Acta Neurol. Scandinav. 51, 29-36, 1975
Gentofte University Hospital, Department of Clinical Neurophysiology, Surgical Department H, vascular service and Department of Radiology.
PERIPHERAL NERVE INJURY AS A COMPLICATION
OF AXILLARY ARTERIOGRAPHY B. BLATTLYON,B. ASSER HANSEN and T. MYGIND ABSTRACT Five patients with peripheral nerve injury after axillary arteriography are presented. The clinical and electromyographic pictures of this complication are described. In 4 patients the brachial plexus was damaged due to haematoma or pseudoaneurysm-formation a t the site of the arterial puncture. The grave prognosis for this complication is illustrated on the basis of the literature and our cases. Since it is concluded that the prognosis is better if rapid surgical correction of the complication is performed, certain steps to prevent the disabling outcome are proposed.
One of the most severe complications in axillary arterial catheterization is a permanent loss of function of the hand and forearm due to bleeding from the site of the puncture. Haematoma after arterial catheterization is a well-known phenomenon. It occurs more often after catheterization in the upper extremity than in the lower (Dauidsen et al. 1961). The specific problem in axillary arteriography arises from the anatomical relationship of the axillary artery to the brachial plexus, where a compression for a few hours may lead to extensive axonal degeneration of some o r all of the nerves in the arm. Similar injuries are seen in war time after accidents with penetrating missiles ( H a y m a k e r & W o o d h a l l 1953). A series of case reports 1966-74 (Staal P t al. 1966, Dudrick et al. 1967, Carroll & W i l k i n s 1970, W e s t c o t t & Taylor 1972, Molnar & Paul 1972), including this paper, shows that the prophylaxis and treatment of this complication are still a problem. The purpose of this paper is to illustrate this complication, and to suggest prophylactic and therapeutic measures.
30 hlATERIAI, In a five-year period from 1968-73 peripheral nerve complication arose i n 5 of 77 cases i n which aortography o r selective arteriography via the axillary artery a.m. Seldinger was attempted or performed i n this hospital. The average age was 60 years for t h e entire group (range 9-73 years), and 62 years for the 5 patients with peripheral nerve complication (range 47-71 gears). In all 5 patients arteriography through the femoral arteries was impossible. The disease leading to arteriography in these 5 patients was severe arteriosclerosis o r aortic coarctation, and aortography was indicated a s preoperative evaluation f o r reconstructive surgery on major arteries. This reconstructive operation was eventually performed and had good results in 3 of the 5 patients. A typical case hi\tory is presented by patient no. 1. L.C.A.O. A 71-year-old female with arteriosclerotic insufficiency of the lower extremities. The femoral and the left axillary arteries were inaccessible. Right axillary catheterization was performed on August 26, 1971. On the following two days pain and palsy of the right arm increased. There was a large haematoma i n the right axilla. Neurological examination on August 28 showed palsy of all movements of the hand and elbow, as well as decreased shoulder movement and hypoaesthesia of the arm. Two weeks later the neurological findings persisted, and a n aneurysm on the axillary artery was palpable and auscultable. Electromyography on October 18 showed severe neurogenic affliction of the biceps, triceps, deltoid, extensor digitorum communis, abductor digiti 5 and infraspinate muscles. On October 27 (i.e. 2 months after the arteriography), surgical intervention with excision of a false aneurysm from the right axillary artery was performed. After the operation the function of the proximal part of the arm remitted, but the lack of function of t h e hand and forearm remained unchanged. Neurological examination after one year showed only slight impairment of the shoulder movement and elbow flexion-extension, severe palsy of muscles of the hand and forearm, innervated by the median, ulnar and radial nerves. The hand was atrophic and contracted. Electromyography in the biceps brachii showed slight loss of motor units and rare fibrillation potentials: in the extensor digitorum communis severe loss of motor units and many fibrillation potentials; in the abductor digiti 5, loss of voluntary activity and occasional fibrillation was found.
CLINICAL RESULTS
The case histories and results are summarized in Table 1. The symptoms were persistent pain, paraesthesiae and palsies in the arm, beginning immediately or, mure often, a few hours after the diagnostic procedure. In four patients two or more of the following nerves were involved : median, ulnar, radial, musculocutaneous, axillary and suprascapular (i.e. these four patients had clinical signs of brachial plexus complication). In one case the signs of peripheral nerve injury involved only the ulnar nerve. Electrophysiological examination was performed in four patients, in three of them on two or more occasions (Table 2 ) . The four patients with brachial plexus lesion underwent surgery between 12 hours and 3 months after the initial symptoms. I n all,
I
art. sclerosis extr. inf.
art. sclerosis extr. inf.
