralis minor muscle (Baker & Liu, 1993). "
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ABSTRACT: The aim of this study was to determine changes in axillary artery diameter and peak systolic velocity in asymptomatic individuals during upper limb positioning commonly used to assess vascular pathology in athletes.
Repeated measures observational study.
Subjective and objective screening excluded individuals with past, or present, conditions related to neurovascular compression syndromes. Thirty-one subjects (21 females, 10 males; mean age: 25+/-4 years) were included in the final analysis.
Sonographically determined axillary artery diameter and peak systolic velocity, as well as symptom production, were recorded for a series of 12 randomised arm positions, incorporating varying degrees of abduction, external rotation, and horizontal flexion/extension.
The majority of arm positions revealed no change in artery diameter and peak systolic velocity. However, at the extreme of abduction, and arm positions incorporating 120 degrees abduction, significant (p<0.0005) reductions in axillary artery diameter were noted. All mean results masked wide heterogeneity: 13% demonstrating a greater than 50% reduction in diameter, 10%, a doubling of peak systolic velocity, and 42%, reporting symptoms.
The number of individual clinically "positive" responses questions the specificity of individual diagnostic tests, such as the hyperabduction manoeuvre, and highlights the need to interpret test results in conjunction with the subjective assessment and other physical findings from the objective assessment.
Available from: Serge Van Sint Jan
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ABSTRACT: The thoracic outlet includes three compartments (the interscalene triangle, costoclavicular space, and retropectoralis minor space), which extend from the cervical spine and mediastinum to the lower border of the pectoralis minor muscle. Dynamically induced compression of the neural, arterial, or venous structures crossing these compartments leads to thoracic outlet syndrome (TOS). The diagnosis is based on the results of clinical evaluation, particularly if symptoms can be reproduced when various dynamic maneuvers, including elevation of the arm, are undertaken. However, clinical diagnosis is often difficult; thus, the use of imaging is required to demonstrate neurovascular compression and to determine the nature and location of the structure undergoing compression and the structure producing the compression. Cervical plain radiography should be performed first to assess for bone abnormalities and to narrow the differential diagnosis. Computed tomographic (CT) angiography or magnetic resonance (MR) imaging performed in association with postural maneuvers is helpful in analyzing the dynamically induced compression. B-mode and color duplex ultrasonography (US) are good supplementary tools for assessment of vessel compression in association with postural maneuvers, especially in cases with positive clinical features of TOS but negative features of TOS at CT and MR imaging. US may also allow analysis of the brachial plexus. However, MR imaging remains the method of choice when searching for neurologic compression.
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