A 56-years-old male presented with complaints of chest pain for which he was evaluated and found t have triple vessel disease. The patient had an emergency CABG under median sternotomy incision. The Patient developed left Horner syndrome the very next day after surgery.
The patient proceeded with CT and MR Imaging to find out the cause of radicular pain and horner's syndrome. Imaging with CT and MRI revealed undisplaced fracture with oedema showing STIR hyperintense signals in the neck of left 1st rib. Mild soft tissue oedema was also seen near the fractures. Edematous changes and asymmetric thickening were seen in the left stellate (inferior cervical) ganglion with increased IR signal intensity in the left C8 nerve root which was likely due to oedema.
Background
Horner's syndrome occurs due to disruption of the oculosympathetic pathway, which consists of a long sympathetic three order neuron pathway extending from the hypothalamus to orbit. Causes of horner's syndrome include hypothalamic, thalamic, and brainstem ischemia, demyelination or tumours, preganglionic causes like a cervical rib, Pancoast tumour, trauma, and tumours, postganglionic causes include internal carotid artery dissection or aneurysm and cavernous sinus pathology. [1]
Clinical Perspective
Horner's syndrome classically presents as an ipsilateral enophthalmos, blepharoptosis, pupillary miosis, and facial anhydrosis. Affected extraocular movements, ipsilateral conjunctival injection, changes in accommodation, and reduced intraocular pressure may also occur. [2]
Pharmacologically, topical Cocaine is used to confirm Horner's syndrome in subtle cases. Topical Apraclonidine, an alpha-adrenergic agonist, is also used in diagnosis.[3]
Imaging Perspective
Radiologically, horner's syndrome is approached by the aetiology and suspected site of pathology producing horner's syndrome. In central lesions, MRI is the most appropriate method of imaging which provides good soft-tissue contrast and spatial resolution with a major role in detecting the central causes of horner's syndrome. In preganglionic lesions, both CT and MRI have a role because horner’s syndrome is usually caused by tumours or trauma. MRI is performed to include the cervical spine, thoracic inlet, and upper thoracic spine, and coronal images to include coexisting brachial plexus injury. Contrast-enhanced CT may be required if apical lung or upper mediastinum or anterior neck lesion is considered. Postganglionic Horner’s syndrome evaluation includes MRI, CT angiography, and digital subtraction angiography to detect carotid artery dissection or thrombus within the vessel. Skull base fractures are detected using bone algorithm CT and the para sellar region imaging is better with MRI. [4]
Outcome
The patient was advised to rest, antiinflammatories, and steroids with which he improved clinically. Median sternotomy remains the incision of choice for the majority of cardiothoracic surgical procedures. [5] The complication rate is reported at approximately 0.5–5%. Complications include hardware complications like wire migration, sternal wire fracture, and wire rotation. Osseous complications like cartilaginous fracture, osseous fracture, sternal dehiscence, malunion or nonunion, infectious complications like osteomyelitis, mediastinitis, abscess formation, and postoperative hematoma can also occur. [6] There is no individual treatment for horner's syndrome. The management involves diagnosing and treating the underlying cause of horner's syndrome.
Take-Home Message:
We present this case because median sternotomy complication producing horner's syndrome is sparsely described in the literature and hence including this complication in the checklist for horner's syndrome in post sternotomy patients is of utmost importance.
Written informed patient consent for publication has been obtained.
Fracture of left first rib and thickening of cervical ganglion
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Based on the provided CT and MRI images, local changes can be seen in the left upper thoracic region or cervicothoracic junction area (as indicated by the arrow) near the vertebral body and transverse process. Slightly abnormal signals suggest possible local postoperative irritation, contusion, or inflammatory changes. No obvious signs of a mass lesion were noted, and there is no clear vertebral fracture or extensive bony destruction. The soft tissue in the corresponding area appears relatively blurred, which could be associated with postoperative reaction, potential inflammation, or small-scale soft tissue injury.
The patient developed ipsilateral (left-sided) Horner’s syndrome following a median sternotomy coronary artery bypass surgery. In conjunction with imaging findings showing soft tissue and local structural abnormalities in the region described, this may indicate involvement of the cervical sympathetic trunk or stellate ganglion due to surgical procedure or postoperative inflammatory response, consistent with clinical presentation.
Neoplasms such as a neck or lung apex tumor (Pancoast tumor) can also cause Horner’s syndrome; however, the patient had no related symptoms before surgery, and imaging did not indicate any obvious masses or lung apex abnormalities, making this less likely.
Internal carotid artery dissection can present with Horner’s syndrome, but current imaging does not show clear vascular lesion signs. Considering the postoperative timeline and local tissue changes, nerve injury is more likely.
In summary, taking into account the patient’s age, previous coronary artery disease, type of surgery (median sternotomy), and the onset of left-sided Horner’s syndrome on the day following surgery, the most likely diagnosis is:
“Left-sided Horner’s syndrome due to postoperative sympathetic trunk involvement (a complication of median sternotomy).”
(If further verification is needed, a high-resolution MRI assessment of the cervical sympathetic trunk and related soft tissues can be performed to rule out other rare space-occupying or vascular lesions.)
Based on the current findings, the specific treatment and rehabilitation strategies include:
Since the median sternotomy requires sufficient healing, early exercise should focus on protecting the incision, improving circulation, and maintaining basic fitness.
These exercise guidelines should follow the FITT-VP principle (Frequency, Intensity, Time, Type, Progression, Individualization) and be adjusted based on the patient’s actual tolerance and cardiopulmonary function.
Special Note: If the patient has osteoporosis or chronic cardiopulmonary diseases, exercise intensity and progression should be appropriately reduced, under the guidance of a professional rehabilitation team to ensure safety.
This report is a reference analysis based on the existing clinical and imaging data and does not replace face-to-face consultation or a personalized medical decision by a professional physician. For specific treatment decisions, please combine the clinical situation with advice from specialized doctors.
Fracture of left first rib and thickening of cervical ganglion
