Radial Motor Nerve Palsy Following Transradial Coronary Intervention
2018; Lippincott Williams & Wilkins; Volume: 11; Issue: 11 Linguagem: Inglês
10.1161/circinterventions.118.007203
ISSN1941-7632
AutoresAlbert Youngwoo Jang, Jongwook Yu, Pyung Chun Oh, Kyounghoon Lee, Woong Chol Kang, Seung Hwan Han, Taehoon Ahn, Soon Yong Suh, Jiwon Yang,
Tópico(s)Nerve Injury and Rehabilitation
ResumoHomeCirculation: Cardiovascular InterventionsVol. 11, No. 11Radial Motor Nerve Palsy Following Transradial Coronary Intervention Free AccessCase ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessCase ReportPDF/EPUBRadial Motor Nerve Palsy Following Transradial Coronary Intervention Albert Y. Jang, MD, Jongwook Yu, MD, Pyung Chun Oh, MD, Kyounghoon Lee, MD, Woong Chol Kang, MD, Seung Hwan Han, MD, Taehoon Ahn, MD, Soon Yong Suh, MD, PhD and Jiwon Yang, MD Albert Y. JangAlbert Y. Jang Division of Cardiology, Department of Internal Medicine (A.Y.J., J.Y., P.C.O., K.L., W.C.K., S.H.H., T.A., S.Y.S.), Gachon University Gil Medical Center, Incheon, Republic of Korea. , Jongwook YuJongwook Yu Division of Cardiology, Department of Internal Medicine (A.Y.J., J.Y., P.C.O., K.L., W.C.K., S.H.H., T.A., S.Y.S.), Gachon University Gil Medical Center, Incheon, Republic of Korea. , Pyung Chun OhPyung Chun Oh Division of Cardiology, Department of Internal Medicine (A.Y.J., J.Y., P.C.O., K.L., W.C.K., S.H.H., T.A., S.Y.S.), Gachon University Gil Medical Center, Incheon, Republic of Korea. , Kyounghoon LeeKyounghoon Lee Division of Cardiology, Department of Internal Medicine (A.Y.J., J.Y., P.C.O., K.L., W.C.K., S.H.H., T.A., S.Y.S.), Gachon University Gil Medical Center, Incheon, Republic of Korea. , Woong Chol KangWoong Chol Kang Division of Cardiology, Department of Internal Medicine (A.Y.J., J.Y., P.C.O., K.L., W.C.K., S.H.H., T.A., S.Y.S.), Gachon University Gil Medical Center, Incheon, Republic of Korea. , Seung Hwan HanSeung Hwan Han Division of Cardiology, Department of Internal Medicine (A.Y.J., J.Y., P.C.O., K.L., W.C.K., S.H.H., T.A., S.Y.S.), Gachon University Gil Medical Center, Incheon, Republic of Korea. , Taehoon AhnTaehoon Ahn Division of Cardiology, Department of Internal Medicine (A.Y.J., J.Y., P.C.O., K.L., W.C.K., S.H.H., T.A., S.Y.S.), Gachon University Gil Medical Center, Incheon, Republic of Korea. , Soon Yong SuhSoon Yong Suh Soon Yong Suh, MD, PhD, Division of Cardiology, Department of Internal Medicine, Gachon University, Gil Medical Center, 1198 Guwol-dong, Namdong-gu, Incheon 405–760, Republic of Korea. Email E-mail Address: [email protected] Division of Cardiology, Department of Internal Medicine (A.Y.J., J.Y., P.C.O., K.L., W.C.K., S.H.H., T.A., S.Y.S.), Gachon University Gil Medical Center, Incheon, Republic of Korea. and Jiwon YangJiwon Yang Department of Neurology (J.Y.), Gachon University Gil Medical Center, Incheon, Republic of Korea. Originally published16 Nov 2018https://doi.org/10.1161/CIRCINTERVENTIONS.118.007203Circulation: Cardiovascular Interventions. 2018;11:e007203The transradial access site is currently the gold standard for cardiac catheterization, as it has been shown to dramatically reduce complication rates.1 Complications such as radial nerve palsy (RNP) can be overlooked because of their rare incidence and a poor understanding of the forearm vessels and nerve anatomy. Herein, we report a case that provides mechanistic insight of how RNP may occur in transradial intervention.A 76-year-old female with a history of diabetes mellitus and hypertension attended our cardiology outpatient clinic with chest pain. An elevated troponin I (1.157 ng/mL) and a regional wall motion abnormality in the right coronary artery territory were observed on echocardiography. We performed a coronary angiogram via the right radial artery (RA). After forearm angiography (Figure [A]), a guidewire was advanced through the RA. There was resistance during the passage of the guidewire, with the patient simultaneously reporting a sharp pain in the proximal forearm area. We observed that the guidewire was deviated sideways towards the recurrent RA (RRA). The patient's pain subsided following withdrawal of the guidewire into the main the RA. Percutaneous coronary intervention was undertaken in the right coronary artery. Eight hours later, patient complained of an inability to abduct or extend her right thumb (Figure [B]). She also reported pain in the right forearm area, where ecchymosis and a hematoma were noted (Figure [C]). An initial NCS (nerve conduction study) was performed 4 days postintervention, revealing no compound muscle action potential in the right radial motor nerve, as well as normal responses in the left radial motor and both left and right superficial radial sensory nerves, suggestive of right RNP (Figure [D] and [E]). Despite improvement of forearm pain, her right thumb palsy did not recover during the next 5 days during her admission. A follow-up NCS was done 50 days later, which showed electrophysiological improvement in the right radial motor nerve (Figure [D] and [E]). Her symptoms gradually subsided over the course of 7 months to eventually achieve full recovery in her right thumb motor function.Download figureDownload PowerPointFigure. Clinical course and anatomy related