629

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Sonography the Wrist

of the Radial

Artery

at

Gretchen

A. W. Gooding1

The radial artery as a superficial structure at the wrist is susceptible both to direct penetrating injury and to blunt trauma, with the potential development of both false and true aneurysms. This report summarizes the sonographic features of seven consecutive patients who were referred for evaluation of the radial artery. The diagnoses include two cases of radial artery aneurysm, one tortuous nonaneurysmal artery, two cases of arteriovenous fistulae (one surrounded by fluid and one aneurysmal), a ganglion, and an inflammatory mass of the wrist. Although radial aneurysms are unusual and angiography may be required to define the nature and extent of distal embolization to the hand, the nature of a palpable

aneurysm
resolution

in this region, vascular

sonography.

vs avascular,

is easily and quickly

assessed

with high-

At the wrist, the radial artery is a palpable, superficial vessel susceptible to both blunt and penetrating injury [i , 2]. True aneurysms are associated with blunt trauma from injury to the media [3, 4], whereas false aneurysms are associated with penetrating injuries of the arterial wall, which with enlargement, result in secondary trophic changes and symptoms related to nerve compression. The aneurysms are distinctly uncommon. The literature suggests that wrist angiography is the technique of choice for detecting the presence of thrombosis or distal ernbolization and for determining the location and morphology of aneurysms [i]. Alternatively, soft-tissue masses in the area need to be distinguished from radial artery abnormalities, and sonography is highly regarded in the examination of such superficial structures [5, 6]. This report summarizes the sonographic features of seven consecutive patients referred for evaluation of the radial artery (Fig. i ). Two patients had false aneurysms, two had iatrogenic arteriovenous fistulas, one had radial artery tortuosity, and two had extravascular lesions.

Subjects

and Methods of the wrist; pulsations in wrist in both had a wateragent.

Received September 14, 1987; accepted after revision November 1 3, 1987. I Department of Radiology, University of California, San Francisco, San Francisco, CA 941 43 and Veterans Administration Medical Center, San Francisco, CA 941 21 . Address reprint requests to 0. A. W. Gooding, Dept. of Radiology, VA Medical COnter, 41 50 Clement St., San Francisco, CA 94121. AJR 150:629-631, March 1988 0361-803X/88/1 503-0629 American Roentgen Ray Society

Seven men, ranging in age from 40 to 70 years, had palpable abnormalities the abnormality pulsated in five, had a transmitted pulse in one, and had no another. Each patient had high-resolution 10-MHz real-time sonography of the longitudinal and transverse planes. The transducer (a mechanical, linear scanner) bath interface (Picker, Microview, Cleveland, OH). Acoustic gel was the coupling

Results

Sonography showed a number of abnormalities. In two patients, there were pulsatile false radial-artery aneurysms that were subsequently confirmed by angiography (Figs. 2 and 3). In one, there was a tortuous nonaneurysmal radial artery, also confirmed by angiography (Fig. 4). In two patients on hemodialysis, there was

630

GOODING

AJR:150,

March

1988

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Fig. 1.-Longitudinal
radial artery.

sonogram

shows

normal

Fig. 2.-Longitudinal sonogram shows fusiform aneurysm of radial artery (arrow).

small

Fig. 3.-Longitudinal sonogram shows cular radial artery aneurysm (arrow).

sac-

Fig. 4.-A and B, Longitudinal sonograms rather than aneurysm (arrows along tortuous C, Angiogram shows tortuous radial artery

define what appears wall of radial artery). (arrow).

in A to be a radial

artery

aneurysm.

