Multi-picture knowledge | This disease easily confused with cervical spondylosis is related to posterior cerebral artery stroke

Numbness, pain or paresthesias in the upper limbs are very common symptoms of neurological diseases.
Generally, it is easy to diagnose cervical spondylosis and carpal tunnel syndrome.
Patients are often given a few boxes of painkillers or are advised to go for physical therapy
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If it is only a past medical history of the above symptoms, it is more likely to be ignored
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A case report in BMC Neurology of a posterior cerebral artery stroke associated with thoracic outlet syndrome (TOS) suggests that extra caution should be exercised with any of the common symptoms, regardless of whether the patient is elderly or young Everyone should "get to the bottom of their medical history", and sometimes one more question "opens up a new world"
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Author: Hu Tianye, attending physician (Jiaxing First Hospital) This article is published by the author with the authorization of Yimaitong, please do not reprint without authorization
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Review of medical history This is a young male patient.
The past medical history and examination results are as follows: 1.
Right-sided TOS and Raynaud's disease
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2.
CTA of the superior aortic artery showed mild stenosis of the right subclavian artery with compression, with typical post-stenosis dilatation and no thrombus
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3.
Ultrasound of the superior aortic artery showed a focal occlusion at the termination of the right brachial artery
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4.
Cervical rib was not found on cervical spine and chest X-ray, but cervical rib was found on cervical spine CT
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The patient was scheduled for surgery because of right brachial artery occlusion and post-stenotic dilation of the right subclavian artery
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Unfortunately, 1 month before surgery, the patient developed transient memory loss and paresthesias in the left lower extremity
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Although the symptoms only lasted for 30 minutes, the younger brother was immediately taken to the emergency room and underwent a bunch of examinations
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Neurological disorders are the first to be considered based on the symptoms a patient presents
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However, like all interesting cases, this case was "out of line" and the physical examination of the nervous system was unremarkable
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The main positive results found in the follow-up examination are: 1.
The pulse pressure of the upper extremities on both sides is different, the right side is 101/67mmHg, and the left side is 127/78mmHg (does this matter?)
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2.
Brain MRI showed acute right posterior cerebral artery infarction, CTA showed a 24.
1mm thrombus within the stenotic aneurysm sac (thrombus here)
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3.
Ultrasound of the superior aortic artery confirmed the presence of post-stenotic dilatation and showed a small mobile thrombus on the distal aneurysm wall, 5 cm from the ostium of the right vertebral artery
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The finding of positive result 2 explained the patient's "transient memory loss and left lower extremity paresthesias", and the thrombus disappeared after heparin treatment, and the operation continued as usual
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But the "mystery" remains unsolved, why do these symptoms occur? The patient is a young male with no history of cardiovascular and cerebrovascular diseases, and no history of alcoholism.
The symptoms appeared suddenly, and were quickly relieved after treatment
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 At this time, you should pay attention to the positive result 1
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The obvious pulse pressure difference between the upper extremities on both sides, even greater than 20 mmHg, is the characteristic performance of vascular TOS
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At the same time, the patient had cervical ribs
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And positive result 3 can be used to explain the link between 1 and 2
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 Next, let's get to know the "protagonist"
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In line with the basic attitude of "knowing people and faces, we must know the heart", we must not only understand his performance (symptoms), but also be familiar with his heart (anatomy, etiology), and only through some knowledge skills (examination) can we truly understand him ( diagnosis)
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In fact, learning about a disease is really the same as developing a relationship
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 The anatomical basis of TOS Everyone's constitution is different, and the diseases that are easy to get are also different.
The constitution is the "foundation"
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Likewise, TOS occurs because of a specific anatomical basis
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TOS is a cluster of symptoms due to compression of the neurovascular bundle at the thoracic outlet
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It is precisely because of the existence of a special anatomical basis and the influence of external factors that the symptoms appear
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The thoracic outlet is composed of bony structures (spine, first rib, clavicle), scalene triangle, rib-clavicular space, and subcoracoid space.
The specific scope and which nerve vessels are involved are shown in Figure 1
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Fig.
1 The composition of the thoracic cageFig.
2 The anatomical basis of TOS Etiology and classification of TOS Does the same constitution necessarily lead to the same disease? Of course not
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The influence of "causation" is very crucial.
Just like the old aunts who are also dancing square dances, some people get dizzy when they turn in circles too much, some twist their hips inappropriately, and some get a cold due to sweating.
The same dance, into different subjects"
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The difference in etiology is directly related to the difference in classification
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The most common cause of TOS is hemorrhage, hematoma, and fracture displacement caused by high-speed motor vehicle accidents, which may compress the neurovascular system (the racing party should be careful)
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The second is repetitive exercise.
Injuries caused by excessive exercise can also cause swelling, small bleeding, fibrosis, and lead to muscle hypertrophy, causing compression (home women, assembly line workers, athletes, please pay attention)
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Tumor is also one of the causes of TOS.
The common malignant tumor is the upper lung tumor, which can invade and compress the thoracic plexus (non-oncology colleagues, especially those in acupuncture and moxibustion, please attach great importance to exclude this situation, and the efficacy is not good and is questioned.