GI P
63 P
2
3
68 8
5
art. sclerosis extr. inf.
aortae
9
pseudoaneurysm
haematoma
haematoma
+
haematoma pseudoaneurysm
Complication
0
2 hours
2 hours
2 hours
G hours
. After 5 weeks the patient had a lethal stroke.
41
4
8 coarctatio
art. sclerosis extr. inf.
0
71
1
Diagnosis
,":
Case no. sex
Time from arterial puncture to onset of symptoms
not operated
3 months
16 hours
12 hours
2 months
Time from onset of symptoms to operation of complication
no operation
2 days
no operation
18 d a j s
27 d a j s
Time from arteriography to surgical correction of main disease
+
0
a l l muscles innervated b j t h e median and ulnar nerve
0
triceps all muscles of forearm and hand
+
biceps, triceps all muscles of forearm and hand
Paralysis (muscles)
+
analgesia distal digit 2 ; hypoaesthesia hand and dorsal forearm
anaesthesia of hand and ulnar part of a r m ; hypoaesthesia of radial part of a r m and hand
Sensory disturbances
ahd. dig. 5, add. poll.
0
hypoaesthesia of ulnar part of hand and forearm
+
+
0
0
flex. digit. all hand muscles
Paralysis (muscles)
flex. carpi uln.
slight diffuse loss of force
+ +
flex. digit., flex. carpi uln. slight of ahd opp. poll. and abd. dig. 5
deltoid, biceps, triceps, ext. dig. comm.
Palsies (muscles)
hypoaesthesia of ulnar, dysaesthesia of median part of hand
diffuse hypoaesthesia of forearm and hand
dysaesthesia of hand and fingers innervated by the median nerve
hypoaesthesia of fingertips; dysaesthesia of volar hand
Sensory disturbances
Final outcome
unchanged
hjpo-anaesthesia flex. digit. of ulnar median + all hand part of hand muscles
biceps diffuse all muscles hypoaesthesia of of forearm forearm and hand and hand
biceps
deltoid, infraspinate
Palsies (muscles)
Preoperative
N E U R 0 L 0 G I C A I. F I N D I N G S
Table I . Clinical findings in 5 patients with peripheral nerve injury after millory artery puncture.
8 months
6 months
5 weeks'
2 years 2 months
1 year 10 months
Time from operation to final evaluation
32 Table 2 . Electromgographic findings in 5 patients w i t h peripheral nerve injury after a x i l t a r ~artery puncture.
Case no.
1
1
Days between arterial Muscle puncture and EMG 53 br. biceps (preoperative) br. triceps deltoid infraspinate ext. dig. eomrn. abd. dig. 5 170
1
334
2
2 years and 2 months
4
5
*)
br. biceps br. triceps deltoid br. biceps ext. dig. comm. abd. dig. 5 fl. carpi uln. fl. dig. prof. abd. dig. 5 abd. poll. br.
22 fl. carpi uln (preoperative) fl. dig. prof. et subl. br. biceps br. triceps 55 and 92
Jr: 2-3
deltoid abd. dig. 5 abd. poll. br.
++: 4-5 +++: 6 o r m o r e
Pattern of max. contractions
0
0 d. a. low amplitude d. a. low amplitude 0 0
Fibrillation potentials.
+++ +++ -k + +++
++f
0 0 - d. a. low amplitude
4-
d. a. -mixed
0
mixed d. a. low amplitude
0 d. a. -mixed d. a. low amplitude mixed - interference mixed 0
0 interference intcrference interference d. a. -mixed interference
f
+ +++ f 0
+ + + +++ +S+ 0 0 0
++ 0
No. of sites with fibrillation potentials outside t h e endplate zone.
0 = no voluntary activity. d. a. = discrete activity. mixed = mixed pattern.
