1
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Szaro P, Suresh R, Molokwu B, Sibala DR, Mendiratta D, Chu A, McGrath A. Magnetic resonance imaging for diagnosis of suspected neurogenic thoracic outlet syndrome-a systematic scoping review. Front Physiol 2023; 14:1198165. [PMID: 37920804 PMCID: PMC10619157 DOI: 10.3389/fphys.2023.1198165] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 10/06/2023] [Indexed: 11/04/2023] Open
Abstract
Background: Neurogenic Thoracic Outlet Syndrome (nTOS) is a rare pathology caused by dynamic conditions or compression of neurovascular structures in the thoracic outlet region. nTOS can be difficult to diagnose due to nonspecific symptoms and magnetic resonance imaging (MRI) techniques are increasingly used to aid the diagnosis and surgical planning. This scoping systematic review explores how MRI is used for diagnosing nTOS and summarizes details of published MRI protocols. Methods: A systematic screening of PubMed, Cochrane, Web of Science, and CINAHL databases using PRISMA-IPD guidelines was conducted in September 2022 to include full-text English papers on MRI and nTOS. Inclusion criteria involved studies describing MRI protocols for the diagnosis of TOS, with a focus on the imaging sequences and protocols. Results: 6289 papers were screened to include 28 papers containing details of MRI protocols. The details of MRI protocols in the analyzed articles were incomplete in all studies. Most authors used 1.5T systems and included T1 and T2-weighted sequences. Most studies applied fat suppression, mainly with STIR. Positioning of the arm differed between studies, including neutral, hyperabducted and abducted and externally rotated positions. Conclusion: Our review highlights a prevalent lack of detailed MRI protocol documentation for brachial plexus. Authors primarily rely on conventional 1.5T systems, employing standard T1 and T2-weighted sequences. The adoption of novel MRI sequences is notably lacking, and fat suppression techniques predominantly adhere to older methods as STIR. There is a clear imperative for authors to provide more comprehensive reporting of the MRI protocols utilized in their studies, ultimately enhancing comparability and clinical applicability. Establishing clear protocol reporting guidelines is crucial to allow for comparison between studies.
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Affiliation(s)
- Pawel Szaro
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Musculoskeletal Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Rohan Suresh
- Department of Orthopaedics, Rutgers New Jersey Medical School, Newark, NJ, United States
| | - Brian Molokwu
- Department of Orthopaedics, Rutgers New Jersey Medical School, Newark, NJ, United States
| | - Dhiraj Raju Sibala
- Department of Orthopaedics, Rutgers New Jersey Medical School, Newark, NJ, United States
| | - Dhruv Mendiratta
- Department of Orthopaedics, Rutgers New Jersey Medical School, Newark, NJ, United States
| | - Alice Chu
- Department of Orthopaedics, Rutgers New Jersey Medical School, Newark, NJ, United States
| | - Aleksandra McGrath
- Department of Clinical Sciences, Umeå University, Umeå, Sweden
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
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2
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Muacevic A, Adler JR, Miyakoshi N. Bakody's Test Positive Thoracic Outlet Syndrome Caused by Anomalous Muscle: A Case Report. Cureus 2023; 15:e33646. [PMID: 36788867 PMCID: PMC9918333 DOI: 10.7759/cureus.33646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2023] [Indexed: 01/13/2023] Open
Abstract
Anomalous muscle causes thoracic outlet syndrome (TOS). A 40-year-old man presented with numbness of the left upper extremity, similar to cervical spondylotic radiculopathy. He presented with a positive Bakody's test. However, magnetic resonance imaging showed no significant changes in the cervical spine and revealed an anomalous muscle adjacent to the left brachial plexus. We diagnosed the muscle as the cause of TOS and performed a resection, which resulted in symptomatic improvement.
