Unsuspected Herniated Lung Obstructing the Right Internal Jugular Vein and Internal Carotid Artery in a Patient with Thoracic Outlet Syndrome: MRI/MRA and MRV.

61-year-old, right-handed female complained of tingling and numbness in the ulnar aspect of the Aleft hand eight weeks prior to a second orthopedic evaluation. She had presented twelve years earlier with right neck and shoulder pain. She underwent physical therapy and practiced yoga, with some relief. One year prior to her second evaluation she was a victim of domestic violence and also involved in a motor vehicle accident. Her symptoms progressed to include increased pain over the right neck and both shoulders; episodic headaches; back pain radiating down into both legs; fainting at high altitudes, and tingling and numbness (paresthesias) radiating into the extensor surface of the left arm and down into the 3rd, 4th, and 5th fingers of her left hand. Electromyography and nerve conduction studies were positive for mild sensory C8/T1 dysfunction, but negative for left cervical radiculopathy or brachial plexopathy. Physical examination revealed blood pressure 110/70, pulse 72, and temperature at 36.5 C; forward rotated shoulders, right drooped as compared to left; tenderness to palpation over the base of the left neck and supraclavicular fossa, and complaint of pain when the neck was turned to the right or to the left. The requesting neurologist suspected thoracic outlet syndrome