Two cases are presented; 1st is about throacic outlet syndrome due to cervical rib. 2nd case is fungal sinusitis.

1. CASE PRESENTATION
BY
Dr. M Kaleem
MD Resident, Radiology LGH

2. A 40 years old male presented with History of pain, claudication,
numbness and Change in color of right upper limb for 2 weeks.
No history of paresthesia/ weakness of hand or forearm.
O/E, Right hand looks cold, swollen and
Area of gangrene seen on radial aspect of hand. Distal radial
pulse was not palpable.
CTA right upper limb advised.
Case # 1

3. CT FINDINGS
• Right subclavian artery showing string like narrowing
involving a segment measuring 2 cm in length in
costoclavicular space between the cervical rib and
clavicle. Right axillary and proximal brachial arteries
show normal contrast opacification. Distal brachial artery
shows partial thrombus & is accompanied by collaterals.
Radial artery remains unopacified in distal forearm and
hand. Rest of the length of radial artery and ulnar artery
show fair contrast opacification.

4. Diagnosis:
Right sided arterial thoracic outlet syndrome with
subclavian artery compression and distal embolic
phenomena

5. • The thoracic outlet extends from the cervical spine and superior
border of the mediastinum to the lateral border of the pectoralis minor
muscle. The brachial plexus, subclavian vein, and subclavian artery
traverse the thoracic outlet, and when compressed, can result in upper
extremity symptoms. Patients with symptoms from compression of
the neurovascular bundle in the thoracic outlet are described as
having thoracic outlet syndrome....
• which is best thought of as three conditions classified according to which
structures are involved:
1: Neurogenic TOS (from compression of the brachial plexus nerves),
2: venous TOS (from compression of the subclavian vein).
3: Arterial TOS (from compression of the subclavian artery)

6. • There are three common sites of
compression:
• 1: Scalene triangle: between scalenus
anterior and scalenus medius muscles
• 2: Costoclavicular space: between the clavicle and 1st rib
• 3: Retropectoralis minor space: between pectoralis
minor and coracoid process
• The scalene triangle is defined by the first rib and the
anterior and middle scalene muscles and is the most
medial compartment. The subclavian artery and branches
of the brachial plexus pass through the borders of this

18. Arterial TOS
consists of two components: damage to the
subclavian artery at the level of the first rib and distal
embolic phenomena. Arterial TOS is almost
always associated with underlying bone
abnormalities, either a cervical rib, anomalous first
rib,
or first rib or clavicle fracture

22. Case # 2

23. • A 25 years old male patient presented with complaint of
fever off & on, nasal obstruction & left eye proptosis since
3 months.
• No history of DM, HTN & smoking.
• His CT PNS was done.

26. • Findings
Heterogenous expansile soft tissue density lesion in left
maxillary, ethmoidal,frontal, sphenoid sinuses and left nasal
cavity with internal hyperdensity. There is ballooning, thinning
and erosion of left lamina papyracea and left cribriform plate
with possible extension into the left orbit.
Diagnosis:
Chronic invasive Fungal Sinusitis

27. Fungal sinusitis is a sinus infection that results from a
fungus.
TYPES
1- Non-invasive: hyphae do not invade the mucosa
e.g: I: Allergic fungal sinusitis II: Sinus fungal mycetoma
2- invasive: hyphae are seen invading mucosa +/- beyond
I: Acute invasive fungal sinusitis
II: Chronic invasive fungal sinusitis
III: Granulomatous invasive fungal sinusitis
Fungal sinusitis

28. Pathology
Infection is believed to originate in the nasal cavity (most often the middle
turbinate) with subsequent spread to the paranasal sinuses.
The infection can spread rapidly from the sinuses via vascular invasion
and bony erosion, potentially leading to an extension to the orbit, brain,
cavernous sinus or carotid arteries.

29. • Complications
• intraorbital extension
• intracranial extension
– leptomeningeal enhancement
– intracranial granulomas
– epidural abscess and empyema
• vascular invasion
– cavernous or dural venous sinus thrombosis
– mycotic aneurysm formation
– cerebral infarction or hemorrhage
– systemic dissemination