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3
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Panther EJ, Reintgen CD, Cueto RJ, Hao KA, Chim H, King JJ. Thoracic outlet syndrome: a review. J Shoulder Elbow Surg 2022; 31:e545-e561. [PMID: 35963513 DOI: 10.1016/j.jse.2022.06.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 06/06/2022] [Accepted: 06/27/2022] [Indexed: 02/01/2023]
Abstract
Thoracic outlet syndrome (TOS) is a rare condition (1-3 per 100,000) caused by neurovascular compression at the thoracic outlet and presents with arm pain and swelling, arm fatigue, paresthesias, weakness, and discoloration of the hand. TOS can be classified as neurogenic, arterial, or venous based on the compressed structure(s). Patients develop TOS secondary to congenital abnormalities such as cervical ribs or fibrous bands originating from a cervical rib leading to an objectively verifiable form of TOS. However, the diagnosis of TOS is often made in the presence of symptoms with physical examination findings (disputed TOS). TOS is not a diagnosis of exclusion, and there should be evidence for a physical anomaly that can be corrected. In patients with an identifiable narrowing of the thoracic outlet and/or symptoms with a high probability of thoracic outlet neurovascular compression, diagnosis of TOS can be established through history, a physical examination maneuvers, and imaging. Neck trauma or repeated work stress can cause scalene muscle scaring or dislodging of a congenital cervical rib that can compress the brachial plexus. Nonsurgical treatment includes anti-inflammatory medication, weight loss, physical therapy/strengthening exercises, and botulinum toxin injections. The most common surgical treatments include brachial plexus decompression, neurolysis, and scalenotomy with or without first rib resection. Patients undergoing surgical treatment for TOS should be seen postoperatively to begin passive/assisted mobilization of the shoulder. By 8 weeks postoperatively, patients can begin resistance strength training. Surgical treatment complications include injury to the subclavian vessels potentially leading to exsanguination and death, brachial plexus injury, hemothorax, and pneumothorax. In this review, we outline the diagnostic tests and treatment options for TOS to better guide clinicians in recognizing and treating vascular TOS and objectively verifiable forms of neurogenic TOS.
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Affiliation(s)
- Eric J Panther
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Christian D Reintgen
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Robert J Cueto
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Kevin A Hao
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Harvey Chim
- Department of Plastic and Reconstructive Surgery, University of Florida, Gainesville, FL, USA
| | - Joseph J King
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, FL, USA.
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4
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Szaro P, McGrath A, Ciszek B, Geijer M. Magnetic resonance imaging of the brachial plexus. Part 1: Anatomical considerations, magnetic resonance techniques, and non-traumatic lesions. Eur J Radiol Open 2022; 9:100392. [PMID: 34988263 PMCID: PMC8695258 DOI: 10.1016/j.ejro.2021.100392] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 11/30/2021] [Accepted: 12/12/2021] [Indexed: 12/28/2022] Open
Abstract
For magnetic resonance imaging (MRI) of non-traumatic brachial plexus (BP) lesions, sequences with contrast injection should be considered in the differentiation between tumors, infection, postoperative conditions, and post-radiation changes. The most common non-traumatic inflammatory BP neuropathy is radiation neuropathy. T2-weighted images may help to distinguish neoplastic infiltration showing a high signal from radiation-induced neuropathy with fibrosis presenting a low signal. MRI findings in inflammatory BP neuropathy are usually absent or discrete. Diffuse edema of the BP localized mainly in the supraclavicular part of BP, with side-to-side differences, and shoulder muscle denervation may be found on MRI. BP infection is caused by direct infiltration from septic arthritis of the shoulder joint, spondylodiscitis, or lung empyema. MRI may help to narrow down the list of differential diagnoses of tumors. The most common tumor of BP is metastasis. The most common primary tumor of BP is neurofibroma, which is visible as fusiform thickening of a nerve. In its solitary state, it may be challenging to differentiate from a schwannoma. The most common MRI finding is a neurogenic variant of thoracic outlet syndrome with an asymmetry of signal and thickness of the BP with edema. In abduction, a loss of fat directly related to the BP may be seen. Diffusion tensor imaging is a promising novel MRI sequences; however, the small diameter of the nerves contributing to the BP and susceptibility to artifacts may be challenging in obtaining sufficiently high-quality images. MRI allows narrowing the list of differential diagnoses of brachial plexus lesions. MRI helps to distinguish neoplastic infiltration from radiation neuropathy in T2-weighted images. Differentiation between tumors, infection, postoperative conditions and post-radiation changes is possible with contrast. MRI helps to determine the extent of the infection. Diffusion tensor MRI is a promising method for brachial plexus assessment.
