Carlos Torres MD, FRCPC, Associate Professor of Radiology Department of Radiology, University of Ottawa

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1 Carlos Torres MD, FRCPC, Associate Professor of Radiology Department of Radiology, University of Ottawa

2 None

3 1. Simplify the complex imaging anatomy of the BP using clear anatomical landmarks. 2. Outline different MR protocols. 3. Review BP pathologies using case-based approach.

4 Anatomy

5 Brachial Plexus Formed by ventral rami of the nerves C5 -T1 - pre fixed - post fixed Responsible for motor and cutaneous innervation of upper extremity, except for: Motor: Trapezius and levator scapulae Cutaneous: Axila, suprascapular & scapular regions

6 Brachial Plexus Segments Roots Trunks Divisions Cords Branches

7 Brachial Plexus Segments Radiologists Technologists Drink Cold Beer

8 Roots The ventral rami of the spinal nerves C5 to T1 are the roots of the plexus. A P * A M * ^ R ^

9 Trunks C5 - C6: Upper T C7 : Middle T C8 T1: Lower T A * ^ * T ^

10 Divisions Each trunk splits in 2 to give an anterior and posterior division A * ^ * ^ D

11 Divisions

12 Cords Lat: Ant divisions of sup & middle trunks Medial: Ant division of lower trunk Post: 3 post divisions B * C ^ C

13 Branches Musculocutaneous N. Axillary N. Median N. Radial N. Ulnar N. ^ B

14 Branches

16 Method of choice Multi planar Exquisite soft-tissue contrast Castillo. AJR 2005, 185: S Todd et al. Top Magn Reson Imaging 2004, 15: Saifuddin. Skeletal Radiol 2003, 32: Wittenberg et al. Radiographics 2000, 20:

17 Surface coil Thin sections with no/small gap (3D) T1, T2 and STIR Contrast may be given Two imaging protocols at TOH

18 Neck coil and body array Localizer in 3 planes Sequence Time ST TR TE Cor T2 Space 5: Cor T1 2D 4: Cor T2 STIR 3: Sag T1 2D 4:

20 McGill/MGH The Ottawa Hospital Sagittal T1W 3/4 mm (thickness/gap), T2W 3/4 mm Coronal T1W 3/4mm and FAST STIR 3/4 mm Axial T1W 4/5 mm, T2W 3/4 mm, +/- Gadolinium enhanced: Coronal 3/4 mm,axial and sag T1W 4/5 mm with fat saturation

21 MODIFIED TECHNIQUE FOR THE STUDY OF THE BRACHIAL PLEXUS WITH MR MODIFIED TECHNIQUE : 3 plane LOCALIZER Increase number of slices in the coronal plane Parameters FSE T1 Parameters FSE T2 Matrix: 448x224 cm

22 CONVENTIONAL TECHNIQUE MODIFIED TECHNIQUE LOCALIZER

23 MODIFIED TECHNIQUE FOR THE STUDY OF THE BRACHIAL PLEXUS WITH MR MODIFIED TECHNIQUE

are planned off the coronal localizer parallel to the

24 MODIFIED TECHNIQUE FOR THE STUDY OF THE BRACHIAL PLEXUS WITH MR MODIFIED TECHNIQUE: The axial oblique sequences are planned off the coronal localizer parallel to the plane of the roots, trunks and divisions of the brachial plexus.

25 MODIFIED TECHNIQUE FOR THE STUDY OF THE BRACHIAL PLEXUS WITH MR MODIFIED TECHNIQUE: The coronal sequences are planned off the axial oblique dataset following the plane of the brachial plexus.

26 MODIFIED TECHNIQUE FOR THE STUDY OF THE BRACHIAL PLEXUS WITH MR MODIFIED TECHNIQUE: The sagital sequences are planned off the axial oblique images, perpendicular to the segments of the brachial plexus.

27 MODIFIED TECHNIQUE FOR THE STUDY OF THE BRACHIAL PLEXUS WITH MR CONVENTIONAL TECHNIQUE MODIFIED TECHNIQUE

28 CONVENTIONAL TECHNIQUE MODIFIED TECHNIQUE

29 CONVENTIONAL TECHNIQUE MODIFIED TECHNIQUE

30 MODIFIED TECHNIQUE FOR THE STUDY OF THE BRACHIAL PLEXUS WITH MR CONVENTIONAL TECHNIQUE MODIFIED TECHNIQUE Axial T1 : 7 min 25 sec 3 min 59 sec Axial T2: 8 min 03 sec 3 min 54 sec Coronal T1: 4 min 22 sec 4 min 36 sec Coronal T2: 4 min 44 sec 3 min 54 sec Sagital T1: 9 min 16 sec 6 min 17 sec Sagital T2: 7 min 32 sec 6 min 08 sec Total scan time: 41 min 22 sec 28 min 48 sec

