|Year : 2020 | Volume
| Issue : 2 | Page : 197-200
Persistent thrombosed median artery – A rare cause for acute wrist pain: A case report and review of literature
B Nishan, Vishal Hudgi, K Siva Krishna, I Surya Kiran, Vishnu Motukuru
Department of Vascular and Endovascular Surgery, Jain Institute of Vascular Sciences, A Unit of Bhagwan Mahaveer Jain Hospital, Bengaluru, Karnataka, India
|Date of Submission||06-Nov-2019|
|Date of Acceptance||10-Dec-2019|
|Date of Web Publication||17-Jun-2020|
Dr. B Nishan
Department of Vascular and Endovascular Surgery, Jain Institute of Vascular Sciences, A Unit of Bhagwan Mahaveer Jain Hospital, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
Persistent median artery (PMA) is an anatomical variation of the hand vascularity arising from brachial artery in early embryonic life. The presence and thrombosis of PMA may result in several complications such as carpal tunnel syndrome. Early diagnosis and treatment of acute thrombosis of PMA is important because many complications and the need for surgery can be prevented with early anticoagulation therapy. In this report, we present the findings of a thrombosed PMA causing wrist pain in a 37-year-old male. Early anticoagulant therapy provided a complete resolution of the symptoms.
Keywords: Persistent median artery, thrombosis, wrist pain
|How to cite this article:|
Nishan B, Hudgi V, Krishna K S, Kiran I S, Motukuru V. Persistent thrombosed median artery – A rare cause for acute wrist pain: A case report and review of literature. Indian J Vasc Endovasc Surg 2020;7:197-200
|How to cite this URL:|
Nishan B, Hudgi V, Krishna K S, Kiran I S, Motukuru V. Persistent thrombosed median artery – A rare cause for acute wrist pain: A case report and review of literature. Indian J Vasc Endovasc Surg [serial online] 2020 [cited 2020 Jul 4];7:197-200. Available from: http://www.indjvascsurg.org/text.asp?2020/7/2/197/286917
| Introduction|| |
Persistent median artery (PMA) has a reported prevalence of 0.6%–30% and is known to be a rare but independent cause for wrist pain.,,,, The vascular supply of the hand is variable, and the PMA is one of the numerous variations. Thrombosis of PMA can cause some emergency complications such as acute carpal tunnel syndrome (CTS) or digital ischemia.,,,,
The aim of this article is to present the imaging findings of acute thrombosis of a PMA as a cause of wrist pain in a young male and to discuss the case in reference to the existing literature.
| Case Report|| |
A 37-year-old male presented with the left (nondominant) wrist pain for 3 months, increased in intensity for 15 days, sudden in onset, gradual in progression, localized to wrist, and no radiation of pain. Wrist pain was aggravated by motion. He had no paresthesia, weakness, or nocturnal pain. He is a hypertensive on medication. Medical history did not include any trauma, drug use, alcohol use, or chronic disease such as hypercoagulability or diabetes. Inspection and palpation of the volar and dorsal aspects of the hand was normal. There were no nodules or soft-tissue swelling. He had only hypersensitivity on the volar aspect of the wrist. The range of motion was not restricted. Phalen, Tinel, and Finkelstein tests were negative. The neurological examinations of the hand including sensation and motor function tests were normal. X-ray and laboratory tests were normal. Nerve conduction studies were normal (both ulnar and median nerves show normal latencies, sensory nerve action potential amplitudes and conduction velocities, and compound muscle action potential amplitudes); duplex examination [Figure 1] and [Figure 2] revealed PMA arising from ulnar artery with focal segmental thrombosis (4–5 cm) and distention of the lumen at wrist, flexor, and extensor tendons of the wrist were normal, no tenosynovitis, no median nerve compression. Computed tomography angiography [Figure 3] and [Figure 4] of the left upper limb reported PMA in the forearm – arising at the level of interosseous artery origin from ulnar artery – shows acute persistent thrombotic occlusion-antebrachial type (length of 3.8 cm). The patient started on injectable anticoagulation and oral analgesics and treated in outpatient basis. He was advised for a review after 1 month. The patient had no further pain, a follow-up duplex after 1 month showed subacute segmental thrombotic occlusion of median artery with partial recanalization of the lumen and decrease in diameter of the affected artery. The patient started on oral anticoagulation (non-Vitamin K antagonist oral anticoagulants) for 3 months and advised for follow-up monthly for 6 months. On follow-up, the patient was totally symptom free. A written informed consent was obtained from the patient for publication of this case report and accompanying images.
|Figure 1: Duplex scan showing the relation of persistent median artery and median nerve -no compression|
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|Figure 2: Duplex scan showing the relation of persistent median artery and median nerve -no features of compression|
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|Figure 3: Computed tomography image (axial view) showing relation of persistent median artery and median nerve|
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|Figure 4: Reconstructed image showing thrombosed persistent median artery arising from the ulnar artery|
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| Discussion|| |
The median artery is usually a transitory vessel that develops from the brachial axial artery in the early embryonic life. It accompanies the median nerve in the forearm, and during embryonic development acts as an important vessel of the forearm and the hand.,, After 8th week of gestation, the median artery usually regresses, and the ulnar and radial arteries dominate arterial supply of the hand. The vestigial median artery remains as the arteria comitans nervi median which accompanies the median nerve into the forearm. It becomes perceived as a “PMA” when it is of a diameter large enough to be noticed either through visual inspection or ultrasound. PMA has been described in two different patterns based on the vascular territory: palmar and antebrachial. In the palmar type, the PMA reaches the hand while in the antebrachial type, it terminates before reaching the wrist. When extending into the carpal tunnel, PMA may join the superficial volar arch, may supply the radial digits with an absent arch, or may end as a thrombosed vessel.
