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Magnetic Resonance Neurography Evaluation in Children

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Magnetic Resonance Neurography Evaluation in Children Clinical Neurology Neurology Clinical on 3T scanners. 2D imaging can be disadvantageous as peripheral nerves the lesions along the axis of the nerve, Magnetic Resonance Neurography obtained similarly on both types of travel in neurovascular bundles. course deviations, focal neuroma, scanners, although it takes a little Use a TR/TE/TF of ~ 3800–4000/60– neurotmesis, etc. and for better pre- Evaluation in Children longer on 1.5T scanners, especially 65/15–25 for T2 SPAIR imaging. operative planning. In extremities, when one tries to attain similar image Sagittal STIR imaging is particularly another 3D imaging, i.e. 3D DW PSIF quality on thin section (2–3 mm) useful in brachial plexus imaging to (diffusion-weighted reversed steady 1, 2 2 2 Avneesh Chhabra, M.D. ; Vibhor Wadhwa, MBBS ; Sahar J. Farahani, M.D., MPH ; scans. High resolution imaging with obtain uniform fat suppression in a state in free precession) is extremely 2 2 Gaurav K. Thawait, M.D. ; John A. Carrino, M.D., MPH combined 2D and 3D isotropic spin difficult neck area and to tease out useful to create nerve specific isotropic echo type imaging is essential for asymmetrical or individual nerve sig- images due to effective fat and vas- 1 University of Texas Southwestern Medical Center, Dallas, TX, USA optimal assessment of small peripheral nal intensity and caliber alterations. cular suppression (TR/TE/SL ~ 12/3/0.9, 2 The Russel H. Morgan Department of Radiology and Radiological Science, nerves. The inability to stay still for Dixon type fat suppression is also b-value for diffusion~60–80 ms and Johns Hopkins University School of Medicine, Baltimore, MD, USA infants and small children makes useful in generating uniform fat water selective fat suppression). imaging more challenging, frequently suppression. Additional coronal T1w, STIR/PD SPAIR requiring sedation or general images aid in detection of lesions 3D images complement information Abstract MR Neurography technique anesthesia for adequate results and along the long axis of the nerves as generated from 2D imaging by show- to avoid repeat acquisition [1]. well as allow assessment of regional Magnetic Resonance Neurography firming and localizing the neuropa- The currently available 3 Tesla scan- ing nerves in longitudinal planes. The joints and musculotendinous struc- has proven to be an excellent tech- thy, but also in ruling out neuropathy ners (MAGNETOM Skyra, Verio and Trio, One should use dedicated coils as far imaging can be obtained using iso- tures. These also serve as fall back nique for the evaluation of peripheral by showing normal appearing nerves Siemens Healthcare, Erlangen, Ger- as possible. For MRN imaging around tropic 3D SPACE (Sampling Perfection sequences, in case the subject moves neuropathies. However, its use in and regional muscles. The authors many) are preferred over 1.5T systems the joints, use joint specific coils, such with Application optimized Contrasts during the scan or if there is failure pediatric age group has been less well describe the MRN technique used in (MAGNETOM Aera and Avanto) due as wrist, elbow, ankle etc. If a joint using variable flip angle Evolutions) of 3D imaging for any reason. IV gad- described. In this article, the authors pediatric age group and discuss a to higher signal-to-noise ratio (SNR) and specific coil is not available, use the technique. A variety of contrasts are olinium contrast is not routinely used discuss the technical considerations, spectrum of peripheral nerve pathol- short imaging times on the higher smallest possible flex coil to cover the available on SPACE sequence, includ- in injury cases, however is useful for various common causes of peripheral ogies that can be observed in chil- field scanners. Additionally 3D imaging expected anatomy. For contiguous ing T1, T2, PD, STIR and SPAIR. Non- differentiating types of neural hyper- neuropathies in children* and the dren using relevant case examples. with fat suppression is better obtained imaging of the joint and extremity, e.g. fat suppressed T2 SPACE (TR/TE/TF ~ trophy such as suspected neoplasm, role of magnetic resonance neurog- wrist and forearm, use wrist coil and 1500–1700/110–120/42–50) is used infection, inflammation, diffuse poly- raphy in their diagnosis and 1 flex coil separately in the adolescent for spine imaging, which is necessary neuropathy, neurocutaneous syn- management. child to avoid excess blank (air) space in plexus evaluation. One can rou- dromes, or post-operative complica- around the extremity. In a child or tinely obtain 0.8–0.9 mm isotropic Introduction tion [7, 8]. infant, a single flex coil can suffice for images through the cervical or lumbar A wide spectrum of