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Affiliation(s)
- Pawel Szaro
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Musculoskeletal Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Alexandra McGrath
- Umeå University, Faculty of Medicine, Department of Clinical Sciences, Professional Development. Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Sweden
| | - Bogdan Ciszek
- Department of Descriptive and Clinical Anatomy, Centre of Biostructure Research, Medical University of Warsaw, Chałubinskiego 5, 02-004 Warsaw, Poland.,Department of Neurosurgery, Bogdanowicz Memorial Hospital, Niekłanska 4/24, 03-924 Warsaw, Poland
| | - Mats Geijer
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Musculoskeletal Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Clinical Sciences, Lund University, Lund, Sweden
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5
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Colafati GS, Marrazzo A, Cirillo M, d'Angelo P, Barbuti D, Tanturri de Horatio L, Tomà P, Bartoloni A. The Pediatric Spine. Semin Musculoskelet Radiol 2021; 25:137-154. [PMID: 34020474 DOI: 10.1055/s-0041-1727095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The spine, a frequently investigated site in children, has a complex development in relation to both nervous and bone/cartilaginous structures and shows several particular features in children compared with adults. We report the main normal variants and pathologies of the pediatric spine, from the prenatal period to adolescence, focusing on a multimodality imaging approach.
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Affiliation(s)
| | - Antonio Marrazzo
- Imaging Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Marco Cirillo
- Imaging Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Paola d'Angelo
- Imaging Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Domenico Barbuti
- Imaging Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | | | - Paolo Tomà
- Imaging Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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6
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Abstract
Imaging studies play a significant role in assessment of thoracic outlet syndrome. In this article, we discuss the etiology and definition of thoracic outlet syndrome and review the spectrum of imaging findings seen in patients with thoracic outlet syndrome. We then discuss an optimized technique for computed tomography and MRI of patients with thoracic outlet syndrome, based on the experience at our institution and present some representative examples. Based on our experience, a combination of computed tomography angiography and MRI (with postural maneuvers) effectively demonstrate thoracic outlet syndrome abnormalities.
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Affiliation(s)
- Omid Khalilzadeh
- Department of Radiology, Division of Musculoskeletal Radiology, Johns Hopkins University, Baltimore, MD, USA
| | - McKinley Glover
- Department of Radiology, Division of Neuroradiology, Massachusetts General Hospital and Harvard Medical School, Room: GRB-273A, 55 Fruit Street, Boston, MA 02114, USA
| | - Martin Torriani
- Department of Radiology, Division of Musculoskeletal Radiology, Massachusetts General Hospital and Harvard Medical School, Room: YAW-6-6048, 32 Fruit Street, Boston, MA 02114, USA
| | - Rajiv Gupta
- Department of Radiology, Division of Neuroradiology, Massachusetts General Hospital and Harvard Medical School, Room: GRB-273A, 55 Fruit Street, Boston, MA 02114, USA.
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7
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Han CY, Tarr AM, Gewirtz AN, Kaunzner UW, Roy-Burman P, Cutler TS, MacGowan DJ. Brachial plexopathy as a complication of COVID-19. BMJ Case Rep 2021; 14:e237459. [PMID: 33766961 PMCID: PMC8006770 DOI: 10.1136/bcr-2020-237459] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2020] [Indexed: 12/23/2022] Open
Abstract
COVID-19 affects a wide spectrum of organ systems. We report a 52-year-old man with hypertension and newly diagnosed diabetes mellitus who presented with hypoxic respiratory failure due to COVID-19 and developed severe brachial plexopathy. He was not treated with prone positioning respiratory therapy. Associated with the flaccid, painfully numb left upper extremity was a livedoid, purpuric rash on his left hand and forearm consistent with COVID-19-induced microangiopathy. Neuroimaging and electrophysiological data were consistent with near diffuse left brachial plexitis with selective sparing of axillary, suprascapular and pectoral fascicles. Given his microangiopathic rash, elevated D-dimers and paucifascicular plexopathy, we postulate a patchy microvascular thrombotic plexopathy. Providers should be aware of this significant and potentially under-recognised neurologic complication of COVID-19.
