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Chapter Supplement 3

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The Many Causes of Rib Notching

Lawrence R. Goodman, MD

Felson: We offer this chapter as a bonus. While it doesn't quite mesh with the subject matter of the rest of the book, it is important
and does embody certain principles of chest roentgenology. Besides, it was available."

1
How many causes of rib notching do you know? Write them down:
You probably wrote coarctation of the aorta and then were stuck. That is by far the commonest, but there are many others.

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2
Notching of the inferior margin of a rib is generally caused by enlargement of one of 3 important structures in the intercostal space:
the artery , the vein, or the nerve.

* This chapter is based on an exhibit by M. L. Boone, B. E. Swenson, B. Felson, H. B. Spitz, and A. S. Weinstein, shown in 1963
at the American Roentgen Ray Society meeting in Montreal and at the Radiological Society of North America meeting in
Chicago. Most of the illustrations were taken, with permission, from an article of the same title by M. L. Boone, B. E. Swenson,
and B. Felson, published in Am J Roentgenol 91:1075, 1964 (Charles C Thomas, Springfield, Illinois).

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3
First, let's discuss the intercostal arteries. Certainly, the best known and most common cause of rib notching is coarctation
of the
aorta
. In this condition, notching is caused by the dilated and tortuous
intercostal
arteries.
A.

B.

Figure S3-1A

Figure S3-1B

Note the rib notching in Figure S3-1A. Incidentally, the terms scalloping (shallow wave-like indentations) and notching (narrow
deep indentations) are used interchangeably since these deformities have the same significance. In close-up, Figure S3-1B, note
notching under the posterior 3rd 6th ribs (arrows).

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4
A.

Figure S3-1C

Figure S3-1C is an angiogram of a coarctation beyond the left subclavian (arrow). Identify:
A.

brachiocephalic

artery

B.

left carotid

artery

C.

left subclavian

artery

Not surprisingly, they are very large.

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5
In coarctation, blood must bypass the aortic constriction to get to the abdomen and lower extremities. The collateral
pathways arise almost exclusively from the 2 subclavian arteries. The blood then passes via the thyrocervical, costocervical,
mammary
and internal
branches of the subclavian, and the subdivisions of these arteries, to reach the
posterior intercostals. The blood in these intercostals then flows [toward/away from] the descending aorta.

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A.

6
Trace the collateral flow from the subclavian to the posterior intercostal arteries in
Figure S3-2, etc. Let's review this again by means of an arterial flow chart:
Ascending aorta

(1)

right and left

subclavians
internal mammary

(2)
(3)

thyrocervical
costocervical
branches
posterior

(4)

intercostals
descending
thoracis aorta

Figure S3-2

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A.

The flow of fluids is always from the higher pressure to the lower pressure area. *
In coarctation, the notching usually involves several posterior ribs bilaterally,
from the 3rd through the 9th. The first 2 intercostal arteries do not connect
aorta
directly to the
and the last 3 have no connection to
the subclavian system (see Figure S3-2 again).

The anterior intercostals, arising from the internal mammaries, are paired in each
intercostal space. They do not lie close to the anterior ribs and therefore do not
notch them.

* Tu Hunghai: Chinese Med J 14.281, 1372 BC.

Figure S3-2

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8
If the coarctation lies distal to the left subclavian artery, as it almost always does, the notching will be bilateral. If the coarctation lies
proximal to the left subclavian artery, the rib notching will be [unilateral/bilateral].
A.
B.

Figure S3-3A

Figure S3-3B

The high pressure in the subclavian arteries in coarctation favors the filling of collateral pathways. When the left subclavian arises
distal to the coarctation (Figure S3-3A), the pressure in this artery is low and notching will only be present on the right .
The notching in this patient is confined to the right 4th to 6th ribs (Figure S3-3B).*
Patient: Doctor, I have big troubles. Some days I feel like a curtain.
Doctor: Pull yourself together, man.
* Courtesy Dr. John A. Campbell, Indianapolis.

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9
If there is an anomalous right subclavian artery that arises distal to the coarctation, the notching will be unilateral (Figure S3-4A).
Since little blood is reaching the right subclavian artery, the pressure in this artery is too low to permit collateral flow, and the notching
will be confined to the
side.
left
A.

B.

Figure S3-4A

Figure S3-4B

Figure S3-4B is an example of this. The left 6th and 7th ribs are notched (arrows).*
* Courtesy Dr. John A. Campbell, Indianapolis.

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10
Thus, unilateral rib notching can occur in coarctation, and one can then usually predict the pathologic anatomy of the aortic arch.
The notching is always on the [same/opposite] side as the subclavian artery, which comes off proximal to the coarctation.
A.

B.

Figure S3-4A

Figure S3-4B

* Courtesy Dr. John A. Campbell, Indianapolis.

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11
OK, let's summarize coarctation. The collateral flow is:
Aorta

B.