33 2005 a b c Case: 27 y/o pt with left ulnar neuropathy

34 a b c 2011 d

36 Pathology

37 Vague and nonspecific symptoms. Trauma: most common cause of plexopathy Tumors: 2 nd most common Post radiation Others : Inflammatory, infectious and hereditary

38 Imaging studies play an essential role in differentiating preganglionic injuries from postganglionic lesions, a differentiation that is crucial for determining the management of BPI

39 Trauma may be due to: Traction/Compression Penetrating injuries Local fractures or dislocations. What to look for? Pseudomeningoceles Clumping, thickening and signal Hematomas

40 25 y/o pt, assault

42 Post Traumatic Pseudo aneurysm Concentric rings of varying signal intensity due to clot that forms the walls of this pseudo aneurysm c/o Mauricio Castillo, UNC

43 MVA Stretch injury Pseudo meningoceles

44 Stretch injury Pseudo meningocele + n root avulsion A B C

45 Primary: Schwannoma Neurofibroma Secondary: Direct extension/compression: tumors in the vicinity of the BP: lung, bones or soft tissues of the neck. Metastasis: Breast, lung.

47 NEUROFIBROMA

49 NEUROFIBROMAS NF1

50 NF1

51 10 y/o pt with neck swelling since he was 18 months c/o Manu Shroff, Sickkids Univ of Toronto.

52 Schwannomatosis - 3 rd major form of NF - Distinct from NF1 and NF2 - Noncutaneous schwannomas - Absence of vest schwannomas c/o Manu Shroff, Sickkids U of Toronto.

54 PANCOAST TUMOR

56 METS MELANOMA

57 58 y/o pt with pain in the left arm

58 NEUROLYMPHOMATOSIS: B-cell NHL

59 54 y/o pt with left brachial plexopathy A B

61 A B NEUROLYMPHOMATOSIS: T-cell Lymphoma

62 NEUROLYMPHOMATOSIS: T-cell Lymphoma

64 Post Radiation: Progressive neuropathy resulting from fibrosis and obliteration of the vasa-nervorum. Patients receiving > 60 Gy. Months years after therapy Thickenning of n. roots Low signal on both T1 and T2 Inflammatory poly neuropathy : MMN, CMT, CIDP Brachial Neuritis: viral, idiopathic, drugs, hereditary.

65 60 y/o pt with Hx of Breast Ca + Radiation

67 26 y/o pt with bilat weakness and numbness arms/legs

68 CHRONIC INFLAMMATORY DEMYELINATING POLYNEUROPATHY CIDP

69 MR imaging & nerve root thickening: Seen in ~40% children, ~60% adult CIDP patients

70 MR imaging & nerve root thickening: Nerve root thickening also noted in other diseases: CMT1A patient CIDP patient

72 Diffusion tensor imaging (DTI) and tractography of the brachial plexus: Feasibility and initial experience in neoplastic conditions. Vargas M et al. Neuroradiology (2010) 52: normal volunteers, 12 patients benign & malignant ( 3 Qx, 9 medical) ADC & FA maps 2 Radiologists

73 No statistically significant difference in FA and ADC values of normal fibers and fibers at the level of pathology. Tractography revealed major differences regarding fiber architecture. Benign: Malignant: Displacement Disruption/Destruction Encasement Disorganization

74 Tractography of the brachial plexus in a 37-year-old male volunteer

The displaced fibers of the posterior cord (white arrows) passing around

75 MIP Coronal reconstruction of the 3D STIR SPACE sequence showing a distal schwannoma of the brachial plexus. The displaced fibers of the posterior cord (white arrows) passing around the schwannoma (asterisk) suggesting an easier surgical enucleation. The findings were confirmed at surgery

76 Step-by-step reconstruction of the tractography of the brachial plexus in a 42 year-old male patient fibers within and around the benign neurogenic tumor

77 Sixty-five-year-old patient with adenocarcinoma of the lung, disorganization and interruption of nerve fibers on the tractography reconstruction image

78 Rads & Techs Drink Cold Beer MR is the imaging method of choice Different protocols: 3T vs 1.5T Advanced Imaging Techniques

79 Carlos Torres MD, FRCPC, Associate Professor of Radiology Department of Radiology, University of Ottawa

MRI of the Brachial Plexus. Christopher F. Beaulieu, MD, PhD Stanford University Medical Center

MRI of the Brachial Plexus. Christopher F. Beaulieu, MD, PhD Stanford University Medical Center MRI of the Brachial Plexus Christopher F. Beaulieu, MD, PhD Stanford University Medical Center Outline Anatomy MRI techniques Imaging anatomy Clinical Cases Primary tumors Metastatic disease Neuritis Trauma