Cervical rib, a rare cause of recurrent stroke in the young: case report.

BACKGROUND: Cervical rib usually causes neurological symptoms in the upper limb but stroke as an initial presentation is very uncommon. Recurrent supratentorial and infratentorial stroke in a single patient is very rare. Cervical rib can lead to anterograde or retrograde thromboembolic phenomenon leading to ischemic stroke. CASE REPORT: A 14-year-old girl presented with a history of sudden onset of loss of consciousness and left hemiparesis of 2 days duration. She had a similar episode 2 years ago, from which she had recovered to a large extent with minimal residual left hemiparesis. On examination, she was unconscious and localizing to pain on the right side. Radial pulse was absent on the right side. Magnetic resonance imaging of the brain revealed a right fronto-temporo-parietal old infarct with a new subacute infarct involving right cerebellar hemisphere and brainstem. X-ray of the chest showed a right-sided cervical rib. Computed tomographic angiography of the neck vessels revealed stenosis of subclavian artery at the site of the cervical rib with poststenosis dilatation. Patient was managed with anticoagulant and antiplatelet therapy initially and excision of the cervical rib was performed as a definitive procedure. She responded well to the treatment and at 6 months of follow-up, the strength on the left side had improved substantially. She was capable of doing her daily activities independently with little imbalance. CONCLUSIONS: The reported patient is the first in the literature who suffered recurrent supratentorial and infratentorial stroke as a complication of cervical rib. We stress the need for early diagnosis of this easily treatable cause of stroke in the young.

First rib resection using videothorascopy for the treatment of thoracic outlet syndrome.

OBJECTIVE: Thoracic outlet syndrome is a condition caused by compression of the subclavian artery, subclavian vein and/or the brachial plexus. Scalene muscle section and first rib removal is the most effective treatment. The objective of this article is to demonstrate first rib resection using videothoracoscopy. TECHNIQUE: We describe first rib removal by videothoracoscopy using three 12 mm entrance ports (although one is widened to 3 cm to introduce periosteotomy cutters and rib shears). We have performed this operation on three cases of thoracic outlet syndrome with very good results. CONCLUSIONS: Removal of the first rib by videothoracoscopy is a viable and very aesthetic technique with a low morbidity. It is a very good option for the majority of patients affected by this syndrome, particularly in obese patients or those with Pager-Schroetter syndrome.

Cervical rib with stroke as the initial presentation.

Cervical ribs rarely become symptomatic. Cerebral ischemia or infarct due to cervical rib is extremely rare and, invariably, these patients have a history of upper limb symptoms before presenting with stroke. We report a young boy with cervical rib who presented with stroke. A right sided cervical rib was noted during angiogram, causing mild stenosis and post stenotic dilatation of right subclavian artery distal to the rib. An abduction angiogram showed complete occlusion of the right subclavian artery and visualization of collaterals. Right carotid angiogram also showed evidence of thromboembolic episodes in the right middle cerebral artery territory.

[Falconer-Weddel's costoclavicular syndrome].

Analysed herein are the findings of examination and outcomes of surgical management of fifty-eight patients (25 men and 33 women) presenting with Falconer-Weddel's costoclavicular syndrome in which the subclavian artery and vein and the brachial plexus at the thoracic outlet appear to be compressed. Of the 58 patients,five subjects were found to have a rudimentary cervical rib and three more (5.3%) patients had trophic disorders on their digits fingers: dystrophy of the nail plates, their fragility, periodically opening trophic ulcers at the digital tips and one patient presented with gangrene of the inguinal phalanx of the middle finger. Three patients had hyperemia of the face. A further four patients had roughening, hyperkeratosis of the skin of the hands, cracks. The presence of the supernumerary ribs was determined roentgenologically. Haemodynamics was studied using Doppler ultrasonography making it possible to reveal disordered blood flow in the upper-limb arteries in the physiological position assumed, in the Adson test as well as with Raynaud syndrome, which was observed in 39 patients. The function of the nerves was studied using electroneuromyography (ENMG). All patients were operated on under endotracheal anaesthesia. Decompression-medical operations were carried outperformed in all 58 patients, with the following four types of interventions being performed: transaxillary resection of the first rib combined with sympathectomy carried out in 23 patients, resection of the first rib without sympathectomy in eighteen patients, resection of the first rib via a surpraclavicular approach in four patients, scalenotomy and selective cervicothoracic sympathectomy in 13 patients.

Cervical rib causing thrombosis of subclavian artery.

We describe here an unusual case of thrombosis of left subclavian artery in a patient with cervical rib. The patient presented with features of ischaemia of left upper limb. X-ray chest revealed bilateral cervical ribs, longer on the left side. Color Doppler studies showed echogenic thrombus within the left subclavian artery. Angiography revealed complete occlusion of left subclavian artery. Embolectomy was done. She was planned for excision of rib.

Dolor y cambios autonómicos en los brazos en una deportista / No disponible

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[Unusual reason for unilateral (corrected) Raynaud's phenomenon with intensification when the arms are elevated]. / Einseitiges Raynaud-Phänomen mit Verstärkung bei Elevation des Arms.