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Affiliation(s)
| | - Andrew M Tarr
- Neurology, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York City, New York, USA
| | - Alexandra N Gewirtz
- Neurology, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York City, New York, USA
| | | | - Paula Roy-Burman
- Medicine, Weill Cornell Medical College, New York City, New York, USA
| | - Todd S Cutler
- Medicine, Weill Cornell Medical College, New York City, New York, USA
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8
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Combine contrast-enhanced 3D T2-weighted short inversion time inversion recovery MR neurography with MR angiography at 1.5 T in the assessment of brachial plexopathy. MAGNETIC RESONANCE MATERIALS IN PHYSICS BIOLOGY AND MEDICINE 2020; 34:229-239. [DOI: 10.1007/s10334-020-00867-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 06/20/2020] [Accepted: 07/08/2020] [Indexed: 12/21/2022]
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9
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Zurkiya O, Ganguli S, Kalva SP, Chung JH, Shah LM, Majdalany BS, Bykowski J, Carter BW, Chandra A, Collins JD, Gunn AJ, Kendi AT, Khaja MS, Liebeskind DS, Maldonado F, Obara P, Sutphin PD, Tong BC, Vijay K, Corey AS, Kanne JP, Dill KE. ACR Appropriateness Criteria® Thoracic Outlet Syndrome. J Am Coll Radiol 2020; 17:S323-S334. [PMID: 32370976 DOI: 10.1016/j.jacr.2020.01.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 01/22/2020] [Indexed: 10/24/2022]
Abstract
Thoracic outlet syndrome (TOS) is the clinical entity that occurs with compression of the brachial plexus, subclavian artery, and/or subclavian vein at the superior thoracic outlet. Compression of each of these structures results in characteristic symptoms divided into three variants: neurogenic TOS, venous TOS, and arterial TOS, each arising from the specific structure that is compressed. The constellation of symptoms in each patient may vary, and patients may have more than one symptom simultaneously. Understanding the various anatomic spaces, causes of narrowing, and resulting neurovascular changes is important in choosing and interpreting radiological imaging performed to help diagnose TOS and plan for intervention. This publication has separated imaging appropriateness based on neurogenic, venous, or arterial symptoms, acknowledging that some patients may present with combined symptoms that may require more than one study to fully resolve. Additionally, in the postoperative setting, new symptoms may arise altering the need for specific imaging as compared to preoperative evaluation. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Omar Zurkiya
- Research Author, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts
| | | | - Sanjeeva P Kalva
- Panel Chair, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Lubdha M Shah
- Panel Chair, University of Utah, Salt Lake City, Utah
| | | | | | - Brett W Carter
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ankur Chandra
- Scripps Green Hospital, La Jolla, California; Society for Vascular Surgery
| | | | - Andrew J Gunn
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - David S Liebeskind
- University of California Los Angeles, Los Angeles, California; American Academy of Neurology
| | - Fabien Maldonado
- Vanderbilt University Medical Center, Nashville, Tennessee; American College of Chest Physicians
| | - Piotr Obara
- Loyola University Medical Center, Maywood, Illinois
| | | | - Betty C Tong
- Duke University School of Medicine, Durham, North Carolina; The Society of Thoracic Surgeons
| | | | - Amanda S Corey
- Specialty Chair, Atlanta VA Health Care System and Emory University, Atlanta, Georgia
| | - Jeffrey P Kanne
- Specialty Chair, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Karin E Dill
- Specialty Chair, UMass Memorial Medical Center, Worcester, Massachusetts
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10
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Malignant synovial sarcoma: An unpredictable cause of brachial plexopathy. Clin Neurol Neurosurg 2020; 193:105767. [PMID: 32197143 DOI: 10.1016/j.clineuro.2020.105767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 02/27/2020] [Accepted: 03/01/2020] [Indexed: 11/21/2022]
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11