A.
(1)

right and left

subclavians

(2)

internal mammary

(3)
(4)

thyrocervical
costocervical
branches
posterior
Figure S3-4A

(5)

Figure S3-4B

intercostals

descending
thoracis aorta
* Courtesy Dr. John A. Campbell, Indianapolis.

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12
Rib notching involves the
[usually/seldom]

3rd

through the

9th

ribs. Are all these ribs notched in an individual patient?

13
left
More summarizing and then we are through with this. Notching confined to the right ribs usually indicates that the
subclavian artery arises distal to the coarctation. Notching confined to the left side usually indicates that the
right
subclavian
artery comes off distal to the coarctation.
Now let's really get down to work.

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14
In thrombosis of the abdominal aorta, the lower intercostal arteries serve as collaterals to the lower part of the body. They become
large and tortuous and may cause notching of the lower ribs. Obviously, here the intercostal artery flow is [toward/away from]
the aorta.
A.

Figure S3-5

In Figure S3-5 the thoracic aortogram shows abdominal aortic occlusion with dilatation of the 8th to 10th intercostal arteries, which
carry blood to the lower part of the body. Note the tortuous intercostals indenting the ribs.

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15
You have now learned 2 mechanisms and 2 causes of rib notching.
Mechanism
(a) High aortic obstruction. (Intercostal flow is
(b) Low aortic obstruction. (Intercostal flow is

toward
from

the aorta.)
the aorta.)

Cause
(1) Coarctation of aorta
(2) Thrombosis of abdominal aorta

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16
Deficient blood flow to the arm occurs following the Blalock-Taussig (subclavian-pulmonary
artery) anastomosis for tetralogy of Fallot. A good part of the arterial collateral flow to the
arm is:
A.
Aorta
posterior
intercostals
long and short thoracics
axillary
This may eventually result in [
rib notching.

unilateral

bilateral

Figure S3-6

Figure S3-6 shows a patient with unilateral notching of the 3rd to 7th left (arrows), which
appeared after a left Blalock-Taussig operation.

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17
"Pulseless disease" is caused by either arteritis (Takayasu's disease) or arteriosclerosis obliterans. It is associated with occlusion
arm
of 2 or more of the brachiocephalic arteries at their origin. This results in diminished flow to the
, similar to
Blalock-Taussig
that following the
operation, and the collateral flow is much the same. So here is another arterial cause
of rib notching.
A.

Figure S3-7

Figure S3-7 is an example of pulseless disease of all the great vessels arising from the aorta and shows definite notching (arrow).

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18
Following the Blalock-Taussig procedure and in pulseless disease, the blood flow in the intercostal arteries is [toward/away from]
the aorta. In these 2 conditions the rib notching will be on the [side of/side opposite] the occluded subclavian artery.

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19
You should now know 4 arterial causes of rib notching. Do you?
High aortic obstruction: (1)
coarctation
aortic
thrombosis
Low aortic obstruction: (2)
Subclavian obstruction: (3)
Blalock-Taussig operation
(4) pulseless disease

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20
A.
Next, we have several conditions that occasionally cause arterial rib notching by
another mechanism. In congenital cardiovascular lesions with decreased pulmonary
blood flow, the pulmonary circulation may be augmented by blood from the intercostal
arteries via the bronchial arteries, branches perforating through the chest wall, etc.
Example: tetralogy of Fallot.
Can you think of some other congenital lesions with decreased pulmonary flow?
1)
pulmonary valvular stenosis
2)
absent pulmonary artery
3)
pseudotruncus (atresia of the main pulmonary artery)

Figure S3-8

Figure S3-8: tetralogy of Fallot with absent right pulmonary artery. The notching of the left 6th rib (arrow) appeared a year after the
Blalock-Taussig operation. The notching on the right (arrows) antedated the operation. Therefore, there are two mechanisms for rib
notching in this patient.

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21
Four congenital cardiovascular lesions with decreased pulmonary flow in which rib
notching has been reported are:
A.
(1) pseudotruncus
absent
(2)
pulmonary artery
Fallot
tetralogy
(3)
of
pulmonary
(4)
valvular stenosis
These usually cause unilateral rib notching.

Figure S3-9A

B.

Figure S3-9B

Severe emphysema, with extreme local oligemia, can also cause unilateral rib notching. In Figure S3-9A, the pulmonary vessels
are markedly diminished in the RUL (arrow points to one of several notched ribs). In Figure S3-9B, note tortuous intercostal
arteries below multiple ribs. From: The Internet Journal of Pulmonary Medicine (ISSN: 1531-2984). Plaza P, Herrejon
A: Pulmonary emphysema as a cause of rib-notching. Volume 2, Number 1, 2001. With permission of Internet Scientific
Publications; www.ispub.com.

