Brachial indications

Isner 1998 Buerger s disease Critical ischemia, resistant to maximal medical therapy, not surgical candidates Naked plasmid VEGF 165 Intramuscular injection Phase 1 4 months Improvements in wound healing, rest pain, ankle brachial indices, new vessels on MRl and angiogram... 

In the periphery, the siroUmus-coated cordis self-expandable stent (SIROCCO) trial, a randomized, donble-bhnd study comparing sirolimus eluting stents to nitinol bare metal stents in patients with chronic limb ischemia caused by superficial femoral artery occlusions or stenoses, reported no difference between drag elntmg and bare metal stents. Both stent types improved the arterial brachial indices and claudication symptoms, and both stent types demonstrated similarly low restenosis rates (22.9% for sirolimus eluting stents vs 21.1% for nitinol bare metal stents p>0.05)... 

Claudication, Class I is hemodynamically significant LEAD diagnosed, either by physical examination, by arterial flow studies, or by ankle brachial indices but without symptoms. 

The variability can be accounted for largely by the diffusion barriers of the different fibre types and by Na+ channel density. For example, the presence of a Schwann cell and myelin sheath poses a considerable barrier to the diffusion of local anaesthetic to the interior of the cell. There is in vitro evidence to indicate that all desheathed nerves require a similar minimum concentration of local anaesthetic to induce block irrespective of fibre type. A consequence of the physical architecture of a mixed nerve is that access of the drug to the outer fibres is easier than access to fibres at the core. It is for this reason that the onset of proximal analgesia of the limb precedes distal analgesia with a brachial plexus block. 

Several additional factors can result in erroneous BP measurements. Pseudohypertension is a falsely elevated BP measurement that is seen in elderly patients with a rigid, calcified brachial artery. In these patients, the true arterial BP when measured directly intraarterially (the most accurate measurement of BP) is much lower than that measured using the indirect cuff method. The Osier s maneuver can be used to test for pseudohypertension. In this maneuver, the BP cuff is inflated above peak SBP. If the radial artery remains palpable, the patient has a positive Osier s maneuver (rigid artery), which indicates pseudohypertension. 

Lidocaine hydrochloride is a local anesthetic/vasopressor preparation. Lidocaine stabilizes neuronal membranes by inhibiting the ionic fluxes required for the initiation and conduction of impulses, thereby effecting local anesthetic action. Epinephrine stimulates both alpha and beta receptors within sympathetic nervous system relaxes smooth muscle of bronchi and iris and is an antagonist of histamine. They are indicated for production of local or regional anesthesia by infiltration techniques such as percutaneous injection, by peripheral nerve block techniques such as brachial plexus and intercostals, and by central neural techniques such as lumbar and caudal epidural blocks. 

Injury to the proximal humerus can be either a metaphyseal fracture or more typically a Salter-Harris type 1 physeal separation. This will not be evident on the plain film as the proximal humeral physis does not start to ossify until 3-6 months of age. The radiological finding of widening of the joint space occurs in physeal separation, dislocation, brachial plexus palsy and septic arthritis. Ultrasound maybe indicated to clarify the diagnosis (Zieger et al. 1987). However, since healing is rapid at this age periosteal new bone will often be apparent within 10-14 days. 

Fig. 6.56. Normal brachial plexus paravertebral area. Transverse 12-5 MHz US image over the left anterolateral neck demonstrates the main landmarks for identification of the nerve roots. Note the position of the left lobe of the thyroid Thy), the esophagus (Esoph), the common carotid artery (CA), the internal jugular vein (IJV) lying between the superficial sternoclei-domastoideus (SternoCt) and the deep longus colli (LC) muscles. Deep to these structures, the lateral aspect of the C6 vertebra shows a wavy hyperechoic contour, which delineates the vertebral body (1), the pedicle (2) and the transverse process (3), which exhibits in turn two prominent anterior (asterisk) and posterior (star) tubercles. The C6 root (arrow) appears as a hypoechoic image contained between these tubercles. The insert at the upper left side of the figure indicates transducer positioning...

Fig. 6.61a,b.Normal brachial plexus infraclavicular region. Oblique transverse 12-5 MHz US images obtained under the clavicle a over the major axis of the axillary artery (AA) and b immediately behind it. The cords of the brachial plexus (open and white arrowheads) are visualized as elongated fascicular structures coursing around the axillary artery and deep to the pectoralis minor muscle (Pm). PMj, pectoralis major muscle. The insert at the upper left side of the figure indicates transducer positioning... 

Struthers , which joins the anomalous bony process and the medial epicondyle. Clinically, this condition typically affects young sportsmen as a result of intense muscular activity in the elbow and forearm and may start with pain and numbness in the first three fingers and weakness of forearm muscles innervated by the median nerve (Sener et al. 1998). US can demonstrate the relationship of the median nerve with the anomalous bone and ligament. Although not yet reported in the radiological literature, displacement of the nerve by these structures may represent an indicator of entrapment. Therapy includes excision of the ligament of Struthers and ablation of the supracondylar process. The brachial artery can also be compressed by an anomalous insertion of the pronator teres muscle into the supracondylar process (Talha et al. 1987). 

Fig. 8.13a,b. Median nerve and brachial artery. Longitudinal gray-scale (a) and color Doppler (b) 12-5 MHz US images over the antecubital fossa demonstrate the normal appearance of the median nerve (white arrows in a) and the brachial artery (open arrows in b). Both lie superficial to the brachialis muscle (hr). Note the humeral capitellum (HC) and the radial head (RH). The inserts at the upper left side of the figures indicate probe positioning... 

In the anterior elbow, cubital bursitis and ganglion cysts are definite indications for US-guided injections (Fig. 18.18). Because the brachial vessels... 

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