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High Resolution Neurography of the Brachial Plexus by 3Tesla Magnetic

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High Resolution Neurography of the Brachial Plexus by 3Tesla Magnetic Document downloaded from http://www.elsevier.es, day 03/11/2017. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited. Radiología. 2016;58(2):88---100 www.elsevier.es/rx UPDATE IN RADIOLOGY High resolution neurography of the brachial plexus ଝ by 3 Tesla magnetic resonance imaging a,∗ a a b C. Cejas , C. Rollán , G. Michelin , M. Nogués a Departamento de Imágenes, Fundación para la lucha de las enfermedades neurológicas de la infancia Dr. Raúl Carrea (FLENI), Buenos Aires, Argentina b Departamento de Neurología, Fundación para la lucha de las enfermedades neurológicas de la infancia Dr. Raúl Carrea (FLENI), Buenos Aires, Argentina Received 15 January 2015; accepted 16 December 2015 Available online 29 March 2016 KEYWORDS Abstract The study of the structures that make up the brachial plexus has benefited particu- Brachial plexus; larly from the high resolution images provided by 3 T magnetic resonance scanners. The brachial Magnetic resonance plexus can have mononeuropathies or polyneuropathies. The mononeuropathies include trau- imaging; matic injuries and trapping, such as occurs in thoracic outlet syndrome due to cervical ribs, Diseases of the prominent transverse apophyses, or tumors. The polyneuropathies include inflammatory pro- peripheral nervous cesses, in particular chronic inflammatory demyelinating polyneuropathy, Parsonage---Turner system syndrome, granulomatous diseases, and radiation neuropathy. Vascular processes affecting the brachial plexus include diabetic polyneuropathy and the vasculitides. This article reviews the anatomy of the brachial plexus and describes the technique for magnetic resonance neurography and the most common pathologic conditions that can affect the brachial plexus. © 2016 SERAM. Published by Elsevier España, S.L.U. All rights reserved. PALABRAS CLAVE Neurografía de alta resolución en resonancia magnética 3 Tesla del plexo braquial Plexo braquial; Resonancia Resumen El estudio de las estructuras que conforman el plexo braquial se ha visto par- magnética; ticularmente beneficiado con las imágenes de alta resolución que brindan los equipos de Enfermedades del resonancia 3 T. El plexo braquial puede presentar mononeuropatías o polineuropatías. Entre sistema nervioso las primeras se distinguen los traumatismos, el atrapamiento, como el síndrome de la aber- periférico tura torácica por costillas cervicales, apófisis transversas prominentes o tumores. En el grupo de las polineuropatías se encuentran los procesos inflamatorios, entre los que destacan la ଝ Please cite this article as: Cejas C, Rollán C, Michelin G, Nogués M. Neurografía de alta resolución en resonancia magnética 3 Tesla del plexo braquial. Radiología. 2016;58:88---100. ∗ Corresponding author. E-mail address: ccejas@fleni.org.ar (C. Cejas). 2173-5107/© 2016 SERAM. Published by Elsevier España, S.L.U. All rights reserved. Document downloaded from http://www.elsevier.es, day 03/11/2017. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited. High resolution neurography of the brachial plexus 89 polineuropatía desmielinizante inflamatoria crónica, la plexitis autoinmunitaria (síndrome de Parsonage Turner), enfermedades granulomatosas y la neuropatía por radiación. Entre los pro- cesos vasculares se mencionan la polineuropatía diabética y las vasculitis. En esta revisión se repasa la anatomía del plexo braquial y se describe la técnica de estudio de la neurografía por resonancia magnética y las principales patologías que pueden afectar al plexo braquial. © 2016 SERAM. Publicado por Elsevier España, S.L.U. Todos los derechos reservados. Introduction Roots C5-C6 make up the upper trunk, root C7 contin- ues as the medial trunk and roots C8-T1 make up the lower trunk. The three trunks go through the scalene anterior and The study of the Peripheral Nervous System (PNS) through 13,14 medius muscles (interscalene triangle). magnetic resonance imaging (MRI) dates back to the 1,2 The subclavian and suprascapular nerves come from the 1990’s. MR neurography (MRN) has coined the term thanks upper trunk. The phrenic nerve originates from roots C3-C5, to high-resolution techniques, in particular those provided 3,4 the dorsal scapular nerve stems from root C5 and the long by 3 T equipment. These sequences have revolutionized thoracic nerve from roots C5 to C7. the study of plexuses and peripheral nerves because they The trunks split to form three anterior and three poste- provide us with a significant improvement in the signal/noise rior divisions, which in turn join to form three distal cords, relation in shorter acquisition times, and they convey high 5 --- 7 located on the lateral edge of the first rib. When it comes to resolution and contrast images. Diagnosis of PNS disor- their relation with the axillary artery, cords are classified as ders was traditionally based on three pillars: medical history, 8 lateral, posterior and medial. The lateral cord