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Patel RH, Sheth RN. Post-operative emergence of acute brachial neuritis following posterior cervical laminectomy with fusion: A case report and review of the literature. Int J Surg Case Rep 2019; 65:197-200. [PMID: 31726257 PMCID: PMC6854072 DOI: 10.1016/j.ijscr.2019.07.065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 07/14/2019] [Accepted: 07/18/2019] [Indexed: 11/18/2022] Open
Abstract
Introduction Idiopathic brachial plexus neuritis or neuralgic amyotrophy is a rare neurological condition whose true etiology currently remains unknown. Epidemiologically, the incidence of this condition is exceptionally rare with only 1.6 cases for every 100,000 people (Turner and Parsonage, 1987). Symptoms present an initial acute and sudden pain to the shoulder girdle and upper arm which is followed by a sense of profound weakness and numbness to the upper arm (Parsonage and Turner, 1948). Localized neuropathy within the arm-pit region may also be presented. The pain often exacerbates upon movement of the shoulder. Due to the anatomic location affected and the nature of the clinical symptoms presented, accurate diagnosis of brachial plexus neuritis poses a challenging diagnostic task for physicians due to remarkably similar symptoms expressed by differential diagnoses. Presentation of case Here, we report the case of a 55-year-old woman who underwent surgery entailing cervical laminectomy with instrumented fusion. She presented with postoperative symptoms of severe pain in the left arm with significant weakness within 24 h after surgery. A diagnosis of brachial plexus neuritis was made based on the symptoms presented and upon review of imaging scans. Discussion After a six-month follow-up visit, the patient recovered from the brachial neuritis but has residual numbness in the hand. The presentation of this case serves to transmit three fundamental purposes. First, this case serves to establish an intriguing possible association of the post-surgical period of cervical laminectomy with acute brachial neuritis and signifies the importance post-operative linkage with brachial neuritis in general. Second, this case also highlights the importance of close clinical monitoring of patients with unique symptoms within the postoperative follow-up period to ensure successful improvement and accurate diagnosis. Conclusion As an underdiagnosed and relatively obscure condition, this case serves as an imperative reference for physicians to illuminate differential diagnosis of similar symptomatic conditions and also to promote knowledge of brachial plexus neuritis which can lead to an early and precise diagnosis.
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Affiliation(s)
- Raj H Patel
- University of South Florida, Tampa, FL, United States.
| | - Rishi N Sheth
- Department of Clinical Biomedical Sciences, Florida Atlantic University, Boca Raton, FL, United States
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12
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Degree of Agreement between Electrodiagnostic Testing and Magnetic Resonance Imaging in the Evaluation of Brachial Plexopathy. Am J Phys Med Rehabil 2019; 98:545-548. [PMID: 30664530 DOI: 10.1097/phm.0000000000001139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Electrodiagnostic study (EDX) and magnetic resonance imaging (MRI) are commonly used in the diagnosis of brachial plexopathy, but the agreement between these 2 studies is unknown. The aim of this study was to evaluate the agreement of EDX and MRI in patients with brachial plexopathy. DESIGN The records of 69 patients with symptoms of brachial plexopathy who underwent EDX and MRI were reviewed. Based on the degree of agreement of EDX and MRI results, patients were classified as a "complete match," "partial match," or "mismatch." RESULTS Both studies yielded similar results for the majority of patients (63.2%). Among the enrolled patients, 26.4% were classified as a "complete match," 36.8% as "partial match," and 36.8% as "mismatch." However, only 1 test, either EDX or MRI, revealed abnormal findings in 21.1% of patients. CONCLUSIONS The agreement between EDX and MRI was high in patients with brachial plexopathy. However, only one of these tests, not both, revealed abnormal findings in several cases. Although both EDX and MRI were in accord with the diagnosis of brachial plexopathy in majority of cases, these 2 studies remain complementary diagnostic modalities for evaluating brachial plexopathies.