5)
either a haematoma or a false aneurysm on the axillary artery, or both, was found which was interfering with the brachial plexus. Two patients (nos 2 and 3 ) were operated upon 12 hours after the puncture, and in both the palsies remitted within days. In one of these patients a slight lack of function and a diffuse hypoaesthesia were recognizable during the following month, at the end of which the patient died of an acute cerebro-vascular accident. The other patient had regained full force of
33 Table 3. No. O f axillary arterio-
graphies Newton (1963) 160 Staal, Voorthuisen & uan Dijk (1966) 21 Dudrick, Masland & Mishkin (1967) 305 Carroll & W i l k i n s (1970) not given Rend, Hernandez & Faucher (1970) 62 W e s f c o f t& Taglor (1972) Molnar h Paul (1972) B f a f fLgon, Hansen & Mllgind (this paper)
239 1762
77
Haematoma o r aneurysm with lesion of plexus brachialis
No.
%
0
0
2
9.5 0.7
2 2 1 (perhaps 2 ) 2 8
1.6 (perhaps 3.2) 0.89 0.5
4
5.2
shoulder-elbow movement and extension of hand and fingers at follow-up examination 2 years later. However, a moderately decreased force of finger flexion and thumb opposition persisted as well as dysaesthesia in the part of the hand innervated by the median nerve, and she complained of pronounced reflex dystrophic pain. Two patients (cases no. 1 and 4) were operated upon for a false aneurysm 2 and 3 months after the onset of symptoms, and after electromyography showed signs of extensive denervation in the muscles of the hand and arm. A t follow-up, 2 years and 8 months later, respectively, both patients had a severely disabling lack of function of the hand-forearm, with contractures in case 1 . ELECTROMYOGRAPHIC RESULTS
Electromyography (EMG) was not performed in our material in the acute stage of the complication. The findings are described in Table 2. EMG was performed pre- and postoperatively in case 1 ; postoperatively in case 2 ; preoperatively in case 4; and twice in case 5. In the last case repeated electrophysiological studies showed a partial ulnar nerve lesion with normal sensory and motor conduction velocity in all segments of the nerve. These findings, together with lack of clinically or ultrasonically identifiable aneurysm formation, led to conservative treatment of this patient. Cases 1 and 4 showed severe neurogenic impairment with loss of voluntary activity in muscles innervated by the median and ulnar nerves, In one of these cases (no. 1 ) muscles innervated by the radial 3
ACTA NEUROL. SCAND.
51, 1
34 and musculocutaneous nerves were equally involved, and there was a severe neurogenic impairment of muscles innervated by the axillary and suprascapular nerves as well. After 9 months some recovery was found, but only in the proximal muscles. The EMG did not reveal subclinical involvement of any muscles examined, nor was it possible in this study to evoke a muscle action potential in a clinically paralyzed muscle, either by voluntary effort or by electrical stimuli to the nerve. Thus, the EMG findings supported the grave prognosis of the brachial plexus lesions. DISCUSSION
The axillary artery has been recommended as a pathway for aortography because it allows ready access; it has a greater diameter than the brachial artery; it is rarely the seat of atheromatous plaques; and after the puncture it is easily compressed against the underlying bone (caput humeri) (Newton 1963, Hanafee 1963, Roy 1965, Rosenklint 1973). The risk of brachial plexus complications with disabling outcome, which varies from 0 to 9.5 per cent (Table 3) may suggest either surgical exposure of the artery before arteriography or the choice of some other access to the aorta such as the translumbar route, when the femoral route is not accessible. When the axillary route is not the first choice for arteriography, but the second or third choice, it will often be in patients in whom arteriosclerosis or hypertension predispose to bleeding from the site of puncture. The high incidence of haematoma and pseudoaneurysm formation in the present material (5.2 per cent) might be explained by the predisposing arterial conditions in our patients, who all had well recognized arteriosclerotic vessels or hypertension with malformation which made arteriography by the femoral route impossible. These features were also noted in the cases of Staal et al. and in cases 1 and 2 of Molnar h Paul. The age distribution in our material (average 62 years) also indicates a higher risk group. The importance of rapid surgical intervention in the case of brachial plexus compression is stressed by Dudrick et al. (1967), who presented a case of progressing palsy after axillary arteriography. Ten days elapsed between onset of the median and ulnar palsies and decompression, but only twelve hours between onset of radial nerve deficit and surgery. Electrical study prior to surgery, confirmed by the clinical postoperative course, revealed a good prognosis for the recent radial palsy, but a poor one f o r the older ulnar and median palsies. Similarly, Molnar & P a d (1972) reported, that 3 out of 4 patients, who
