EURORAD ESR

Case 10709

Thrombosed persistent median artery - A rare cause of carpal tunnel syndrome

Author(s)
B Ashiq Zindha, K S Sekhar, M Parveen Sulthana, Dipti S Hingolikar

Department of Radiology and Imaging Sciences, Billroth Hospitals, Chennai, India; Email:dr_ashiqzindha@yahoo.co.in
 
Patient
male, 36 year(s)
 
 
  • Figure 1
    High frequency ultrasound of wrist (10 to 16 MHz)
     

    Axial ultrasound sections proximal to the carpal tunnel show the median nerve on each side and an abnormal well-defined rounded hypoechoic structure adjacent to the median nerve on the left side.

     
    Area of Interest: Musculoskeletal soft tissue; Neuroradiology peripheral nerve; Vascular; Imaging Technique: Ultrasound; Procedure: Diagnostic procedure; Special Focus: Congenital; Embolism / Thrombosis;

    Axial ultrasound section of left wrist at the level the carpal tunnel shows a well-defined rounded structure filled with echogenic contents within the carpal tunnel adjacent to the median nerve.

     
    Area of Interest: Musculoskeletal soft tissue; Neuroradiology peripheral nerve; Vascular; Imaging Technique: Ultrasound; Procedure: Diagnostic procedure; Special Focus: Congenital; Embolism / Thrombosis;

    Axial ultrasound section of the right wrist at the level of the carpal tunnel shows a normal-sized median nerve with no other abnormal structure adjacent to it.

     
    Area of Interest: Musculoskeletal soft tissue; Neuroradiology peripheral nerve; Vascular; Imaging Technique: Ultrasound; Procedure: Diagnostic procedure; Special Focus: Congenital; Embolism / Thrombosis;
     
     
  • Figure 2
    Colour Doppler and Spectral Doppler
     

    Sagittal ultrasound section of distal left forearm and wrist with colour Doppler shows a tubular hypoechoic structure which appears distended with echogenic contents distally. No definite colour flow is demonstrable...

     
    Area of Interest: Vascular; Imaging Technique: Ultrasound; Ultrasound-Colour Doppler; Procedure: Diagnostic procedure; Special Focus: Congenital; Embolism / Thrombosis;

    Axial ultrasound section with colour Doppler shows colour flow within a rounded hypoechoic structure at mid forearm level. This structure was traced distally into the wrist and the carpal tunnel.

     
    Area of Interest: Vascular; Imaging Technique: Ultrasound; Ultrasound-Colour Doppler; Procedure: Diagnostic procedure; Special Focus: Congenital;

    Spectral waveform obtained from the rounded hypoechoic structure in mid forearm with slow flow settings shows arterial flow pattern. The short systolic peaks and absent diastolic flow are likely due to distal thrombosis.

     
    Area of Interest: Vascular; Imaging Technique: Ultrasound; Ultrasound-Spectral Doppler; Procedure: Diagnostic procedure; Special Focus: Embolism / Thrombosis;
     
     
  • Figure 3
    T1Weighted MRI
     

    Axial T1W image at the level of proximal carpal tunnel shows a rounded structure with mild T1W hyperintense signal within the the tunnel, adjacent and superficial to the median nerve.

     
    Area of Interest: Musculoskeletal soft tissue; Neuroradiology peripheral nerve; Vascular; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Congenital; Embolism / Thrombosis;

    Axial T1W image at the level of distal carpal tunnel shows the rounded hyperintense structure within the tunnel, superficial to the median nerve. The median nerve appears normal in size and shows normal signal.

     
    Area of Interest: Musculoskeletal soft tissue; Neuroradiology peripheral nerve; Vascular; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Congenital; Embolism / Thrombosis;
     
     
  • Figure 4
    Proton Density Weighted fat saturated MRI
     

    Axial PD fat saturated image at the level of proximal carpal tunnel shows a rounded structure with peripheral hyperintense signal within the tunnel abutting median nerve.

