Acute Median Neuropathy Due to Persistent Median Artery Thrombosis Following Cupping Therapy: The Diagnostic Value of High-Resolution Ultrasound.

Persistent median artery (PMA) thrombosis is a rare cause of acute median neuropathy that may mimic typical carpal tunnel syndrome. We report the case of a 45-year-old man with several months of intermittent numbness without weakness affecting the radial three-and-a-half digits of the right hand who developed rapidly worsening pain, forearm erythema and swelling, distal coldness, and finger weakness following acupuncture and cupping therapy. High-resolution ultrasonography revealed a bifid median nerve and an enlarged PMA containing a long-segment hypoechoic thrombus. Spectral Doppler demonstrated progressive flow impairment, with preserved proximal pulsatile flow progressing to a dampened monophasic waveform at the proximal carpus and then to absent flow distal to the carpal tunnel inlet. Preserved flow in the ulnar and common digital arteries indicated adequate collateral perfusion. Anticoagulation with enoxaparin followed by dabigatran etexilate resulted in substantial pain relief. This report demonstrates the value of high-resolution gray-scale and Doppler ultrasonography for identifying PMA thrombosis, characterizing arterial occlusion, and assessing associated median nerve and distal vascular involvement. PMA thrombosis should be considered in rapidly progressive median neuropathy accompanied by severe pain, distal coldness, or other signs of vascular compromise.