More

meticulous

evaluation

(B) defines

tortuosity

one instance of fluid around an iatrogenic arteriovenous fistula (Fig. 5) that was subsequently proved to be infected. There was also a case of radial aneurysmal dilatation of another iatrogenic fistula. One of the two patients with a radial artery aneurysm had a distinct dilatation of the right radial artery in a fusiform configuration (Fig. 2). The other patient had a distinct saccular aneurysm emanating from the wall of the radial artery (Fig. 3). These false aneurysms were well discriminated from the proximal normal radial artery (Fig. i) and had distinct pulsations on real-tirne sonography without any perivascular cornponent. Both of these patients had had previous arterial line placement in the area. One of them had developed a periarterial abscess and, subsequent to that, a septic arthritis; the other had developed a radial artery aneurysm that produced showers of septic ernboli to the fingers. A third patient who had had a penetrating injury of the radial artery had what at first glance appeared to be a radial

artery aneurysm sonographically, but closer inspection revealed a markedly tortuous bend of the radial artery; this was subsequently confirmed by angiography (Fig. 4). Another patient had a palpable mass with a faint pulsation clinically at the radial wrist, which on sonography appeared to be a tiny ganglion of the flexor tendon sheath next to the normal radial artery (Fig. 6) [5]. A seventh patient with a nonpulsatile mass in the same area was subsequently proved to have coccidioidornycosis, a disease process emanating from an adjacent septic arthritis and not affecting the radial artery (Fig. 7). These last two patients were the only ones who did not have a confirmatory angiogram.

Discussion

On sonography, smooth wall tube

the normal with a distinct

radial artery appears as a pulsation. An aneurysm of

AJR:150, March 1988

RADIAL

ARTERY

AT

THE

WRIST

63i

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Fig. 5.-Transverse
(arrow) around

sonogram

shows

fluid

Fig. 6.-Transverse
(G) adjacent to radial

sonogram
artery (R).

shows ganglion

Fig. 7.-Longftudinal

sonogram

shows

dis-

an arterlovenous

shunt at wrist.

crete inflammatory mass of coccidioidomycosis (arrows), at wrist separate from radial artery (which is not seen in image).

the radial artery produces a focal expansion, either fusiform or saccular, that may or may not contain visible thrombus. Arteriography is an expensive, invasive, but appropriate method of determining the nature and extent of the involvement of the radial artery. Angiography is required to define the nature and extent of distal ernbolization to the hand and can pinpoint the radial artery as a possible source. However, high-resolution real-time sonography, which does not require contrast material, is a quick and effective method of diagnosing radial abnormalities. High-resolution sonography allows a rapid diagnosis-that is, an aneurysm or tortuosity vs a mass adjacent to the radial artery-with a transmitted pulse. The value of sonography of the radial artery is that not only can a normal vessel be distinguished from an aneurysm, but the characteristics of the wall can be defined and pulsation appreciated. In addition, the nature of the tissue beyond the wall can be assessed, and adjacent solid masses or fluid

collections that would not be shown by angiography may be identifiable. Either solid or cystic extravascular lesions around the wrist, such as the ganglion and the inflammatory mass, can be distinguished from the radial artery [5]. REFERENCES
1 . Eugenidis N, Fink F, Anabitarte and palmar arteries. Radiology M. False traumatic aneurysms 1976;121 :331 -332 of the radial

2. Duchateau

J, Moermans

J-P.

False aneurysms

for the radial artery. J

Hand Surg [Am] 1985;10-A(1): 140-141 3. Ho PK, Dellon AL, Wilgis EFS. True aneurysms of the hand resulting from athletic injury: report of two cases. Am J Sports Med 1985:13(2): 136-1 38 4. Leitner DW, Ross JS, Neary JR. Granulomatous radial arteritis with bilat-

eral, nontraumatic,

true arterial aneurysms

within the anatomic

snuffbox.

J Hand Surg [Am] 1985;10-A(1): 5. De Flaviis L, Nessi A, Del Bo ultrasonography of wrist ganglia. 6. Gooding GAW. Tenosynovitis of J Ultrasound Med (in press)

131 -1 35 P. Calon G, Balconi G. High-resolution JCU 1987:15:17-22 the wrist: a sonographic demonstration.