Cardiovascular Radiology

Case 5:
A 24-year-old female presents with pain along the left arm and wasting of muscles of the hand. Following an x-ray, an MRI is performed. Scans shown here are T1 and T2 weighted axial images of relevant area. 
What is the diagnosis?

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Fig 1

Fig 2

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Imaging Findings reveal a cervical rib on the left side with evidence of brachial plexus compression. Thickening of the cords and trunk of the brachial plexus is noted on the left.

Diagnosis: Cervical Rib

Cervical rib found in course of routine investigations rarely gives rise to symptoms, while when they are looked for in a symptomatic patient, they are rarely found!

Epidemiology :
Occurs in about 0.5% people. It is slightly more common on the right side, and is commoner in females. It may be associated with other spinal anomalies.

Pathology :
4 pathological types seen :

Complete rib - articulates anteriorly with the manubrium or the 1st rib.
Incomplete rib - has broad end which expands into a knob like mass.

Incomplete rib with tapering end with fibrous band attached to the manubrium / 1st rib.
Complete fibrous band.

The fibrous band types give more pressure symptoms.

Vascular effects -
Higher arching of Subclavian artery, post - stenotic dilatation, slowing of blood flow (thrombosis), gangrene (Raynaud's phenomenon)

Neural effects -
include higher arching of T1 segment of the brachial plexus, pain & parasthesiae in ilnar area of arm, forearm and hand

Treatment :
If bony rib found - extra-periosteal resection
If fibrous band - excision and/ or division of scalenus antecus.
If no fibrous band or rib - division of scalenus, and/or excision of 1st rib.
Cervical sympathectomy may be done.

Dr. Ashok Raghavan, Manipal Hospital, Bangalore