35 underwent surgery within 24 hours of the onset of neurological symptoms, recovered; whereas only 1 out of 3 patients operated after 48-96 hours recovered, but not until 18 months later. This tendency was confirmed in this study: the 2 patients who underwent operation within 12 hours made a faster and more complete recovery of their motor function than the two patients in whom the operation was delayed. Because the described complication is rare, the same neurologist or surgeon is unlikely to see two, and most unlikely to see more than two, cases of this type. The impression is gained from the cases presented in this report as well as those found in the literature that the neurological implications of the patients’ “postpunctural” complaints are not realized until it is too late. Therefore, the necessity of informing the patient and maintaining good rapport before, during and after the arteriography should be stressed. Signs of brachial plexus injury, which most often arise within 24 hours, may occasionally occur as late as 9 to 15 days after the arteriography (Molnar & Paul 1972). Clear instructions about the signs and surgical urgency of this particular complication should be available to the personnel in charge of the patient during the 48 hours following the arterial puncture. CONCLUSIONS
Brachial plexus injury following puncture of the axillary artery, which is seen after accidents with penetrating missiles (Haymaker & W o o d hall 1953), is most often an iatrogenic disease, which if it is untreated or if treatment is delayed may lead to a severe neurological deficit. The complication arises even with experienced arteriographers in large series of axillary artery punctures. The literature reveals that the first two cases in any hospital are not treated with the necessary urgency. The complication may be overlooked, since the patients are usually housed in different wards in the hospital or may even have left the hospital weeks before the signs of this complication arise. However, the symptoms usually begin within the first 24 hours. In order to prevent a poor outcome the following precautions are recommended : 1 ) Prophylactic compression of the puncture site for 10 minutes after withdrawal of the needle or catheter. 2 ) Patients, who are submitted to percutaneous puncture of the axillary artery, should be instructed to report any pain, paraesthesia o r palsy in the arm, which persists or arises more than two hours after the examination. 3‘
36
3 ) The medical personnel in charge of the patient in the postangiographic period should be instructed to check for these symptoms, the attendant physical signs and the presence of a haematoma or pulsatile mass in the axilla. The staff should be well acquainted, perhaps in written form, with this specific complication of the axillary arteriography. They should be aware of the serious prognosis as to hand-arm function incurred by brachial plexus injury, and the better prognosis, if the brachial plexus compression is promptly relieved before total paralysis has developed. Those persons responsible for the indication leading to axillary catheterization, its performance, and the postangiographic observation should all be aware of this disabling complication. Furthermore, surgery need not be delayed by timeconsuming electrophysiological studies. REFERENCES Carroll, S. E. & W. W. Wilkins (1970) : Two cases of brachial plexus injury following percutaneous arteriograms. C.M.A. Journal 102, 861-862. Davidsen, H. G., C. E. Gudhjerg & G. Thomsen (1961) : Complications of selective angiocardiography and percutaneous transarterial aortography. Acta chir. scand. s u p p l . 283, 168-181. Dudrick, S . , W. Masland & M. Mishkin (1967): Brachial plexus injury following axillary artery puncture. Radiology 88, 271-273. Hanafee, W. (1963) : Axillary artery approach to carotid, vertebral, abdominal aorta, and coronary angiography. Radiology 81, 559-567. Haymaker, W. & B. Woodhall (1953): Peripheral Nerve Injuries. W. B. Saunders, London. Molnar\ Cbmpylca\:ons of axillary arteriotomies. Radiology
IT\
u,Q. p’?i\\ (\$la)!
104, 269-276. Newton, T. H. (1963): The axillary artery approach t o arteriography of the aorta and its branches. Am. J. Roentgen. 89, 275-283. RenC, L., C. Hernandez & B. Faucher (1970):Les risques neuro-artkriels d a m l’exploration par catheterisme arteriel retrograde percutan6 p a r voie axillaire. Chirurgie 96, 436-440. Rosenklint, A. (1973) : Personal communication. Roy, P. (1965): Percutaneous catheterization via t h e axillary artery; a new approach to some technical roadblocks i n selective arteriography. Amer. J. Roentgen. 94, 1-18. Staal, A., A. E. van Voorthuisen & L. M. van Dijk (1966) : Neurological complications following arterial catheterization by the axillary approach. Br. J. Radiol. 39, 115-116. Westcott, J. L. & P. T. Taylor (1972): Transaxillary selective four vessel arteriography. Radiology 104, 277-281. Received May 17, 1974.
13. Btatt L ~ J O RM.D. ,
Dept. Clinical Neurophysiology, Gentofte Hospital, DK-2900 Hellerup, Denmark.