If the matter is small, it is possible to say "goodbye" to "books" if the illness is delayed); benign tumors can also cause TOS, such as large osteochondromas
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Since it was mentioned that the occurrence of TOS is based on anatomical structure, anatomical factors are naturally a cause that cannot be ignored.
The most common one is the existence of cervical ribs (what is cervical ribs, see Figure 3), about It accounts for 1%-2% of the general population and is a high risk factor for TOS; neck sprains are prone to lead to TOS and are also related to the existence of cervical ribs; congenital muscle tissue variation is also related to the occurrence of TOS
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Figure 3 Cervical rib TOS can be divided into thoracic neurogenic TOS (nTOS) according to the etiology, mainly manifested as functional compression of the brachial plexus, upper limb pain, numbness, paresthesia, hand-lifting or shoulder movement aggravated symptoms, nighttime Symptoms may also occur
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Venous TOS (vTOS), mainly manifested as subclavian vein obstruction, forearm fatigue, upper extremity paresthesia, edema, cyanosis, upper extremity edema is due to venous compression or obvious deep vein thrombosis, which is a sign of vTOS
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Arterial TOS (aTOS) is mostly spontaneous, almost always accompanied by the presence of cervical or abnormal ribs, upper extremity pain, paresthesia, pale skin, and decreased blood pressure and distal pulse in the affected extremity
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 TOS physical examination requires skills to recognize people, and methods to recognize diseases
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For TOS, the most intuitive and important examination method is the physical examination, including the evaluation of the cervical spine, shoulders and upper limbs
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Skin color, temperature, hair distribution, thinness and frailty, bilateral contrast
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 Some characteristic signs suggest different types of TOS: blood pressure in the upper extremities can differ by more than 20 mmHg in vascular TOS; edema of the shoulders and chest may occur in patients with vTOS; pallor or cyanosis may appear in the upper limbs in patients with aTOS; The characteristic Gilliatt–Sumner hand is due to atrophy of the abductor pollicis brevis and, to a lesser extent, the hypothenar musculature and the interosseous muscles
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Figure 4 The diagnosis of Gilliatt–Sumner handTOS has finally reached the final step to truly understand "him" (you can hold hands soon, aren't you looking forward to it?)
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The diagnosis of TOS mainly relies on provocative tests, imaging and ultrasonography
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Figure 5.
The commonly used diagnostic tool for evaluating TOS The commonly used provocative test for TOS: Wright test: the test is divided into two steps, the patient sits in a comfortable position, the head is forward, the arms are passively abducted, the external rotation is 90°, the head is not tilted, and the elbow is flexed Not exceeding 45° for 1 minute, then the examiner monitors the patient's onset of symptoms and the quality of the radial artery, repeating the test with excessive limb abduction
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Figure 6 Wright testAdson test: Extend the arm, turn the head to the affected side, take a deep breath; the test is considered positive if the radial artery disappears or weakens and/or the patient's symptoms worsen
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Figure 7 Adson testRoos test (also known as EAST test elevated arm stress test): The patient places the arms in a 90° abduction position, flexes the elbows to 90°, and then opens and closes the hands for 3 minutes
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Normal people may have mild muscle fatigue discomfort, but people with TOS have more severe symptoms, repeated discomfort so that the test may not be completed, the examiner observes the limb during this period for sagging, which may indicate fatigue or arterial damage, check The person should also observe the color of the distal limb, compare left and right, and monitor the appearance of symptoms
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Figure 8 Roos test ding! Hand in hand with success! After that, should I think about how to "get him to obey"? There is nothing special about the method of "subduing" TOS, other than limiting repetitive movements and excessive stress to the cause, mastering relaxation techniques, physical therapy and medication, including analgesics (NSAIDs and/or Opioids), muscle relaxants, anticonvulsants and/or antidepressants, local anesthetics, steroids or botulinum toxin type A are injected into the anterior scalene and/or pectoral muscles
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When the above treatments are ineffective, surgery can be used
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In other words, soft is not hard
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 To summarize the current mechanisms regarding the link between TOS and posterior cerebral artery stroke include retrograde thrombus propagation to the vertebral or common carotid arteries, and transient retrograde flow and embolism from a stenotic subclavian aneurysm to the vertebral artery
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Learning a disease is like getting to know a certain fate, remember to follow the good guidance and step by step to "win"
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Although aTOS is uncommon, it can have disastrous effects
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By "picking it out" early, serious and irreversible situations can be avoided
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References: 1.
Adam Celier1, Simon Chabay, Aurélien Maurizot, et al.
Posterior cerebral artery stroke by reverse flow embolism in thoracic outlet syndrome - a case report.
BMC Neurol.
2020 ;4;20(1):229.
2.
LA Watson , T.
Pizzarib, S.
Balstera.
Thoracic outlet syndrome part 1: Clinical manifestations, differentiation and treatment pathways.
Man Ther.
2009 ;14(6):586-95.
3.
Melissa Mackel.
Thoracic Outlet Syndrome.
Curr Sports Med Rep.
2016 ;15(2):71-2.
4.
Mark R.
Jones, Amit Prabhakar, Omar Viswanath, et al.
Thoracic Outlet Syndrome: A Comprehensive Review of Pathophysiology, Diagnosis, and Treatment.
Pain Ther.
2019;8(1):5 -18.