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Because of the overlap in innervation with the stellate ganglion, Klumpkes palsy may also be
associated with ipsilateral Horners syndrome.
Several findings may be indicative of a more severe injury to the BP. A plexopathy associated
findings similar to a Brown-Sequard syndrome may suggest a proximal nerve root avulsion and
spinal cord injury. A nail limb with complete absence of deep tendon reflexes is indicative of a
complete disruption of the BP.
INDICATIONS OF MR IMAGING:
1. Are symptoms unilateral or bilateral? The presence of bilateral brachial plexopathies is
usually associated with a lesion in the epidural space or neural foramina, and these
patients should be evaluated initially with a dedicated imaging study of the cervical
spine.
2. Is there a history of trauma? These patients often require dedicated sectional imaging
studies of the cervical spine to supplement the evaluation of the peripheral components
of the plexus.
3. Is there an associated mass in the neck, supraclavicular fossa or axilla?
Characterization of a palpable mass may require the use of double-echo-T2-weighted
rather than SE-T2 weighted sequence and the administration of intravenous contrast.
4. Are the symptoms produced by a particular arm position? Hand pain with arm elevation
of a common finding with thoracic outlet syndrome secondary to a cervical rib, and
identification of a cervical rib on a frontal radiograph should prompt further evaluation of
the subclavian and axillary arteries rather than the soft-tissue components of the
brachial plexus.
5. Does the patient have a prior history of carcinoma? Studies of patients with a history of
malignancy require a careful search for abnormal signal within the trabecular bone of
the cervical spine, clavicle, scapula, and shoulder as well as the soft tissues adjacent to
the nerves. This is especially important if pain is the only presenting symptom.
6. Is there a history os surgery or radiation therapy to the affected axilla, neck or
supraclavicular fossa? Images of the affected side in these patient are often confusing
and oblique coronal and sagittal imaging of the opposite brachial plexus is often useful
for comparison and identification of subtle changes.
IMAGING IN VARIOUS PATHOLOGIES OF THE BRACHIAL PLEXUS:
TRAUMA
The initial imaging evaluation in patients with a post-traumatic brachial plexopathy should
consist of plain films of the cervical spine, shoulder, clavicle and chest. These plain films
should be assesses for fractures of subluxations which could account for the acute
neurological deficit.
Posttraumatic nerve root avulsion of the BP results from forcible trauma which separates the
arm from the shoulder. This may result in stretching and tearing of fibrous attachments which
extends from the nerves to their respective transverse processes. Pseudomeningoceles arise
from tears of the dura and arachnoid membranes caused by the root sleeves being pulled out
into the intervertebral foramen. Nerve root avulsion results if the traction force exceeds the
elastic tolerance of the root. Spinal cord injury may occur from direct contusion or by avulsion
of the nerve root. Thus, it is possible to have post-traumatic Pseudomeningoceles without a
coexistent nerve root avulsion. Conversely, approximately 20% of clinical nerve root avulsions
are not associated with a pseudomeningocele.
Both CT Myelography and MR imaging may be used to evaluate patients with post-traumatic
brachial plexopathies. The characteristic findings in a posttraumatic BP stretch injury are
Pseudomeningoceles which may be detected by both CT Myelography and MR imaging. Thin
section CT Myelography (1mm-3mm thick sections) allows for consistent visualization of the
ventral and dorsal nerve roots within the spinal canal and is therefore the preferred imaging
modality.
Absence of a nerve root shadow on CT Myelography is indicative of nerve root avulsion. Nerve
root or dural thickening seen on MR imaging is suggestive of nerve root avulsion or edema.
Recent technical advances in MR imaging permit improved visualization of the nerve roots
within the spinal canal in normal patients, however, these advanced techniques are mostly
limited to tertiary institutions and are not currently in general use. MR imaging does allow
visualization of Pseudomeningoceles , which do not fit with contrast on CT Myelography. The
role of MR Myelography for evaluating BP injuries is currently being evaluated.