Gentofte University Hospital, Department of Clinical Neurophysiology, Surgical Department H, vascular service and Department of Radiology.
PERIPHERAL NERVE INJURY AS A COMPLICATION
OF AXILLARY ARTERIOGRAPHY B. BLATTLYON,B. ASSER HANSEN and T. MYGIND ABSTRACT Five patients with peripheral nerve injury after axillary arteriography are presented. The clinical and electromyographic pictures of this complication are described. In 4 patients the brachial plexus was damaged due to haematoma or pseudoaneurysm-formation a t the site of the arterial puncture. The grave prognosis for this complication is illustrated on the basis of the literature and our cases. Since it is concluded that the prognosis is better if rapid surgical correction of the complication is performed, certain steps to prevent the disabling outcome are proposed.
One of the most severe complications in axillary arterial catheterization is a permanent loss of function of the hand and forearm due to bleeding from the site of the puncture. Haematoma after arterial catheterization is a well-known phenomenon. It occurs more often after catheterization in the upper extremity than in the lower (Dauidsen et al. 1961). The specific problem in axillary arteriography arises from the anatomical relationship of the axillary artery to the brachial plexus, where a compression for a few hours may lead to extensive axonal degeneration of some o r all of the nerves in the arm. Similar injuries are seen in war time after accidents with penetrating missiles ( H a y m a k e r & W o o d h a l l 1953). A series of case reports 1966-74 (Staal P t al. 1966, Dudrick et al. 1967, Carroll & W i l k i n s 1970, W e s t c o t t & Taylor 1972, Molnar & Paul 1972), including this paper, shows that the prophylaxis and treatment of this complication are still a problem. The purpose of this paper is to illustrate this complication, and to suggest prophylactic and therapeutic measures.
30 hlATERIAI, In a five-year period from 1968-73 peripheral nerve complication arose i n 5 of 77 cases i n which aortography o r selective arteriography via the axillary artery a.m. Seldinger was attempted or performed i n this hospital. The average age was 60 years for t h e entire group (range 9-73 years), and 62 years for the 5 patients with peripheral nerve complication (range 47-71 gears). In all 5 patients arteriography through the femoral arteries was impossible. The disease leading to arteriography in these 5 patients was severe arteriosclerosis o r aortic coarctation, and aortography was indicated a s preoperative evaluation f o r reconstructive surgery on major arteries. This reconstructive operation was eventually performed and had good results in 3 of the 5 patients. A typical case hi\tory is presented by patient no. 1. L.C.A.O. A 71-year-old female with arteriosclerotic insufficiency of the lower extremities. The femoral and the left axillary arteries were inaccessible. Right axillary catheterization was performed on August 26, 1971. On the following two days pain and palsy of the right arm increased. There was a large haematoma i n the right axilla. Neurological examination on August 28 showed palsy of all movements of the hand and elbow, as well as decreased shoulder movement and hypoaesthesia of the arm. Two weeks later the neurological findings persisted, and a n aneurysm on the axillary artery was palpable and auscultable. Electromyography on October 18 showed severe neurogenic affliction of the biceps, triceps, deltoid, extensor digitorum communis, abductor digiti 5 and infraspinate muscles. On October 27 (i.e. 2 months after the arteriography), surgical intervention with excision of a false aneurysm from the right axillary artery was performed. After the operation the function of the proximal part of the arm remitted, but the lack of function of t h e hand and forearm remained unchanged. Neurological examination after one year showed only slight impairment of the shoulder movement and elbow flexion-extension, severe palsy of muscles of the hand and forearm, innervated by the median, ulnar and radial nerves. The hand was atrophic and contracted. Electromyography in the biceps brachii showed slight loss of motor units and rare fibrillation potentials: in the extensor digitorum communis severe loss of motor units and many fibrillation potentials; in the abductor digiti 5, loss of voluntary activity and occasional fibrillation was found.
CLINICAL RESULTS
The case histories and results are summarized in Table 1. The symptoms were persistent pain, paraesthesiae and palsies in the arm, beginning immediately or, mure often, a few hours after the diagnostic procedure. In four patients two or more of the following nerves were involved : median, ulnar, radial, musculocutaneous, axillary and suprascapular (i.e. these four patients had clinical signs of brachial plexus complication). In one case the signs of peripheral nerve injury involved only the ulnar nerve. Electrophysiological examination was performed in four patients, in three of them on two or more occasions (Table 2 ) . The four patients with brachial plexus lesion underwent surgery between 12 hours and 3 months after the initial symptoms. I n all,
I
art. sclerosis extr. inf.
art. sclerosis extr. inf.
