MR Neurography: Cervical Plexus and Shoulder Girdle

Transcription

1 MR Neurography: Cervical Plexus and Shoulder Girdle Gustav Andreisek, MD, MBA 3rd MSK MRI Meeting 2016 Date: April 23th, 2016 Time: 11:10-11:30 AM Head MSK and MR Imaging Department of Radiology University Hospital Zurich Switzerland

2 Financial Disclosures Gustav Andreisek was co-worker of a study which resulted in US patent (USPTO Number 12/947,256); received grants from Swiss National Science Foundation (SNCF), Holcim, and Siemens; is currently Co-PI or Sub-PI in several third party funded clinical trials at the University of Zurich (Sponsors include: Millennium Pharmaceuticals, Eli Lilly, GlaxoSmithKline, Cytheris SA, Roche, BioChemics, Novartis, Bristol-Meyers Squibb, TopoTarget, and Merck Sharp & Dohme) and where money is paid to the department Gustav Andreisek works for. The department also receives grants from Bayer and Guerbet and has ongoing research collaborations with Siemens. Gustav Andreisek has given workshops and talks at a congress which was sponsored by Mepha Pharma AG, Switzerland, and received a speaker fee. He also gives talks at Lunch symposia and CME courses, which are organized and sponsored by Guerbet, and receives speakers fees. Gustav Andreisek served as a consultant for Otsuka Pharmaceutical Europe Ltd at a one-day meeting in London, and received a consultant fee and reimbursement of travel costs. Gustav Andreisek was invited by GE, Philips and Siemens for official company receptions at international radiological congresses (RSNA).

3 Structure Max. 20 min Plexus Anatomy and Approach to MRN Cases

4 Plexus Anatomy Ho M et al. submitted

5 Plexus Terminology

6 MR Anatomy Pe rso na l us eo UT nly

7 Anatomic Imaging 3D imaging High resolution (>256; in-plane ~1mm) Isotropic acquisition Superior T2 contrast 3T, dedicated coils, parallel imaging (faster, contrast, lower echo times, less image distortion) Curved and multi planar reformations SPACE, VISTA, CUBE Instructor uses e.g. 3D SPACE STIR for plexus; 3D SPACE SPAIR in extremities

8 Functional Imaging Beyond anatomic imaging Functional information e.g. axonal regeneration new therapeutic agents and novel interventions λ 1 λ 3 Diffusion Tensor Imaging FA and ADC λ 2

9 Diffusion in Peripheral Nerves Proton Diffusion is directional. Nerve Fibers Anisotropic Diffusion Graphic taken from

10 Quantitative Parameters FA (fractional anisotropy): Scalar value between 0 (minimal) and 1 (maximal) λ 1 Relationship of vectors (λ1-3) λ 3 ADC ( apparent diffusion coefficient) λ 2 signal attenuated = signal 0 * e b*d Tensor

11 FA and ADC in Peripheral Neuropathies FA and ADC are age-dependent FA and ADC with age FA and ADC were different in controls versus CTS patients FA 0.47: Sens.: 83%, Spez.: 67% FA ADC FA * * Guggenberger R, Andreisek G et al., Radiology. 2012

12 How to do it - Summary Use your best scanner and coils Tailor protocols (transverse plains) Teach your staff T1, T2, T2 fs 3D PACE STIR w vascular suppression MPR and curved MPR PSIF (when appropriate) Post contrast T1 fat sat DTI sequence (FA, ADC) Tractography

13 Clinical Assessment Step-by-Step

14 t2_space_hws_sag Common pathologies Often degenerative disease Myelopathy Radiculopathy

15 t2_space_stir_cor Plexus Symmetric? Course? Thickened? Thinned? Compression? Etc.

16 Multi Planar Reconstruction, true planes

17 MIP Recon cor Overview NF? Etc.

18 mb_resolve_tra_tracew

19 Overlay Control of Diffusion

20 DTI almost never works!

21 tirm_links_sag USE 3D curser!!!!

22 Left versus Right Comparison USE same window level!!!!

23 11_tse_cor Cervical Rib? Clavicula? Fibrous bands?

24 Twist_cor_SUB_MIP Vascular anomalies? Arteries? Veins?

25 t1_tse_dixon_fs_pkm_rechts_sag_w USE 3D curser!!!! There should be no contrast enhancement!

26 Standardized Report

27 Hints for Image Interpretation Identify the anatomic region and the nerve Use web tools for anatomy Describe the nerve abnormality 7 criteria: size, signal, fascicular pattern, course, continuity, perineural fat, and contrast enhancment Look for the innervated muscles Is their signal intensity normal Is there already atrophy?

28 Structure Max. 20 min Plexus Anatomy and Approach to MRN Cases

29 Tip: Correlate with Anatomy High-resolution standard coronal T1 TSE image as reference with overlay from dynamic excitation pulses to achieve selective field-of-view imaging (ZOOMit)

30 Clinical Cases

31 35 ys old male crosscar accident PHM: many other accidents acute plexus traction injury

32 32 ys male, suicide attempt, elbow flexion lost Oberlin Surgery

33 MR Neurography Follow-up Shoulder N. ulnaris N. radialis lateral Thorax Elbow

34 Muscle Assessment

35 35y m, winged scapula after MVA Atrophy of Serratus Muscle

36 Right Thoracic Nerve Left normal

37 Long thoracic nerves comes directly from C5-7 To C5 C6 and C7

38 33 male Chronic inflammatory demyelinating polyneuropathy acquired immune-mediated inflammatory disorder chronic counterpart of Guillain-Barré syndrome asymmetrical variant = Lewis Sumner-Syndrome

39 32y m, Supras- and Infraspinatus Muscle

40 !!! high voltage accident with m/s deficit

41 Compartment Syndrome

42 Young Gunman

43 Intra-operative

44 MR Zurich C-Spine & cervicobrachial plexus Shoulder Upper arm / elbow Lower arm / wrist L-Spine & lumbosacral plexus Various pelvic nerves Tibial, peroneal and sural nerves Ankle / Morton

45 The next level MRN Orthopantomography Dr. Manoliu Dr. Kuhn Dr. Ho

46 MR Neurographic Orthopantomogram

47 Peripheral Nerve Imaging Manoliu A, Ho M, Nanz D, Dappa E, Boss A, Grodzki DM, Liu W, Chhabra A, Andreisek G, Kuhn FP. J Magn Reson Imaging Feb 8. doi: /jmri [Epub ahead of print]

48 Surgical Planning Aid

49 Summary You have learned Plexus Anatomy and how to approach MRN What MRN can reveal

50 Thank you.