     
    Area of Interest: Musculoskeletal soft tissue; Neuroradiology peripheral nerve; Vascular; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Congenital; Embolism / Thrombosis;

    Axial PD fat saturated image at level of distal carpal tunnel showing a rounded hyperintense structure within the tunnel. The margin of the normal-sized median nerve appears indented by this structure.

     
    Area of Interest: Musculoskeletal soft tissue; Neuroradiology peripheral nerve; Vascular; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Congenital; Embolism / Thrombosis;
     
     
  • Figure 5
    Post contrast T1 Weighted fat saturated MRI
     

    Axial post contrast MR image at the level of proximal carpal tunnel shows a rim enhancing rounded structure with a central filling defect within the tunnel adjacent to the median nerve.

     
    Area of Interest: Musculoskeletal soft tissue; Neuroradiology peripheral nerve; Vascular; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Congenital; Embolism / Thrombosis;

    Axial post contrast MR image at the level of distal carpal tunnel shows the rim enhancing structure with a small central filling defect within the tunnel abutting the median nerve.

     
    Area of Interest: Musculoskeletal soft tissue; Neuroradiology peripheral nerve; Vascular; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Congenital; Embolism / Thrombosis;
     
     
  • Figure 6
    Reformatted coronal MIP image of contrast enhanced MR angiography

    On MRA an additional artery is seen in the forearm between the radial and ulnar arteries. This artery appears cutoff and shows a non enhancing segment in the region of the carpal tunnel suggesting thrombosis.

     
    Area of Interest: Vascular; Imaging Technique: MR-Angiography; Procedure: Diagnostic procedure; Special Focus: Congenital; Embolism / Thrombosis;
     
     
Axial ultrasound sections proximal to the carpal tunnel show the median nerve on each side and an abnormal well-defined rounded hypoechoic structure adjacent to the median nerve on the left side.
 
Axial ultrasound section of left wrist at the level the carpal tunnel shows a well-defined rounded structure filled with echogenic contents within the carpal tunnel adjacent to the median nerve.
 
Axial ultrasound section of the right wrist at the level of the carpal tunnel shows a normal-sized median nerve with no other abnormal structure adjacent to it.
 
Sagittal ultrasound section of distal left forearm and wrist with colour Doppler shows a tubular hypoechoic structure which appears distended with echogenic contents distally. No definite colour flow is demonstrable within this structure.
 
Axial ultrasound section with colour Doppler shows colour flow within a rounded hypoechoic structure at mid forearm level. This structure was traced distally into the wrist and the carpal tunnel.
 
Spectral waveform obtained from the rounded hypoechoic structure in mid forearm with slow flow settings shows arterial flow pattern. The short systolic peaks and absent diastolic flow are likely due to distal thrombosis.
 
Axial T1W image at the level of proximal carpal tunnel shows a rounded structure with mild T1W hyperintense signal within the the tunnel, adjacent and superficial to the median nerve.
 
Axial T1W image at the level of distal carpal tunnel shows the rounded hyperintense structure within the tunnel, superficial to the median nerve. The median nerve appears normal in size and shows normal signal.
 
Axial PD fat saturated image at the level of proximal carpal tunnel shows a rounded structure with peripheral hyperintense signal within the tunnel abutting median nerve.
 
Axial PD fat saturated image at level of distal carpal tunnel showing a rounded hyperintense structure within the tunnel. The margin of the normal-sized median nerve appears indented by this structure.
 
Axial post contrast MR image at the level of proximal carpal tunnel shows a rim enhancing rounded structure with a central filling defect within the tunnel adjacent to the median nerve.
 
Axial post contrast MR image at the level of distal carpal tunnel shows the rim enhancing structure with a small central filling defect within the tunnel abutting the median nerve.
 
On MRA an additional artery is seen in the forearm between the radial and ulnar arteries. This artery appears cutoff and shows a non enhancing segment in the region of the carpal tunnel suggesting thrombosis.
 
 
 
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