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Stroke secondary to thoracic outlet syndrome, treated successfully with thrombolytics and thrombectomy in a teenager: a case report

Thoracic outlet syndrome (TOS) is a condition that results from the compression of neurovascular structures as they exit the thorax. Arterial ischemic stroke can occur in TOS due to retrograde embolism, and has been rarely reported in children. We describe a 15-year-old girl who presented with acute left hemiplegia after weeks of right upper extremity numbness and tingling. Imaging showed an acute ischemic stroke due to right middle cerebral artery occlusion.. She was treated with 0.9 mg/kg of IV tissue plasminogen activator at 1.3 hours and mechanical thrombectomy with clot retrieval at 2.4 hours with TICI3 reperfusion after one pass. Though not reported, review of her neck computed tomography angiogram suggested a right subclavian aneurysm. Further evaluation confirmed the finding, along with probable distal thrombosis and anomalous first rib consistent with thoracic outlet syndrome. Three days later she underwent right subclavian artery aneurysmal repair, first rib resection and right brachial/ulnar artery thrombectomy. At 3 months follow up patient had good recovery with minimal neurological deficits. Upper extremity ischemic symptoms may herald TOS, an uncommon cause of stroke in children which may not be detected on routine stroke evaluation. Interventionalists should be aware of the possibility of proximal vascular anomalies; however, this finding does not exclude the possibility of acute stroke intervention.
Keywords: thoracic outlet syndrome, thrombectomy in pediatric stroke