The carpal tunnel through which the median nerve and nine extrinsic flexor tendons pass is bound by the scaphoid and trapezium on the radial side and pisiform and hamate on the ulnar side. The lunate, capitate, and the proximal metacarpals lie posteriorly, and the roof is formed by the flexor retinaculum or transverse carpal ligament. Compartment syndromes are a group of symptoms and signs occurring together that result from an increase in pressure within a limited space, compromising the circulation and function of the tissue.,,, Phelan contributed much to the present understanding of the etiology, diagnosis, and management of CTS. Repeated stretch and vibration were incriminated as a cause for thrombosis.
A PMA arises from the brachial, ulnar, or anterior interosseous artery. Acute CTS has been reported secondary to thrombosis where there is a sudden onset of pain and paraesthesia, often severe. Symptoms usually appear in the younger age group.,, PMA causes both the CTS and the pronator syndrome, consistent with the “double crush” phenomenon. PMA of the forearm is not frequently observed in adult life. Although usually asymptomatic, it can be a cause for CTS.,,, In practice, a causal relationship is difficult to prove, as the great majority of individuals with a PMA have no symptoms. The presence of a PMA of 2–3 mm or larger in size could be an argument to incriminate that anatomical variant.,, It is possible to distinguish two distinct entities, which are related to a PMA. The first is associated with thrombosis which causes a sudden onset of pain and paraesthesia, often severe, whereas the second is associated with a normal artery.,,,,, In the latter case, symptoms predominate during work, and the physical signs are inconsistent, associated presumably with mass effect that may become more pronounced with vasodilatation during activity.,, In cases of large persistent nonthrombosed median artery associated with CTS, excision of the nonthrombosed median artery is not indicated, because it may sometimes substantially contribute to the circulation of the hand. In cases of thrombosed median artery, where symptoms do not resolve of anticoagulation, excision of segment of thrombosed median artery is indicated. Persistent median arteries 1.0–1.5 mm in diameter are typically asymptomatic., Importantly, a PMA could be an independent risk factor for CTS when enlarged to 3 mm in diameter in some pathological conditions, including internal thrombus, aneurysm, and calcified plaque formation., Thus, early detection of the thrombosed median artery using ultrasonography can result in prompt anticoagulant therapy, thus preventing the need for any surgery or thrombolytic therapy.
Pierre-Jerome et al. observed that the PMA was more frequently observed on the left side. When running parallel with the bifid median nerve, the PMA can be visualized in the middle of the two branches of the bifid median nerve or on the ulnar side of the ulnar trunk. When running parallel with the median nerve, the PMA can be detected on the ulnar side or on the surface of the median nerve. Thus, patients should undergo ultrasound scanning of the wrists prior to wrist surgery to avoid accidentally injuring these anatomic variations. In many cases, a bifid median nerve was accompanied by persistent median veins in addition to PMA [Figure 5], [Figure 6], [Figure 7].
|Figure 5: Common persistent median artery positions in relation to median nerve anatomy and percentage of occurrence normal median nerve with eccentric persistent median artery (37.5%)|
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|Figure 7: High division of median nerve with intermediate position of persistent median artery (43.7%)|
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McCormack et al. found the presence of a PMA in 4.4% of cases. Nevertheless, to date, there have only been a few cases in which a PMA was the cause of CTS.,
Acute CTS is rare, and it is even more unusual for it to be caused by a thrombosed PMA. Burnham and Bralliar reported a case of median artery thrombosis as a cause of acute CTS., Resolution of CTS symptoms and recanalization of PMA thrombosis with unspecified therapeutic anticoagulation was also reported in the case report by Salteret al. in 2011.
In 2012, Rzepecka-Wejs et al. described a case of CTS with Doppler ultrasound-proven PMA thrombosis that was managed with unspecified anticoagulant therapy and had nearly complete remission of symptoms over a 3-month follow-up period.
In 2015, Srivastava et al. also described an acute carpal tunnel with ultrasound-proven PMA thrombosis that was treated with therapeutic enoxaparin and warfarin and had marked improvement in symptoms after 4 weeks of anticoagulation.
| Conclusion|| |
A thrombosed PMA can precipitate acute CTS with the consequent tissue inflammation, causing an increase in carpal tunnel contents and subsequent provocation of pressure neuropathy. When a PMA is present and reaches the hand, it may form the only blood supply to the median nerve and neighboring muscles and may be a significant supply of blood to the hand, by contributing to the superficial palmar arch. The presence of a PMA can vary widely. Pathology of the PMA has been implicated in median neuropathy and may cause or mimic CTS, pronator syndrome, or anterior interosseous syndrome.,
Thus, more attention should be given to PMA, which may represent new pathogenic factors for CTS when internal thrombus form in some pathological conditions.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]