Case Report:

Venous Thoracic Outlet

Syndrome as a Cause of

Intractable Migraines

Andrew Abi-Chaker, MD

Vascular Surgery Resident

University of Miami

Nothing to Disclose

Background

• Thoracic outlet syndrome (TOS) is a constellation of symptoms caused by compression of the neurovascular bundle or one of its components within the thoracic outlet.

• Traditionally, symptoms include upper extremity swelling, cyanosis, dysesthesia, and pain.

• TOS is generally confirmed postoperatively on resolution of symptoms.

• Atypical symptoms may include headaches

Venous TOS

• ~10-12% of cases

• Classical patient is a young male involved in repetitive strenuous physical activity

• Hallmark symptom is arm swelling

• When thrombosis is present (Paget-Schroetter disease) thrombolysis and decompression is warranted

Case

• 27M c/o debilitating daily migraines as severe occipital headaches

• Always associated with arm adduction and right arm swelling

• Migraines → numbness and tingling in the right fourth and fifth digits → Severe nausea/vomiting

Workup

• Referred to Vascular Surgery due to arm swelling

• Symptoms were reproduced with complete adduction of his right arm on exam

• Throughout these maneuvers, radial pulses remained intact bilaterally.

• No bony abnormalities were noted.

Imaging

• Duplex Ultrasound performed during the same arm maneuvers showed abnormal venous flow without stenosis

• Chest Xray demonstrates evidence of a cervical rib

Venography

11

Decompressive Surgery

● GETA● Supraclavicular approach● Resection of anterior scalene,

complete cervical rib, first rib● Post resection completion

Venogram + Venoplasty of a stricture site

15

Post-op/Follow up

• Tolerated the procedure well

• Discharged on POD #3

• He reports a dramatic improvement in headache symptoms with no recurrent episodes of right upper extremity swelling or paresthesia.

• 12 months later, remains asymptomatic

Discussion

• Cervical ribs usually associated with aTOS or nTOS

• Migraines can be treated with decompression (botox, etc.)

• Poor venous outflow resulting in venous congestions (similar to SVC syndrome)

• Headache may be a presenting symptom of patients with TOS

References

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Thank You

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