GI P
63 P
2
3
68 8
5
art. sclerosis extr. inf.
aortae
9
pseudoaneurysm
haematoma
haematoma
+
haematoma pseudoaneurysm
Complication
0
2 hours
2 hours
2 hours
G hours
. After 5 weeks the patient had a lethal stroke.
41
4
8 coarctatio
art. sclerosis extr. inf.
0
71
1
Diagnosis
,":
Case no. sex
Time from arterial puncture to onset of symptoms
not operated
3 months
16 hours
12 hours
2 months
Time from onset of symptoms to operation of complication
no operation
2 days
no operation
18 d a j s
27 d a j s
Time from arteriography to surgical correction of main disease
+
0
a l l muscles innervated b j t h e median and ulnar nerve
0
triceps all muscles of forearm and hand
+
biceps, triceps all muscles of forearm and hand
Paralysis (muscles)
+
analgesia distal digit 2 ; hypoaesthesia hand and dorsal forearm
anaesthesia of hand and ulnar part of a r m ; hypoaesthesia of radial part of a r m and hand
Sensory disturbances
ahd. dig. 5, add. poll.
0
hypoaesthesia of ulnar part of hand and forearm
+
+
0
0
flex. digit. all hand muscles
Paralysis (muscles)
flex. carpi uln.
slight diffuse loss of force
+ +
flex. digit., flex. carpi uln. slight of ahd opp. poll. and abd. dig. 5
deltoid, biceps, triceps, ext. dig. comm.
Palsies (muscles)
hypoaesthesia of ulnar, dysaesthesia of median part of hand
diffuse hypoaesthesia of forearm and hand
dysaesthesia of hand and fingers innervated by the median nerve
hypoaesthesia of fingertips; dysaesthesia of volar hand
Sensory disturbances
Final outcome
unchanged
hjpo-anaesthesia flex. digit. of ulnar median + all hand part of hand muscles
biceps diffuse all muscles hypoaesthesia of of forearm forearm and hand and hand
biceps
deltoid, infraspinate
Palsies (muscles)
Preoperative
N E U R 0 L 0 G I C A I. F I N D I N G S
Table I . Clinical findings in 5 patients with peripheral nerve injury after millory artery puncture.
8 months
6 months
5 weeks'
2 years 2 months
1 year 10 months
Time from operation to final evaluation
32 Table 2 . Electromgographic findings in 5 patients w i t h peripheral nerve injury after a x i l t a r ~artery puncture.
Case no.
1
1
Days between arterial Muscle puncture and EMG 53 br. biceps (preoperative) br. triceps deltoid infraspinate ext. dig. eomrn. abd. dig. 5 170
1
334
2
2 years and 2 months
4
5
*)
br. biceps br. triceps deltoid br. biceps ext. dig. comm. abd. dig. 5 fl. carpi uln. fl. dig. prof. abd. dig. 5 abd. poll. br.
22 fl. carpi uln (preoperative) fl. dig. prof. et subl. br. biceps br. triceps 55 and 92
Jr: 2-3
deltoid abd. dig. 5 abd. poll. br.
++: 4-5 +++: 6 o r m o r e
Pattern of max. contractions
0
0 d. a. low amplitude d. a. low amplitude 0 0
Fibrillation potentials.
+++ +++ -k + +++
++f
0 0 - d. a. low amplitude
4-
d. a. -mixed
0
mixed d. a. low amplitude
0 d. a. -mixed d. a. low amplitude mixed - interference mixed 0
0 interference intcrference interference d. a. -mixed interference
f
+ +++ f 0
+ + + +++ +S+ 0 0 0
++ 0
No. of sites with fibrillation potentials outside t h e endplate zone.
0 = no voluntary activity. d. a. = discrete activity. mixed = mixed pattern.