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22
OK, here are 4 mechanisms and 9 causes of arterial rib notching:
(a)
high aortic obstruction
(1)
coarctation of aorta
(b) low aortic obstruction:
(2)
aortic thrombosis
(c) subclavian obstruction:
(3)
Blalock-Taussig procedure
(4)
pulseless disease
(d) pulmonary oligemia:
(5)
tetralogy of Fallot
(6)
absent pulmonary artery
pulmonary valvular stenosis
(7)
pseudotruncus
(8)
emphysema
(9)

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23
Now what about the intercostal veins? Can they cause notching? Sure or else we wouldn't have brought it up.
Fibrosing mediastinitis may cause chronic obstruction of the
superior
vena cava. The azygos system becomes a major
azygos
collateral pathway, and the intercostal veins often carry a considerable amount of blood to the
system.

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24
The intercostal veins may become so dilated and tortuous that they notch the ribs. So far, the only reported cause of venous
superior vena cava
notching has been obstruction of the
secondary to
.
fibrosing mediastinitis
A.

Figure S3-10

Figure S3-10 is a right brachial venogram showing superior vena cava obstruction and numerous collateral veins in the neck and
mediastinum. A large tortuous intercostal vein is notching the right 5th rib (arrow). The left 8th rib is also notched.

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25
Arteriovenous fistulas are characterized by large feeding and draining vessels. The intercostal vessels may be involved and
notch the ribs. Can you name 2 sites of an arteriovenous fistula in which this might occur?
(1)
chest wall
(2)
pulmonary
A.

Figure S-3-10

Notching caused by arteriovenous fistula is the one most people forget. Will you?
Figure S-3-10 shows innumerable tiny pulmonary arteriovenous fistulas in a patient with congenital familial telangiectases. The
right 5th and 7th ribs show notching (the 6th has been resected).

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26
You have now learned an even dozen causes of rib notching 9 arterial, 1 venous, and 2

arteriovenous

Fill in the appropriate responses:

I. Arterial
a)
b)
c)
d)

high aortic obstruction

low aortic obstruction
subclavian obstruction
pulmonary oligemia

II. Venous

(1)

coarctation of aorta

(2)
(3)
(4)
(5)
(6)

aortic thrombosis
Blalock-Taussig procedure
pulseless disease
tetralogy of Fallot
absent pulmonary artery

(7)
(8)

pulmonary valvular stenosis

pseudotruncus

(9)
(10)

emphysema
superior vena cava obstruction

III. Arteriovenous
(11)
(12)

AV fistula of chest wall

pulmonary AV fistula

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27
The third important component of the intercostal space is the

nerve

B.

A.

Figure S3-11

.
C.

Figure S3-12A

Figure S3-12B

If there is a tumor of the nerve, rib notching may occur. In neurofibromatosis, these notches may be multiple. The neurofibroma
may or may not be visible. Figure S3-11 shows broad notching of the right 4th to 7th and left 6th to 8th ribs in a patient with
neurofibromatosis. The mass in each pulmonary apex represents an intercostal neuroma. In a different patient, Figure S3-12A,
there is a visible neurofibroma (arrowheads) and focal rib notching (arrows). Figure S3-12B shows the notched rib and the adjacent
neurofibroma.

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28
Thus, rib notching may be caused by artery, vein, or
A.

nerve

lesions.
B.

Figure S3-13

Figure S3-14

Along the undersurface of every rib are the two ridges in which the vessels and nerves run. If the ridges are of different heights, the
undersurface of the rib is often indistinct (Figure S3-13). This is usually most noticeable on the posterior-lateral 4th-7th rib. In
Figure S3-14, these normal areas may be mistaken for rib nothing.

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29
Occasionally, minimal rib notching is seen without apparent cause. When normal people cant figure something out they say,
Idiopathic*
I dont know. In medicine, if we dont know something, we call it
. This idiopathic notching is probably due
to these uneven ridges.

Dr. Felson reviewed 1000 normal survey chest roentgenograms for rib notching and encountered it in mild degree (never severe)
in one or two ribs with surprising frequency. (He probably had a notched retina.) These are idiopathic.*

* Idio - I don't know; pathic - I wish I did.

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30
So here are 2 more causes of rib notching:
IV. nerve
(13) neurofibromatosis
V. normal
(14) ridges under ribs

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Review

You have learned 15 causes of rib notching. We admit there may be others, but if so, they are about as common as priapism in the
old men's home. Classify the ones you know in the space below:

I.

Arterial

(a)
(b)
(c)

Mechanism
high aortic obstruction
low aortic obstruction
subclavian obstruction

(1)

coarctation of aorta

(2)

aortic thrombosis
Blalock-Taussig procedure

(3)
(4)

(d)

pulmonary oligemia

II. Venous
III.

Arteriovenous

(6)

pulseless disease
tetralogy of Fallot
absent pulmonary artery

(7)

pulmonary valvular stenosis

(8)

pseudotruncus

(9)

emphysema

(10)

superior vena cava obstruction

AV fistula of chest wall
pulmonary VV fistula

(5)

(11)
(12)

IV.

Nerve

(13)

V.

Normal

(14)

neurofibromatosis
normal ridges (idiopathic)

Now compare your answer to the one you gave in Frame 1.

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