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13
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Wade RG, Takwoingi Y, Wormald JCR, Ridgway JP, Tanner S, Rankine JJ, Bourke G. Magnetic resonance imaging for detecting root avulsions in traumatic adult brachial plexus injuries: protocol for a systematic review of diagnostic accuracy. Syst Rev 2018; 7:76. [PMID: 29778092 PMCID: PMC5960500 DOI: 10.1186/s13643-018-0737-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 05/01/2018] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Adult brachial plexus injuries (BPI) are becoming more common. The reconstruction and prognosis of pre-ganglionic injuries (root avulsions) are different to other types of BPI injury. Preoperative magnetic resonance imaging (MRI) is being used to identify root avulsions, but the evidence from studies of its diagnostic accuracy are conflicting. Therefore, a systematic review is needed to address uncertainty about the accuracy of MRI and to guide future research. METHODS We will conduct a systematic search of electronic databases alongside reference tracking. We will include studies of adults with traumatic BPI which report the accuracy of preoperative MRI (index test) against surgical exploration of the roots of the brachial plexus (reference standard) for detecting either of the two target conditions (any root avulsion or any pseudomeningocoele as a surrogate marker of root avulsion). We will exclude case reports, articles considering bilateral injuries and studies where the number of true positives, false positives, false negatives and true negatives cannot be derived. The methodological quality of the included studies will be assessed using a tailored version of the QUADAS-2 tool. Where possible, a bivariate model will be used for meta-analysis to obtain summary sensitivities and specificities for both target conditions. We will investigate heterogeneity in the performance of MRI according to field strength and the risk of bias if data permits. DISCUSSION This review will summarise the current diagnostic accuracy of MRI for adult BPI, identify shortcomings and gaps in the literature and so help to guide future research. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42016049702 .
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Affiliation(s)
- Ryckie G Wade
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, UK. .,Faculty of Medicine and Health Sciences, University of Leeds, Leeds, UK.
| | - Yemisi Takwoingi
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Justin C R Wormald
- Department of Plastic and Reconstructive Surgery, Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, Aylesbury, UK.,Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - John P Ridgway
- Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, UK
| | - Steven Tanner
- Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, UK
| | - James J Rankine
- Department of Radiology, Leeds Teaching Hospitals Trust, Leeds, UK.,Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, UK
| | - Grainne Bourke
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, UK.,Faculty of Medicine and Health Sciences, University of Leeds, Leeds, UK
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14
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Wade RG, Itte V, Rankine JJ, Ridgway JP, Bourke G. The diagnostic accuracy of 1.5T magnetic resonance imaging for detecting root avulsions in traumatic adult brachial plexus injuries. J Hand Surg Eur Vol 2018; 43:250-258. [PMID: 28886666 DOI: 10.1177/1753193417729587] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
UNLABELLED Identification of root avulsions is of critical importance in traumatic brachial plexus injuries because it alters the reconstruction and prognosis. Pre-operative magnetic resonance imaging is gaining popularity, but there is limited and conflicting data on its diagnostic accuracy for root avulsion. This cohort study describes consecutive patients requiring brachial plexus exploration following trauma between 2008 and 2016. The index test was magnetic resonance imaging at 1.5 Tesla and the reference test was operative exploration of the supraclavicular plexus. Complete data from 29 males was available. The diagnostic accuracy of magnetic resonance imaging for root avulsion(s) of C5-T1 was 79%. The diagnostic accuracy of a pseudomeningocoele as a surrogate marker of root avulsion(s) of C5-T1 was 68%. We conclude that pseudomeningocoles were not a reliable sign of root avulsion and magnetic resonance imaging has modest diagnostic accuracy for root avulsions in the context of adult traumatic brachial plexus injuries. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Ryckie G Wade