5)
either a haematoma or a false aneurysm on the axillary artery, or both, was found which was interfering with the brachial plexus. Two patients (nos 2 and 3 ) were operated upon 12 hours after the puncture, and in both the palsies remitted within days. In one of these patients a slight lack of function and a diffuse hypoaesthesia were recognizable during the following month, at the end of which the patient died of an acute cerebro-vascular accident. The other patient had regained full force of
33 Table 3. No. O f axillary arterio-
graphies Newton (1963) 160 Staal, Voorthuisen & uan Dijk (1966) 21 Dudrick, Masland & Mishkin (1967) 305 Carroll & W i l k i n s (1970) not given Rend, Hernandez & Faucher (1970) 62 W e s f c o f t& Taglor (1972) Molnar h Paul (1972) B f a f fLgon, Hansen & Mllgind (this paper)
239 1762
77
Haematoma o r aneurysm with lesion of plexus brachialis
No.
%
0
0
2
9.5 0.7
2 2 1 (perhaps 2 ) 2 8
1.6 (perhaps 3.2) 0.89 0.5
4
5.2
shoulder-elbow movement and extension of hand and fingers at follow-up examination 2 years later. However, a moderately decreased force of finger flexion and thumb opposition persisted as well as dysaesthesia in the part of the hand innervated by the median nerve, and she complained of pronounced reflex dystrophic pain. Two patients (cases no. 1 and 4) were operated upon for a false aneurysm 2 and 3 months after the onset of symptoms, and after electromyography showed signs of extensive denervation in the muscles of the hand and arm. A t follow-up, 2 years and 8 months later, respectively, both patients had a severely disabling lack of function of the hand-forearm, with contractures in case 1 . ELECTROMYOGRAPHIC RESULTS
Electromyography (EMG) was not performed in our material in the acute stage of the complication. The findings are described in Table 2. EMG was performed pre- and postoperatively in case 1 ; postoperatively in case 2 ; preoperatively in case 4; and twice in case 5. In the last case repeated electrophysiological studies showed a partial ulnar nerve lesion with normal sensory and motor conduction velocity in all segments of the nerve. These findings, together with lack of clinically or ultrasonically identifiable aneurysm formation, led to conservative treatment of this patient. Cases 1 and 4 showed severe neurogenic impairment with loss of voluntary activity in muscles innervated by the median and ulnar nerves, In one of these cases (no. 1 ) muscles innervated by the radial 3
ACTA NEUROL. SCAND.
51, 1
34 and musculocutaneous nerves were equally involved, and there was a severe neurogenic impairment of muscles innervated by the axillary and suprascapular nerves as well. After 9 months some recovery was found, but only in the proximal muscles. The EMG did not reveal subclinical involvement of any muscles examined, nor was it possible in this study to evoke a muscle action potential in a clinically paralyzed muscle, either by voluntary effort or by electrical stimuli to the nerve. Thus, the EMG findings supported the grave prognosis of the brachial plexus lesions. DISCUSSION
The axillary artery has been recommended as a pathway for aortography because it allows ready access; it has a greater diameter than the brachial artery; it is rarely the seat of atheromatous plaques; and after the puncture it is easily compressed against the underlying bone (caput humeri) (Newton 1963, Hanafee 1963, Roy 1965, Rosenklint 1973). The risk of brachial plexus complications with disabling outcome, which varies from 0 to 9.5 per cent (Table 3) may suggest either surgical exposure of the artery before arteriography or the choice of some other access to the aorta such as the translumbar route, when the femoral route is not accessible. When the axillary route is not the first choice for arteriography, but the second or third choice, it will often be in patients in whom arteriosclerosis or hypertension predispose to bleeding from the site of puncture. The high incidence of haematoma and pseudoaneurysm formation in the present material (5.2 per cent) might be explained by the predisposing arterial conditions in our patients, who all had well recognized arteriosclerotic vessels or hypertension with malformation which made arteriography by the femoral route impossible. These features were also noted in the cases of Staal et al. and in cases 1 and 2 of Molnar h Paul. The age distribution in our material (average 62 years) also indicates a higher risk group. The importance of rapid surgical intervention in the case of brachial plexus compression is stressed by Dudrick et al. (1967), who presented a case of progressing palsy after axillary arteriography. Ten days elapsed between onset of the median and ulnar palsies and decompression, but only twelve hours between onset of radial nerve deficit and surgery. Electrical study prior to surgery, confirmed by the clinical postoperative course, revealed a good prognosis for the recent radial palsy, but a poor one f o r the older ulnar and median palsies. Similarly, Molnar & P a d (1972) reported, that 3 out of 4 patients, who