is formed by physical examination and electrophysiological studies. The anterior divisions of the upper and medial trunks, gives rise complex anatomy of the brachial plexus makes clinical and to the lateral pectoral nerve (C5-7) and contributes to the electrophysiological assessment difficult; therefore, MRN formation of the musculocutaneous and median nerves. The can be placed as the fourth pillar among diagnostic stud- posterior cord is made up of the posterior divisions of the ies. Firstly, MRN images distinguish a normal plexus from three trunks giving rise to the subscapular nerve. The lower a pathological one; in addition, they determine accurately trunk continues as the medial cord and originates the medial the location of the lesion (root, trunk, division or cord), and pectoral nerve (C8-T1), the medial cutaneous brachial nerve whether it affects one or several of them (mononeuropathy (T1) and the medial cutaneous nerve of the forearm (C8-T1). vs polyneuropathy). On the other hand, MRN images outline The cords end in five branches: the axillary, median, ulnar, the extension of the lesion and it often specifies the etiol- 14 8---11 musculocutaneous and radial nerves. ogy of the plexus disorder. Electrophysiological studies, The brachial plexus innervates the muscles of the shoul- though very useful to determine the location and degree der girdle, and its terminal branches, the muscles of the of nerve compromise, do not define the exact location or 12 upper limbs. Table 1 describes the motor and sense innerva- etiology of brachial plexus lesions. 14,15 tions of the brachial plexus. The goals of this review are to study brachial plexus In MRIs the normal brachial plexus has some sort of a fas- anatomy, describe the study protocol for MRN and the main cicular appearance and a continuous course. In T1-weighted diseases that can affect it. sequences, the signal is isointense to that of the mus- cle and hyperintense with respect to it in the T2-weighed Anatomic analysis of the brachial plexus sequences. In T1 sequences, a thin fat plane is observed through MRIs surrounding every plexus structure. The ganglion annexed to the dorsal root is observed as a pseudo-nodular image MRI anatomic analysis of the brachial plexus benefited sig- thicker than the root and it shows enhancement after the nificantly from neurographic sequences. The anatomical injection of IV contrast. The three brachial plexus trunks points used as reference to assess MRN images are the clav- usually have a similar diameter, they are symmetric between icle, the first rib, the subclavian artery and vein and the both sides and do not present enhancement after the injec- 16,17 scalene anterior and medius muscles. The brachial plexus tion of IV contrast. is formed from the primary ventral branches of the spinal nerves that originate in the cervical (C) 5, 6, 7, 8 and thoracic Protocol for the study of the brachial plexus (T) segments 1. In some individuals smaller ventral braches 13 C4 and T2 participate. through MRIs Topographically, the brachial plexus is divided in five seg- ments: roots, trunks, divisions, cords and terminal branches The study protocol of the brachial plexus in our center (Fig. 1). is done using a Signa HDxt 3.0 T machine (GE, Milwau- The ventral roots exit through the intervertebral foramen kee, Wi), with an eight-channel neurovascular coil (HDNV of the cervical spine and they are divided into pre- and post- Array) simultaneously including both sides of the brachial ganglionic with respect to the ganglion annexed to the dorsal plexus. The sequences used are T1- and T2-weighted coronal root. IDEAL (Iterative Decomposition of water and fat with Echo Document downloaded from http://www.elsevier.es, day 03/11/2017. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited. 90 C. Cejas et al. A B C5 C6 Scalene medius muscles C7 Scalene anterior muscles C8 Interscalene triangle T1 TS TM Brachial plexus TI First rib Clavicle C Figure 1 (A) Diagram of the topographic division of the brachial plexus. (B) IDEAL Sequence water-weighted and with fat sup- pression; maximum intensity reconstruction of projection on coronal plane where we can see all the elements that make up the brachial plexus (UT: Upper trunk; MT: Medial trunk; LT: lower trunk). (C) 3 D GRE sequence in axial slice where we can see the exit of ventral and dorsal roots until the entry of the intervertebral foramen. Asymmetry and Least-squares estimation), with a thickness it is sensitive to respiratory and deglutition movements. of 1---0.1 mm, coronal 3D FIESTA with a thickness of 0.6 mm, The clinical usefulness of this sequence derives from its axial 3D FIESTA with a thickness of 1.4 mm, and T1-weighted capacity to generate an adequate tissue signal with a high 19 coronal sequences 3D IDEAL after the injection of IV T2/T1 relation. It provides a detailed analysis of the contrast (Table 2). The IDEAL sequence developed by intradural tract of the roots since it creates a contrast General Electric (GE) Healthcare, or 3D SPACE (Sampling Per- with the signals of the cerebrospinal fluid (CSF).
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