- 1 Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, UK
- 2 Faculty of Medicine and Health Sciences, University of Leeds, Leeds, UK
| | - Vinay Itte
- 1 Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, UK
- 3 Department of Integrative Medical Biology, Umeå University, Umeå, Sweden
| | - James J Rankine
- 4 Department of Radiology, Leeds Teaching Hospitals Trust, Leeds, UK
- 5 Leeds Musculoskeletal Biomedical Research Centre (LMBRC), Chapel Allerton Hospital, Leeds, UK
| | - John P Ridgway
- 5 Leeds Musculoskeletal Biomedical Research Centre (LMBRC), Chapel Allerton Hospital, Leeds, UK
- 6 Department of Medical Physics and Engineering, Leeds Teaching Hospitals Trust, Leeds, UK
| | - Grainne Bourke
- 1 Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, UK
- 2 Faculty of Medicine and Health Sciences, University of Leeds, Leeds, UK
- 3 Department of Integrative Medical Biology, Umeå University, Umeå, Sweden
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15
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Yang C, Xu J, Chen J, Li S, Cao Y, Zhu Y, Xu L. Experimental study of brachial plexus and vessel compression: evaluation of combined central and peripheral electrodiagnostic approach. Oncotarget 2017; 8:50618-50628. [PMID: 28881588 PMCID: PMC5584177 DOI: 10.18632/oncotarget.16817] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 03/09/2017] [Indexed: 11/25/2022] Open
Abstract
Introduction We sought to investigate the reliability of a new electrodiagnostic method for identifying Electrodiagnosis of Brachial Plexus & Vessel Compression Syndrome (BPVCS) in rats that involves the application of transcranial electrical stimulation motor evoked potentials (TES-MEPs) combined with peripheral nerve stimulation compound muscle action potentials (PNS-CMAPs). Results The latencies of the TES-MEP and PNS-CMAP were initially elongated in the 8-week group. The amplitudes of TES-MEP and PNS-CMAP were initially attenuated in the 16-week group. The isolateral amplitude ratio of the TES-MEP to the PNS-CMAP was apparently decreased, and spontaneous activities emerged at 16 weeks postoperatively. Materials and Methods Superior and inferior trunk models of BPVCS were created in 72 male Sprague Dawley (SD) rats that were divided into six experimental groups. The latencies, amplitudes and isolateral amplitude ratios of the TES-MEPs and PNS-CMAPs were recorded at different postoperative intervals. Conclusions Electrophysiological and histological examinations of the rats’ compressed brachial plexus nerves were utilized to establish preliminary electrodiagnostic criteria for BPVCS.
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Affiliation(s)
- Chaoqun Yang
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Jianguang Xu
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Jie Chen
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Shulin Li
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Yu Cao
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Yi Zhu
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Lei Xu
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China
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Lee JH, Cheng KL, Choi YJ, Baek JH. High-resolution Imaging of Neural Anatomy and Pathology of the Neck. Korean J Radiol 2017; 18:180-193. [PMID: 28096728 PMCID: PMC5240499 DOI: 10.3348/kjr.2017.18.1.180] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 07/10/2016] [Indexed: 11/15/2022] Open
Abstract
The neck has intricately connected neural structures, including cervical and brachial plexi, the sympathetic system, lower cranial nerves, and their branches. Except for brachial plexus, there has been little research regarding the normal imaging appearance or corresponding pathologies of neural structures in the neck. The development in imaging techniques with better spatial resolution and signal-to-noise ratio has made it possible to see many tiny nerves to predict complications related to image-guided procedures and to better assess treatment response, especially in the management of oncology patients. The purposes of this review is to present imaging-based anatomy of major nerves in the neck and explain their relevant clinical significance according to representative pathologies of regarded nerves in the neck.