35 underwent surgery within 24 hours of the onset of neurological symptoms, recovered; whereas only 1 out of 3 patients operated after 48-96 hours recovered, but not until 18 months later. This tendency was confirmed in this study: the 2 patients who underwent operation within 12 hours made a faster and more complete recovery of their motor function than the two patients in whom the operation was delayed. Because the described complication is rare, the same neurologist or surgeon is unlikely to see two, and most unlikely to see more than two, cases of this type. The impression is gained from the cases presented in this report as well as those found in the literature that the neurological implications of the patients’ “postpunctural” complaints are not realized until it is too late. Therefore, the necessity of informing the patient and maintaining good rapport before, during and after the arteriography should be stressed. Signs of brachial plexus injury, which most often arise within 24 hours, may occasionally occur as late as 9 to 15 days after the arteriography (Molnar & Paul 1972). Clear instructions about the signs and surgical urgency of this particular complication should be available to the personnel in charge of the patient during the 48 hours following the arterial puncture. CONCLUSIONS
Brachial plexus injury following puncture of the axillary artery, which is seen after accidents with penetrating missiles (Haymaker & W o o d hall 1953), is most often an iatrogenic disease, which if it is untreated or if treatment is delayed may lead to a severe neurological deficit. The complication arises even with experienced arteriographers in large series of axillary artery punctures. The literature reveals that the first two cases in any hospital are not treated with the necessary urgency. The complication may be overlooked, since the patients are usually housed in different wards in the hospital or may even have left the hospital weeks before the signs of this complication arise. However, the symptoms usually begin within the first 24 hours. In order to prevent a poor outcome the following precautions are recommended : 1 ) Prophylactic compression of the puncture site for 10 minutes after withdrawal of the needle or catheter. 2 ) Patients, who are submitted to percutaneous puncture of the axillary artery, should be instructed to report any pain, paraesthesia o r palsy in the arm, which persists or arises more than two hours after the examination. 3‘
36
3 ) The medical personnel in charge of the patient in the postangiographic period should be instructed to check for these symptoms, the attendant physical signs and the presence of a haematoma or pulsatile mass in the axilla. The staff should be well acquainted, perhaps in written form, with this specific complication of the axillary arteriography. They should be aware of the serious prognosis as to hand-arm function incurred by brachial plexus injury, and the better prognosis, if the brachial plexus compression is promptly relieved before total paralysis has developed. Those persons responsible for the indication leading to axillary catheterization, its performance, and the postangiographic observation should all be aware of this disabling complication. Furthermore, surgery need not be delayed by timeconsuming electrophysiological studies. REFERENCES Carroll, S. E. & W. W. Wilkins (1970) : Two cases of brachial plexus injury following percutaneous arteriograms. C.M.A. Journal 102, 861-862. Davidsen, H. G., C. E. Gudhjerg & G. Thomsen (1961) : Complications of selective angiocardiography and percutaneous transarterial aortography. Acta chir. scand. s u p p l . 283, 168-181. Dudrick, S . , W. Masland & M. Mishkin (1967): Brachial plexus injury following axillary artery puncture. Radiology 88, 271-273. Hanafee, W. (1963) : Axillary artery approach to carotid, vertebral, abdominal aorta, and coronary angiography. Radiology 81, 559-567. Haymaker, W. & B. Woodhall (1953): Peripheral Nerve Injuries. W. B. Saunders, London. Molnar\ Cbmpylca\:ons of axillary arteriotomies. Radiology
IT\
u,Q. p’?i\\ (\$la)!
104, 269-276. Newton, T. H. (1963): The axillary artery approach t o arteriography of the aorta and its branches. Am. J. Roentgen. 89, 275-283. RenC, L., C. Hernandez & B. Faucher (1970):Les risques neuro-artkriels d a m l’exploration par catheterisme arteriel retrograde percutan6 p a r voie axillaire. Chirurgie 96, 436-440. Rosenklint, A. (1973) : Personal communication. Roy, P. (1965): Percutaneous catheterization via t h e axillary artery; a new approach to some technical roadblocks i n selective arteriography. Amer. J. Roentgen. 94, 1-18. Staal, A., A. E. van Voorthuisen & L. M. van Dijk (1966) : Neurological complications following arterial catheterization by the axillary approach. Br. J. Radiol. 39, 115-116. Westcott, J. L. & P. T. Taylor (1972): Transaxillary selective four vessel arteriography. Radiology 104, 277-281. Received May 17, 1974.
13. Btatt L ~ J O RM.D. ,
Dept. Clinical Neurophysiology, Gentofte Hospital, DK-2900 Hellerup, Denmark.