Other post-traumatic lesions which may result in a brachial plexopathy include hematomas,
vascular compression from pseudoaneurysm formation, and complete disruption of the
brachial plexus. The presence of intramedullary or extramedullary haematoma may be
detected with MR imaging. MR imaging is superior to CT for evaluating for the presence and
extent of soft tissue injuries.
arise from the nerve sheaths. The most common benign neural tumors are neurofibromas and
schwannomas. Neurofibromas are the most common neural tumor to involve the BP.
Histologically; these lesions are unencapsulated tumors that are felt to arise from the nerve
fascicles. One-third of these lesions occur in patients with Neurofibromatosis type 1 (NF-1)
while two- thirds of cases are sporadic. Neurofibromas arising in patients with NF 1 occur with
equal incidence in males and females. These tumors are characteristically multiple and
plexiform in appearance with diffuse involvement of the BP. In contrast, sporadic neurofibromas
are more commonly seen in females (2-3:1 female to male ratio). Sporadic neurofibromas are
typically solitary and most likely originate in the supraclavicular BP. Schwannomas are the
second most common neural tumor involving the BP.
The imaging features of solitary neurofibromas are essentially indistinguishable from those of
the schwannomas. On CT, these lesions have similar attenuation to muscle and enhance
variably with contrast. Both tumors may be associated with bony remodeling. On MR imaging,
these two lesions are isointense to muscle on T1W sequences and hyperintense on T2W
sequences. Both tumors typically enhance following intravenous Gadolinium administration.
The diagnosis of neurofibromas may be made with a high degree of confidence if the lesions
have a plexiform appearance or occur in a patient with NF-1.
Malignant neural tumors are very rare and consist mostly of fibro sarcomas and neurogenic
sarcomas (malignant neurofibromas). Secondary neoplasms may extend to involve the
adjacent BP. These lesions may also be either benign or malignant. Benign masses which
involve the BP include: lipoma, lipoblastoma, desmoid, lymphangioma, myoblastoma,
osteochondroma, and ganglioneuroma.
Malignant neoplasms which may involve the BP are commonly due to direct extension from a
Pancoast tumor or metastatic disease. Involvement of the BP by direct extension of a
Pancoast tumor may be suspected in patients who present with supraclavicular pain,
weakness and paresthesias. Imaging findings suggestive of BP invasion by a superior sulcus
tumor are obliteration of the apical fat and proximity of the mass to the BP. Tumors which have
been reported to metastasize to the BP include breast, lymphoma, bladder, gastrointestinal,
testicular, thyroid, lung, melanoma, head and neck, and sarcomas.
The imaging modality of choice in patients with possible neoplastic invasion of the BP is MR
imaging due to its multiplanar capability and high soft tissue characterization. Previous studies
have shown MRI to have a high sensitivity (100%) in detecting neoplastic involvement of the
BP. The extent of disease is also better depicted with MRI than with CT. Coronal T1W images
are especially helpful for assessing the status of the apical fat in patients with Pancoast tumors
and evaluating the relationship of masses to the BP.
INFLAMMATORY
Inflammatory processes may involve the BP include radiation therapy, neuritis, and infections.
Radiation therapy (RT) may injure the BP and cause a plexopathy. Three classical syndromes
of RT induced brachial plexopathy have been described. The most common form is a delayed
progressive radiation fibrosis. The remaining two forms of radiation damage are a reversible or
transient plexopathy and an acute ischemic plexopathy.
Radiation- induced brachial plexopathy is the most common and severe peripheral nervous
system complication of RT. Radiation damage to the BP appears to be dose related and most
likely occurs in patients who have received doses in excess of 6000 cgys. It is most commonly
seen in females who have been treated with RT for breast cancer. The plexopathy tends to be
delayed and progressive with the majority of patients presenting atleast 6 months after the
completion of RT. The initial symptoms include paresthesias, followd by pain and weakness.
These symptoms typically occur in upper trunk distribution with weakness of the arm flexors
and shoulder abduction. Pain can accompany these paresthesias but it usually occurs late in
the course of this syndrome. However, other reports suggest that RT induced plexopathies are
generalized and that the distribution of the deficits is not helpful in separating this variety of
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