to radial nerve palsy. A, Prewire passage angiography of the right radial, ulnar artery, and recurrent radial artery. B, Inability to extend the right first phalanx after transradial intervention. C, Hematoma and ecchymosis in the dorsal side of right forearm. D and E, Conduction velocity and compound muscle action potential 4 and 50 d post–radial nerve palsy. F, An illustration of right forearm vessels, nerve, and muscle anatomy related to radial nerve palsy. CMAP indicates compound muscle action potentialThe radial nerve runs along the spinal groove of the humerus bone, where it divides into the superficial and deep branches, located proximally to the elbow. The superficial branch is known to be purely sensory, whereas the deep branch—called the posterior interosseous (PI) nerve—runs through the Arcade of Frohse, a fibrous band between the 2 heads of the supinator muscle, where it innervates the hand extensor muscles (Figure [F] and Movie I in the Data Supplement).2 The RRA branches off from the RA and runs coaxial with the PI nerve to form the Leash of Henry. These 2 structures, the Arcade of Frohse and the Leash of Henry, are one of the most common sites of external PI nerve compression caused by traumatic insults to the adjoining RRA.2 It is counterintuitive, however, that compression in the proximal forearm causes palsy in the thumb distant from the forearm. This can be explained by the PI nerve innervating the extensors, such as the abductor pollicis and extensor pollicis brevis that insert into the first phalanx.3 We suspect that bleeding caused by a guidewire perforation within the RRA resulted in external compression of the PI nerve.Patients with RNP caused by PI nerve compression present with a combination of complete/incomplete inability to extend the metacarpal phalangeal joints of some or all of the fingers or to abduct the thumb, as seen in our case. Ultrasound and magnetic resonance imaging can be used to confirm the source of external compression.4 NCS is also commonly performed to verify decreased velocity of the PI nerve.Fortunately, the majority of radial nerve impairment recovers by conservative care as in our case. Nonsteroidal anti-inflammatory drugs, immobilization, and local corticosteroid administration can improve symptoms.2 Surgical treatment, such as tendon transfer or nerve grafting, is indicated when no clinical improvement is observed after a period of conservative treatment.2 Surgical decompression of the hematoma may also be an option.Guidewire derailment into the RRA has previously been shown and may frequently occur unnoticed in everyday practice. It is important for interventionalists to keep in mind that forceful advancement of the guidewire through the forearm when resistance to guidewire passage is encountered during transradial intervention should be avoided as it may result in RRA perforation and possibly RNP. In addition, when the patient complains of pain in the forearm during transradial intervention, forearm angiography is advised to determine the cause for pain, and to look for radiocontrast extravasation in the RRA, where application of pressure for hemostasis is advised to prevent the development of a hematoma within the forearm that places the patient at risk of secondary RNP.DisclosuresNone.FootnotesThe Data Supplement is available at https://www.ahajournals.org/doi/suppl/10.1161/CIRCINTERVENTIONS.118.007203.https://www.ahajournals.org/journal/circinterventionsSoon Yong Suh, MD, PhD, Division of Cardiology, Department of Internal Medicine, Gachon University, Gil Medical Center, 1198 Guwol-dong, Namdong-gu, Incheon 405–760, Republic of Korea. Email [email protected]comReferences1. Kiemeneij F, Laarman GJ, Odekerken D, Slagboom T, van der Wieken R. A randomized comparison of percutaneous transluminal coronary angioplasty by the radial, brachial and femoral approaches: the access study.J Am Coll Cardiol. 1997; 29:1269–1275.CrossrefMedlineGoogle Scholar2. Bumbasirevic M, Palibrk T, Lesic A, Atkinson H. Radial nerve palsy.EFORT Open Rev. 2016; 1:286–294. doi: 10.1302/2058-5241.1.000028CrossrefMedlineGoogle Scholar3. Abrams RA, Ziets RJ, Lieber RL, Botte MJ. Anatomy of the radial nerve motor branches in the forearm.J Hand Surg Am. 1997; 22:232–237. doi: 10.1016/S0363-5023(97)80157-8CrossrefMedlineGoogle Scholar4. Andreisek G, Crook DW, Burg D, Marincek B, Weishaupt D. Peripheral neuropathies of the median, radial, and ulnar nerves: MR imaging features.Radiographics. 2006; 26:1267–1287. doi: 10.1148/rg.265055712CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Roy S, Kabach M, Patel D, Guzman L and Jovin I (2022) Radial Artery Access Complications: Prevention, Diagnosis and Management, Cardiovascular Revascularization Medicine, 10.1016/j.carrev.2021.12.007, 40, (163-171), Online publication date: 1-Jul-2022. November 2018Vol 11, Issue 11 Advertisement Article InformationMetrics © 2018 American Heart Association, Inc.https://doi.org/10.1161/CIRCINTERVENTIONS.118.007203PMID: 30571210 Originally publishedNovember 16, 2018 Keywordstransradial interventionradial nerve palsyposterior interosseous nerve compressionPDF download Advertisement SubjectsPercutaneous Coronary Intervention
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