Computed tomography in terms of thoracic outlet syndrome diagnosis

Thoracic outlet syndrome (TOS) comprises a group of clinical syndromes caused by congenital or acquired compression of the brachial plexus or subclavian vessels during their passage through the superior thoracic aperture.
Clinical manifestations vary by TOS type: neurogenic form (arm pain/paresthesia, hand muscle weakness, thenar atrophy), venous form (limb edema/cyanosis, visible collaterals, subclavian vein thrombosis), arterial form (arm ischemia, distal emboli, subclavian artery aneurysms).
The modern diagnostic algorithm includes physical examination (Edson test, Wright test, hyperabduction test) and instrumental diagnostic methods. These include radiography to detect bone abnormalities, ultrasound with Doppler to assess blood flow, MRI to assess soft tissue structures, and CT angiography, which is the "gold standard" for diagnosing vascular forms of TOS.
In the presented case, dynamic CT angiography revealed a rare instance of bilateral TOS in a patient with a long-standing history of shoulder girdle pain, caused by clavicular hyperostosis, dynamic subclavian vein compression, chronic thrombosis signs.
TOS requires comprehensive diagnostics with advanced imaging. Dynamic CT angiography is the preferred confirmatory method. Early diagnosis prevents severe complications (thrombosis, ischemia). Personalized 3D modeling enhances treatment outcomes and surgical planning. Thus, an integrated diagnostic approach helps to prevent the progression of the disease and helps in planning surgical treatment.

1. Li N, Dierks G, Vervaeke HE, Jumonville A, Kaye AD, Myrcik D, et al. Thoracic Outlet Syndrome: A Narrative Review. J Clin Med. 2021 Mar 1;10(5):962. https://doi.org/10.3390/jcm10050962

2. Khalilzadeh O, Glover M, Torriani M, Gupta R. Imaging Assessment of Thoracic Outlet Syndrome. Thorac Surg Clin. 2021 Feb;31(1):19- 25. https://doi.org/10.1016/j.thorsurg.2020.09.002

3. Panther EJ, Reintgen CD, Cueto RJ, Hao KA, Chim H, King JJ. Thoracic outlet syndrome: a review. J Shoulder Elbow Surg. 2022 Nov;31(11):e545-e561. https://doi.org/10.1016/j.jse.2022.06.026

4. Wilbourn AJ. 10 most commonly asked questions about thoracic outlet syndrome. Neurologist. 2001 Sep;7(5):309-12. https://doi.org/10.1097/00127893-200109000-00008

5. Altuwaijri TA. Comparison of duplex ultrasound and hemodynamic assessment with computed tomography angiography in patients with arterial thoracic outlet syndrome. Medicine (Baltimore). 2022 Sep 9;101(36):e30360. https://doi.org/10.1097/md.0000000000030360

6. Rizzo S, Talei Franzesi C, Cara A, Cassina EM, Libretti L, Pirondini E, et al. Diagnostic and Therapeutic Approach to Thoracic Outlet Syndrome. Tomography. 2024 Sep 1;10(9):1365-1378. https://doi.org/10.3390/tomography10090103

7. Kushwaha A, Nayak U, Buggaveeti R, Budharapu A, Vaidyanathan A, Munnangi A. Trans-Cervical Approach To The Thoracic Outlet Syndrome. Indian J Otolaryngol Head Neck Surg. 2024 Aug;76(4):3532-3536. https://doi.org/10.1007/s12070-024-04597-9

8. Cavanna AC, Giovanis A, Daley A, Feminella R, Chipman R, Onyeukwu V. Thoracic outlet syndrome: a review for the primary care provider. J Osteopath Med. 2022 Aug 29;122(11):587-599. https://doi.org/10.1515/jom-2021-0276

9. Expert Panels on Vascular Imaging, Thoracic Imaging, and Neurological Imaging; Zurkiya O, Ganguli S, Kalva SP, Chung JH, Shah LM, Majdalany BS, et al. ACR Appropriateness Criteria® Thoracic Outlet Syndrome. J Am Coll Radiol. 2020 May;17(5S):S323–S334. https://doi.org/10.1016/j.jacr.2020.01.029

10. Stegemann E, Larbig J, Stegemann B, Portig I, Prescher H, Bürger T. Validity of Ultrasound for the Diagnosis of Arterial Thoracic Outlet Syndrome. EJVES Vasc Forum. 2024 Feb 14;61:92-98. https://doi.org/10.1016/j.ejvsvf.2024.02.003