peripheral nerve such imaging due to the relatively small spine. In cases of suspected nerve Normal and abnormal pathologies are encountered in chil- size of the extremity. During plexus root avulsions, one should also obtain peripheral nerves dren, including hereditary neuropathy, imaging, use a combination of body 3D CISS imaging focused at spine for traumatic birth injury and motor array on the front and spine elements high resolution (0.6–0.65 mm isotro- Normal peripheral nerves show isoin- vehicle accident, neoplasm, infection on the back to attain uniformity of pic) evaluation of preganglionic nerve tense signal on T1w and T2w images. and inflammation. Clinical features magnetic signal in the field-of-view. rootlets. For post ganglionic nerve On T2 SPAIR images, minimal hyper- in these cases are often nonspecific assessment in plexuses, fat suppressed intensity is normal, especially where High resolution 2D (dimensional) and invasive electrodiagnostic tests, 3D imaging using STIR SPACE (TR/TE/ the nerves curve around the joints. axial T1-weighted (T1w) and T2 SPAIR such as nerve conduction studies are TF/SL ~ 2000–2200/70–80/50–60/ On 3D STIR SPACE images, the nerves (Spectral Adiabatic Inversion Recovery) usually uncomfortable and not feasi- 1.3–1.5 mm isotropic) is most useful. appear uniformly hyperintense in sequences are useful for demonstrat- ble in the pediatric age group. Periph- There is virtually no pulsation artifact the plexuses due to increased sensitiv- ing regional anatomy of the nerve fas- eral nerve imaging can therefore, on the 3D imaging and once thick ity to the endoneurial fluid. Most cicles. Fascicular architecture of nerves be very useful in small children with slab (8–15 mm) maximum intensity hyperintensity is seen at the dorsal is consistently seen with T2 SPAIR strong clinical suspicion in whom projections (MIPs) are created, the nerve root ganglion level and the images in larger branches, such as fem- the diagnosis cannot be firmly estab- image looks smoothened and shows signal fades distally along the course oral nerves and sciatic nerves, as well lished. However, small size of the the high intensity nerves along their of the nerves. Pathological nerves as in smaller nerves that are affected nerves and the relative lack of specific long axis or in any desired arbitrary show one or a combination of find- and enlarged due to neuropathy, such clinical features makes imaging of plane, e.g. oblique sagittal planes are ings, such as increasing hyperintensity as lateral femoral cutaneous and geni- the nerves challenging and requires useful to depict femoral and sciatic approaching the signal of the regional tofemoral nerves [4, 5]. Fluid sensitive high technical skill for performance nerves along their long axes (Fig. 1). vessels and encompassing a long sequences such as STIR (short tau inver- and interpretation. There is a paucity SPAIR SPACE (0.9–1.0 mm isotropic) segment of the nerve; focal or diffuse sion recovery) images have more uni- of literature describing the diagnostic is very useful in extremity imaging due caliber enlargement (more than adja- form fat suppression and higher T2 role of peripheral nerve imaging in to higher SNR and similar uniform fat cent regional nerves, contralateral contrast, especially in the presence children [1-3]. Magnetic Resonance suppression. The nerve perpendicular counterpart nerve or artery in the neu- of metal or in off-center areas [6], Neurography (MRN) is a non-invasive plane shows cross-sectional appear- rovascular bundle); internal fascicular however STIR imaging is often marred imaging technique, which enables ance of the fascicular anatomy of the by low SNR, pulsation artifacts and *MR scanning has not been established as direct visualization of the anatomy nerve. The longitudinal plane along increased baseline nerve signal inten- safe for imaging fetuses and infants less and pathology of the peripheral the long axis of the nerve shows focal 1 Normal LS plexus and sciatics in a young girl. MIP image from coronal 3D STIR sity. SPAIR produces higher SNR images than two years of age. The responsible nerves and regional muscles, thereby SPACE sequence shows normal symmetrical appearance of the LS plexus nerve or diffuse nerve enlargement and mass and are less prone to blood flow arti- physician must evaluate the benefits of aids in localizing the site of injury roots (short arrows) and bilateral sciatic nerves (long arrows). effect of regional perineural lesions the MR examination compared to those facts than STIR imaging, which could be or tumor. It can not only help in con- [1]. 3D imaging is helpful in localizing of other imaging procedures. 46 MAGNETOM Flash | 2/2014 | www.siemens.com/magnetom-world MAGNETOM Flash | 2/2014 | www.siemens.com/magnetom-world 47 Clinical Neurology Neurology Clinical 2A 2B 2C are used to
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