94 Annals of the Rheumatic Diseases 1994; 53: 94-99 Postmortem angiographic study of degenerative Ann Rheum Dis: first published as 10.1136/ard.53.2.94 on 1 February 1994. Downloaded from vascular changes in arteries supplying the cervicobrachial region Leena I Kauppila, Antti Penttila Abstract belong to those musculoskeletal disorders that Objectives-To study the prevalence of are common in the population, but whose degenerative changes in the arteries possible aetiological and pathological mech- supplying the cervicobrachial region, and anisms are by no means clear. These disorders their relation to cervical disc degener- have heterogeneous symptoms such as pain, ation. tenderness, stiffness and fatigue felt diffusively Methods-Fifty postmortem aortic arch over the posterior neck and shoulder area, and angiographies were evaluated for occlu- exacerbated by physical exertion."1A sions and variations in the diameter ofthe Though many research workers have vertebral arteries and thyro- and costo- suspected local ischaemia as one possible cervical trunks, as well as for tortuosity, explanation for the symptoms,59 we could find average diameter and the highest cervical no reports concerning the condition of arteries level to which the ascending cervical supplying the neck-and-shoulder region. artery, an upward continuation of the Atherosclerosis, manifesting itself in middle thyrocervical trunk, and the deep cervical age or even earlier, and being very common in artery, an upward continuation of the carotid and vertebral arteries, might also affect costocervical trunk, ascended. the thyrocervical and costocervical trunks, the Results-Localised segmental narrow- main feeders of the cervicobrachial region. ings, usually situated close to the ostia of Branches of these trunks, together with the arteries, were common, whereas total branches of the vertebral arteries, supply the occlusions were rare. Thirty (60%) of the cervical spine, as well as the musculature of the subjects showed a segmental narrowing at neck and upper shoulder regions."'O3 least in one of the six arteries analysed, Ageing ofthe vascular system does not occur http://ard.bmj.com/ while only two (4%) showed an occluded simultaneously in all the arteries; some artery, which in both the cases was the branches of the subclavian artery are more thyrocervical trunk. Narrowings were often affected than others. Stenosis of the most common in vertebral arteries, vertebral artery at its origin from the superior followed by costocervical and thyrocer- aspect of the subclavian artery is a well-known vical trunks. Segmental narrowings, as atherosclerotic manifestation,14 15 whereas the well as general tortuosity of the arteries, internal mammary artery, leaving the on September 23, 2021 by guest. Protected copyright. increased with age. It was also found that subclavian artery from its lower surface ascending and deep cervical arteries did opposite the vertebral artery, usually escapes not run as high up in the posterior neck arterial disease.'6 The fate of the thyro- and muscles in older people as in younger costocervical trunks, originating from the ones. Twenty three subjects with marked subclavian artery just after the orifice of the cervical disc degeneration showed on vertebral artery, is unknown. average 2-3 arteries with segmental To dermine the general condition of the narrowings, while the corresponding arteries supplying the cervicobrachial area, we figure for twenty seven subjects without investigated the prevalence of degenerative disc degeneration was 06. Both the changes in the vertebral arteries and thyro- and segmental narrowings and the disc costocervical trunks. We also analysed the degeneration, however, were strongly highest cervical level to which the upward associated with age, and thus the causality continuations of these trunks, the ascending between the former two remained cervical artery from the thyrocervical trunk and Department of the deep cervical artery from the costocervical Forensic Medicine, unclear. University ofHelsinki, Conclusion-The study showed that trunk, ascended. Furthermore, cervical disc Kyt6suontie, Helsinki, degenerative changes are common in the degeneration was assessed to learn whether it Finland arteries supplying the cervicobrachial had any relationship with arterial disease. L I Kauppila A Penttila area, indicating that impaired blood flow Correspondence to: might play a part in some cervicobrachial Dr Leena I Kauppila, disorders. Materials and methods Department ofForensic Medicine, University of NECROPSY Helsinki, PO Box 40, (Ann Rheum Dis 1994; 53: 94-99) Aortic arch angiography was performed on 55 Kytosuontie 11, SF-00014 at the of Forensic Helsinki, Finland. cadavers Department as well as Medicine, of