A 25 year old male patient presented with complaints of pain and swelling near medial aspect of left cubital fossa following a blunt trauma two weeks prior. On examination the swelling was pulsatile in nature and a systolic bruit was appreciable on auscultation.
Colour doppler ultrasound of left upper arm revealed a patent pseudoaneurysm originating from the brachial artery measuring approx 10 by 6mm. The aneurysm was surrounded by a hypoechoic soft tissue (probably a haematoma) of 8mm thickness. Distally the radial and ulnar artery showed normal flow velocity with no evidence of stenosis. These findings were also appreciable on CT angiography of upper limb.
Pseudoaneurysm of the upper extremity is rarer as compared to the lower extremity. Pseudoaneurysms or false aneurysms are formed usually as a sequelae to trauma resulting in penetration of the vessel followed by haemorrhage and extravasation. They lack all the 3 layers of the arterial wall. True aneurysms are formed when the vessels are damaged and lead to dilatation and have all the 3 layers- intima, media and adventitia.
In most cases, brachial artery aneurysms are psedoaneurysms. Causes for brachial artery pseudoaneurysms are broadly classified into 3 castegories: [1] Congenital; [2] Traumatic e.g iatrogenic, penetrating or blunt injury, humerus fracture, supracondylar fracture, crutch use etc; and [3] Systemic causes e.g. Ehler Danlos syndrome, Kawasaki Disease, Mycotic aneurysm, Behcet's disease, Giant cell arteritis etc.
It takes weeks to months for a brachial artery pseudoaneurysm to form. Patients usually present with induration, pain and an expanding pulsatile swelling which is accompanied by a systolic bruit on auscultation. There are various modes of diagnostic imaging including doppler ultrasonography, Angiography, CT Angiography and MRI. Selective arteriography is considered the gold standard, but because doppler ultrasound is faster, cost effective, non-invasive, and more readily available, it is the preferred modality of choice. Doppler ultrasound usually demonstrates a turbulent flow with vessel dilatation.
Early Diagnosis of upper limb pseudoaneurysms is of utmost importance as they are known to cause thromboembolism, leading to ischaemia and gangrene, and finally resulting in amputation. Other complications include neurapraxia, compartment syndrome, rupture and haemorrhage. [1, 2, 3]
There are several treatment options for pseudoaneuryms based on size, location and accessibility. Small pseudoaneuryms can be treated by Ultrasound Guided Compression (USGC). It is also the first line treatment for non-operative pseudoaneurysms. In this technique pressure is applied by the transducer over the center of the neck of the pseudoaneurysm until flow is stopped for about 10-20min and then slowly released. If the flow resumes, the pressure is immediately reapplied. This is repeated until the flow into the pseudoaneurym has completely stopped. The success rate for USGC is between 60-90%. However it has several disadvantages- the compressions are painful and time consuming, high failure and recurrence rates in patients on anticoagulation. Other newer non-invasive techniques include- percutaneous injection of thrombin and endovascular covered stent exclusion. When pseudoaneurysms are large, open surgery is required and these options include primary repair with sutures or a patch angioplasty, pseudoaneurysm excision, or embolisation. [3, 4, 5]
Left Brachial Artery Pseudoaneurysm
1. Color Doppler Ultrasound: A localized vascular lesion is visible in the medial area of the left cubital fossa, appearing as a sac-like protrusion with turbulent blood flow internally. This suggests a defect or rupture in the vascular wall, with blood flowing into the sac. A “neck” connecting to the main vessel can be observed, consistent with pseudoaneurysm characteristics in combination with clinical pulsation and bruit.
2. CT Angiography: A localized enhancing lesion with relatively clear borders is noted along the course of the left brachial artery. It connects to the main artery through a narrowed channel. Mild edema and swelling of the surrounding soft tissue are present. No obvious fractures or bone destruction are identified. These findings support the presence of a pseudoaneurysm.
