Left brachiocephalic vein perforation: computed tomographic features and treatment considerations

Objective: To report the clinical and computed tomographic findings of 5 cases of left brachiocephalic vein perforation (LBCVP). Methods: The clinical and imaging features of 5 patients with LBCVP (1 woman, 4 men; mean age, 57.6 years) encountered over the last 2 decades were reviewed. Results: Etiologies included left jugular central catheter penetration in 2 patients, blunt trauma in 2, and idiopathic in 1. All patients manifested acute chest pain with a widened mediastinum on chest radiographs. Characteristic computed tomographic features included a cord-like hematoma along the course of the left brachiocephalic vein associated with a left upper anterior mediastinal hematoma (AMH). Three clinically stable patients with AMH smaller than 5 cm convalesced after conservative treatment and 2 clinically unstable patients with AMH bigger than 7 cm recovered well after surgery. Conclusions: Computed tomography is helpful in diagnosing LBCVP. Under close surveillance, patients with stable LBCVP with AMH smaller than 5 cm may be managed conservatively. However, emergency surgery is warranted if there are any signs of instability.