Helsinki. Five of the Accepted for publication Cervical disc degeneration, poorly University 15 October 1993 defined cervicobrachial pain syndromes, cases had to be omitted from the study due to Postmortem angiographic study of degenerative vascular changes in arteries supplying the cervicobrachial region 95 ACA This technique of injection will result in the filling of arteries down to 0 1 mm in diameter. Ann Rheum Dis: first published as 10.1136/ard.53.2.94 on 1 February 1994. Downloaded from This angiographic method is in routine use in postoperative necropsies at the Department of VA Forensic Medicine, University ofHelsinki. It is DCA described in detail elsewhere.17 When the contrast medium had solidified, the trachea, oesophagus and thyroid gland were removed en CCT bloc with their contrast-filled vessels in order to provide more selective angiographies of the musculoskeletal structures of the cervical TCT _ region. The vertebral arteries and the thyrocervical and costocervical trunks, as well 6'W-, as their upward continuations; the ascending cervical artery and the deep cervical artery, were then examined in anteroposterior and lateral radiographs. Other branches of these trunks could not be analysed from these two radiological projections. In some cases the first parts of the thyrocervical and costocervical trunks were not clearly seen in angiograms due to their location on the dorsal side of the subclavian artery or r behind each other. In these cases (7 subjects), co AMA after the angiography, the subclavian artery was divided and the vulcanised cast from it and from the first parts of the vertebral artery and thyro- and costocervical trunks removed for macroscopic analysis for narrowings (fig 1). Figure 1 Cast ofthe subclavian artery (SCA) with beginning ofthe vertebral artery (VA); thyrocervical trunk (TCT) with ascending cervical artery (ACA); and costocervical EVALUATION OF ANGIOGRAMS trunk (CCT) with deep cervical artery (DCA). Internal mammary artery (AMA). The following characteristics were recorded from the angiograms: occlusions, variations in the diameter of the vessel (localised segmental narrowing of the contrast-medium pillar), technical failure of the angiography, so tortuosity, average diameter; and also for the http://ard.bmj.com/ altogether 50 bilateral cervical angiographies, ascending and deep cervical arteries, the performed on 40 men and 10 women, were highest cervical level either one of them analysed. Eligible cadavers had not died of an reached. injury to the head or neck region, but in other Variations in the diameter of the vessel were respects the material was unselected. Their determined for the vertebral arteries and for mean age was 48-8 years; range 16-76 years. the thyrocervical and costocervical trunks, but The angiographies were carried out in con- not for the ascending cervical and deep cervical on September 23, 2021 by guest. Protected copyright. nection with routine necropsies 1-9 days after arteries, because the small diameter of these death. vessels made assessment difficult and Drug or alcohol overdose, or suicide was the unreliable. If the first parts of the analysed cause of death in 46% (23) of the cases, arteries were not distinctly visible in angio- coronary artery disease in 38% (19), other grams, the casts when removed were used for vascular diseases in 6% (3), and a variety of analysis. Narrowings to no less than one fifth single diseases in 10% (5). of the lumen were recorded from the casts, equalling the smallest narrowings visible in the angiograms. ANGIOGRAPHIC TECHNIQUE Tortuosity of the vertebral, ascending The cervical arterial system was bilaterally cervical and deep cervical arteries was classified investigated by aortic arch angiography. The into three categories: 1 = straight; 2 = slightly aorta was transected from its ascending part, tortuous; 3 = tortuous. Straight and distinctly cannulated with a mouthpiece, and the tortuous vessels were first separated into common carotid and internal mammary categories 1 and 3. The borderline cases with arteries were clamped. The subclavian arteries probable or mild tortuosity difficult to classify were clamped beyond the origin of the as either straight or distinctly tortuous formed thyrocervical and costocervical trunks. The category 2. Because the degree of tortuosity contrast medium, consisting of liquid silicone was in most cases symmetrical, the right and rubber (Silicon Kautschuk RTV-Vergussmasse left sided arteries were analysed jointly. K, Wacker Chemie Cmbh, Munich, Germany) The average diameter of the vertebral, made radiopaque with 20% lead oxide, mixed ascending cervical and deep cervical arteries with 2% solidifier (Haerter T), was injected was graded into three categories: 1 = normal; under a