Hercules and his Mysterious Strokes

Submitted by jchuen on 2 August 2014 - 6:35pm

Recently I came across the story of Kevin Sorbo, the actor from Hercules: The Legendary Journeys which I must profess I never saw. I did, however see Xena: Warrior Princess where Kevin featured as Hercules.

According to Neurology Now, in 1997 whilst promoting a film Kevin experienced pain in the left arm.

Out of the blue, he began experiencing troubling symptoms in his left arm and hand, including intermittent pain, aching, tingling, and cold sensations.

“At the time, I was promoting the feature film Kull the Conqueror. I had several doctors on my publicity tour check me out, but they didn't believe it was anything serious,” Sorbo recalls. “I even had what seemed like a rational explanation, having recently injured my ulnar nerve—the funny bone.”

After this he went on to see a chiropractor who manipulated his neck, and the following day he developed blurred vision, dizziness, slurred speech, and difficulty walking.

According to the article, he was subsequently by a radiologist at Cedars-Sinai Medical Center in Los Angeles who apparently diagnosed a stroke, and identified blocked arteries in the left hand and an aneurysm in the shoulder. Kevin then went on to have this aneurysm coil embolised (or blocked off via a catheter from the groin, a minimally invasive procedure available for some types of aneurysms) though it is unclear from the media and other reports whether the strokes were affecting the front (anterior circulation) or back (posterior circulation) of his brain. Presumably his radiologist knows from the MRI scans.

In any case Kevin Sorbo went on to make a good recovery and some fingers have been pointed at the chiropractic manipulation causing the strokes.

So what does this have to do with Vascular Surgery and what sparked my interest?

Well, first of all, aneurysms in the shoulder are rather unusual. There are really only a few that we see, and the most common is a subclavian artery aneurysm. The subclavian artery supplies the arm and clots in this artery can cause blockages to the hand with pain, cold, tingling and numbness, and weakness. In the worst case scenario it can damage the muscles of the arm and cause ulcers and gangrene of the hand.

Subclavian artery aneurysms don't usually appear out of nowhere. There are a few rare inherited or primary conditions that can cause them but in most cases they appear due to either a long-term blockage from atherosclerosis at the origin, or start, or the subclavian artery, known as a post-stenotic dilatation (highly unlikely in a young man like this), or as a result of recurrent injury from thoracic outlet compression syndrome.

What is thoracic outlet compression syndrome? Well, essentially the arteries, veins and nerves of the arm pass through a small triangular space in the neck called the thoracic outlet. This space is squeezed between two muscles and the first rib. In some patients there can be an extra rib or a ligament that squeezes this space in certain positions, such as lifting your arms over your head. Rarely a fractured first rib can heal with a callus that reduces this space.

In other patients, the muscles can enlarge abnormally (known as "scalene hypertrophy") and is usually seen in weightlifters and bodybuilders, though it is also seen in athletes such as basketballers (Andrew Gaze is reported to have sustained an upper limb DVT from Venous Thoracic Outlet Compression Syndrome, also known as Paget-Schrötter Sydrome [NEJM Image, Medscape Summary]) or baseballers (eg Jaime Garcia or Chris Carpenter, both of the St Louis Cardinals), swimmers and even ice hockey players (see Adam McQuaid). In others the angle between the clavicle (collarbone) and first rib can pinch these structures causing costoclavicular compression.

The nature or presentation of the problem varies based on which structures are affected. Venous compression causes congestion, swelling and aching of the arm and occasionally can cause a blood clot or DVT in the vein. Rarely this can go to the lung and cause a pulmonary embolus. Arterial compression causes pale, tingling and numb hands when the arms are elevated, premature tiredness and cramping of the arm when exercising (claudication) and a damaged artery can become aneurysmal and send clots to the hand. Nerve compression causes intermittent or constant tingling, numbness and weakness of the arm and sometimes can cause severe chronic pain syndromes that are sometimes impossible to fix completely.

Earlier this year our team at the Austin Hospital in Heidelberg, Melbourne described a case of arterial thoracic outlet syndrome with subclavian artery aneurysm in a young girl, presenting as a stroke. This is unusual because clots in subclavian artery aneurysms should go down the arm, not backwards to the brain. Nevertheless, our experience suggests that this is rare but possible on the right side.

So what happened to Hercules, or Kevin Sorbo? Well, I would suggest that he had an arterial thoracic outlet syndrome with a damaged subclavian artery that has become aneurysmal. This has formed clots, some of which have gone down the arm and given him his symptoms over time. Chiropractic neck manipulation (not a good idea at the best of times, given the association with carotid and vertebral artery dissection and stroke) may have squeezed clot out of the aneurysm backwards into the left vertebral artery, going up the brain and causing his strokes.

So mystery solved? Perhaps. If all of this is true then instead of having the aneurysm coil embolised he should have had his thoracic outlet decompressed by having his first rib resected and the subclavian artery reconstructed by a vascular surgeon. Nevertheless, what is best treatment must be decided on individual circumstances, and presumably Kevin has had the best treatment that was available for him at that time, in his particular situation.