Thoracic outlet syndrome (TOS) is a broad term for compression of the neurovascular structures in the area of the 1. rib and the clavicle. The cause can be either fibrous bands, cervical ribs, anomalous muscles or posttraumatic changes as well as tumors. Symptoms depend on the affected structure, in most cases (up to 97% of TOS patients) neurologic symptoms are present. In case of an arterial compression, for example due to a cervical rib like in our case, embolism of the arm and finger arteries can occur. For mild or moderate symptoms a conservative approach with physiotherapy can be helpful. For severe cases surgical resection of the compressing structure and the first rib is necessary. In our case, the cervical and first rib were excised after an initial lysis therapy. Furthermore, the aneurysm of the subclavian artery was excised.

The prevalence of cervical ribs in a London population.

Cervical ribs are an important cause of neurovascular compression at the thoracic outlet. Previous studies have shown the prevalence of cervical ribs to be between 0.05 and 3%, depending on the sex and race of the population studied. We examined 1,352 chest radiographs to determine the prevalence of cervical ribs in a London population of mixed sex and ethnicity. Our study found that the overall prevalence of cervical ribs was 0.74% with a higher rate in females compared with males (1.09 and 0.42%, respectively). Of the 10 individuals with a cervical rib, five were on the left, three were on the right and two were bilateral. The presence of elongated C7 transverse processes (transverse apophysomegaly) was also noted. We found a total of 30 elongated transverse processes with an overall prevalence of 2.21%. They were also more common in females (3.43%) than males (1.13%).

Pediatric thoracic outlet syndrome: a disorder with serious vascular complications.

BACKGROUND: Thoracic outlet syndrome (TOS), caused by compression of the neurovascular structures between the clavicle and scalene muscles, typically presents with neurologic symptoms in adults. We reviewed our experience with 25 adolescents and propose a diagnostic/treatment algorithm for pediatric TOS. METHODS: From 1993 to 2005, 25 patients were treated with TOS. A retrospective chart review was performed with institutional review board approval. Demographics, clinical presentation, diagnostic studies, and treatment were evaluated. RESULTS: Seven male (28%) and 18 female (72%) patients presented between the ages of 12 to 18 years. Thirteen (52%) had vascular TOS (11 venous, 2 arterial), 11 (44%) had neurologic TOS, and 1 had both. Vascular TOS included subclavian vein thrombosis (7), venous impingement (4), and arterial impingement (2). Three patients had hypercoagulable disorders, and 6 had effort thrombosis. Venography was diagnostic in 10 cases. Neurogenic TOS was diagnosed by clinical symptoms. Five patients with subclavian vein thrombosis underwent thrombolysis, with 3 maintaining long-term patency. Of 25 patients, 24 underwent transaxillary first rib resection. CONCLUSION: Vascular complications are more common in adolescents with TOS than in adults. A diagnostic/treatment algorithm includes urgent venography and thrombolysis for venous TOS and a workup for hypercoagulability. Neurogenic TOS is diagnosed clinically, whereas other studies are rarely beneficial.

Histopathological basis for neurogenic thoracic outlet syndrome. Laboratory investigation.

OBJECT: To the best of the authors' knowledge, no report exists that has demonstrated the histopathological changes of neural elements within the brachial plexus as a result of cervical rib compression. METHODS: Four hundred seventy-five consecutive human cadavers were evaluated for the presence of cervical ribs. From this cohort, 2 male specimens (0.42%) were identified that harbored cervical ribs. One of the cadavers was found to have bilateral cervical ribs and the other a single right cervical rib. Following gross observations of the brachial plexus and, specifically, the lower trunk and its relationship to these anomalous ribs, the lower trunks were submitted for immunohistochemical analysis. Specimens were compared with two age-matched controls that did not have cervical ribs. RESULTS: The compressed plexus trunks were largely unremarkable proximal to the areas of compression by cervical ribs, where they demonstrated epi- and perineurial fibrosis, vascular hyalinization, mucinous degeneration, and frequent intraneural collagenous nodules. These histological findings were not seen in the nerve specimens in control cadavers. The epineurium was thickened with intersecting fibrous bands, and the perineurium appeared fibrotic. Many of the blood vessels were hyalinized. The nerve fascicles contained frequent intraneural collagenous nodules in this area, and focal mucinous degeneration was identified. CONCLUSIONS: Cervical ribs found incidentally may cause histological changes in the lower trunk of the brachial plexus. The clinician may wish to observe or perform further evaluation in such patients.

Thoracic outlet syndrome with right subclavian artery dilatation in a child - transaxillary resection of the pediatric cervical rib.

Cervical rib is a well-documented congenital anomaly, and thoracic outlet syndrome (TOS) with vascular compression is extremely rare in childhood. The subclavian artery, subclavian vein, brachial plexus, or a combination of these can be affected in this syndrome. We present a case of TOS in an eight-year-old boy and describe the rare finding of subclavian artery compression with post-stenotic dilatation and severe brachial plexus compression symptoms. The patient underwent right transaxillary resection of the first thoracic and cervical rib. The presentation is unique and may be elusive.