3. Adjacent Tissue Structures: The humerus and surrounding soft tissue show no obvious fractures or structural abnormalities. No significant nerve compression or displacement is observed; however, subsequent complications such as nerve involvement or increased compartment pressure (e.g., compartment syndrome) cannot be ruled out.
1. Brachial Artery Pseudoaneurysm: This best fits the clinical and imaging findings. The patient has a clear history of trauma, localized pain, swelling, pulsation, and imaging evidence of arterial wall disruption forming a sac-like cavity.
2. True Aneurysm: Typically involves an expansion containing all three layers of the arterial wall and is less common in this context. The history of trauma strongly suggests a “pseudo” rather than a true aneurysm.
3. Local Hematoma or Hemangioma: Both can present as localized masses. However, hemangiomas are often congenital or benign proliferations, and hematomas generally lack sustained blood flow channels, differing from Doppler findings in this case, thus they can be mostly ruled out.
Considering the patient’s age of 25, the onset of a pulsatile mass two weeks after trauma, and the presence of arterial blood flow in a pseudo-cystic cavity as seen on ultrasound and CT angiography, the most likely diagnosis is:
Brachial Artery Pseudoaneurysm
If available, further vascular angiography could help precisely evaluate the arterial defect. However, based on current findings and clinical presentation, the diagnosis is fairly certain.
1. Treatment Options:
• Ultrasound-Guided Compression (USGC): Suitable for small pseudoaneurysms with a narrow neck amenable to direct compression. By applying sustained pressure over the neck under ultrasound guidance, blood flow is cut off to promote thrombosis. Advantages include minimal invasiveness and reduced surgical risk; however, success rates are lower in patients on anticoagulation therapy, and the procedure can be painful.
• Ultrasound-Guided Thrombin Injection: Injecting thrombin into the pseudoaneurysm cavity leads to rapid closure. It is relatively straightforward with a high success rate, but requires close monitoring for potential thrombus extension.
• Endovascular Stent or Covered Stent Placement: For larger vascular lumens, wide-neck pseudoaneurysms, or when open surgery poses high risk, covered stents can be placed via endovascular intervention to seal the defect.
• Surgical Intervention: For larger pseudoaneurysms, high rupture risk, or cases unsuitable for minimally invasive methods, open surgical repair (including direct suture ligation or use of vascular grafts) may be selected.
2. Rehabilitation Plan and Exercise Prescription:
During both treatment and postoperative recovery, caution should be exercised to limit upper limb activity, preventing excessive stretching or impact that could lead to pseudoaneurysm re-rupture or expansion. A staged rehabilitation and exercise prescription is recommended:
• Acute Phase (first 2–4 weeks): Emphasize rest, immobilization, and protective movements. Avoid heavy labor and vigorous exercises. Basic daily activities are permitted, such as light flexion and extension of the elbow or wrist, but any action increasing brachial artery pressure should be avoided.
• Recovery Phase (4–8 weeks): After lesion stabilization and wound healing, gradually introduce light-resistance exercises for the upper limb. Small dumbbells or resistance bands can be used for joint mobility and muscle strength training, 5–10 minutes per session, 2–3 sessions per week. Increase intensity gradually, and carefully monitor for pain or swelling.
• Consolidation Phase (after 8 weeks): If the pseudoaneurysm has been treated and has healed well, moderate-intensity exercises can be considered. These may include upper limb strength training (10–15 repetitions per set, 2–3 sets), and gradually increased band resistance or weight. Sudden impacts or high-risk activities like arm wrestling should still be avoided to prevent repeated vascular injury.
Throughout rehabilitation, follow the FITT-VP principle (Frequency, Intensity, Time, Type, Progression, and Volume), adjusting based on individual pain tolerance and swelling. Seek medical attention if significant pain, bleeding, sudden swelling, or abnormal skin temperature occurs.
Disclaimer: The above report is based on the currently provided medical history and imaging data for reference only. It cannot replace in-person consultation or professional medical advice. If you have any questions or experience changes in your condition, please consult a specialist or visit a hospital promptly.
Left Brachial Artery Pseudoaneurysm