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Affiliation(s)
- Jeong Hyun Lee
- Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Kai-Lung Cheng
- Department of Medical Imaging, Chung Shan Medical University Hospital, Taichung 402, Taiwan.; School of Medical Imaging and Radiological Sciences, Chung Shan Medical University, Taichung 402, Taiwan.; Department of Veterinary Medicine, National Chung Hsing University, Taichung 402, Taiwan
| | - Young Jun Choi
- Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Jung Hwan Baek
- Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
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17
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Karalija A, Novikova LN, Orädd G, Wiberg M, Novikov LN. Differentiation of Pre- and Postganglionic Nerve Injury Using MRI of the Spinal Cord. PLoS One 2016; 11:e0168807. [PMID: 28036395 PMCID: PMC5201258 DOI: 10.1371/journal.pone.0168807] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 12/06/2016] [Indexed: 01/09/2023] Open
Abstract
Brachial plexus injury (BPI) is a devastating type of nerve injury, potentially causing loss of motor and sensory function. Principally, BPI is either categorized as preganglionic or postganglionic, with the early establishment of injury level being crucial for choosing the correct treatment strategy. Despite diagnostic advances, the need for a reliable, non-invasive method for establishing the injury level remains. We studied the usefulness of in vivo magnetic resonance imaging (MRI) of the spinal cord for determination of injury level. The findings were related to neuronal and glial changes. Rats underwent unilateral L4 & L5 ventral roots avulsion or sciatic nerve axotomy. The injuries served as models for pre- and postganglionic BPI, respectively. MRI of the L4/L5 spinal cord segments 4 weeks after avulsion showed ventral horn (VH) shrinkage on the injured side compared to the uninjured side. Axotomy induced no change in the VH size on MRI. Following avulsion, histological sections of L4/L5 revealed shrinkage in the VH grey matter area occupied by NeuN-positive neurons, loss of microtubular-associated protein-2 positive dendritic branches (MAP2), pan-neurofilament positive axons (PanNF), synaptophysin-positive synapses (SYN) and increase in immunoreactivity for the microglial OX42 and astroglial GFAP markers. Axotomy induced no changes in NeuN-reactivity, modest decrease of MAP2 immunoreactivity, no changes in SYN and PanNF labelling, and a modest increase in OX42 and SYN labeling. Histological and radiological findings were congruent when assessing changes after axotomy, while MRI somewhat underestimated the shrinkage. This study indicates a potential diagnostic value of structural spinal cord MRI following BPI.
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Affiliation(s)
- Amar Karalija
- Department of Integrative Medical Biology, Section of Anatomy, Umeå University, Umeå, Sweden
- Department of Surgical and Perioperative Science, Section of Hand and Plastic Surgery, Umeå University, Umeå, Sweden
- * E-mail:
| | - Liudmila N. Novikova
- Department of Integrative Medical Biology, Section of Anatomy, Umeå University, Umeå, Sweden
| | - Greger Orädd
- Department of Integrative Medical Biology, Section of Physiology, Umeå University, Umeå, Sweden
- Umeå Centre for Comparative Biology, Umeå University, Umeå, Sweden
| | - Mikael Wiberg
- Department of Integrative Medical Biology, Section of Anatomy, Umeå University, Umeå, Sweden
- Department of Surgical and Perioperative Science, Section of Hand and Plastic Surgery, Umeå University, Umeå, Sweden
| | - Lev N. Novikov
- Department of Integrative Medical Biology, Section of Anatomy, Umeå University, Umeå, Sweden
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18
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Thoracic outlet syndrome: wide literature for few cases. Status of the art. Neurol Sci 2016; 38:383-388. [DOI: 10.1007/s10072-016-2794-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 12/03/2016] [Indexed: 12/30/2022]
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19
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Ahn SW, Park MS, Yoo IH, Kim JM, Yoon BN, Kim SB, Kim JY. Subcoracoid bursitis presenting with brachial plexopathy involving the posterior cord. Muscle Nerve 2016; 55:E13-E15. [PMID: 27859366 DOI: 10.1002/mus.25474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 11/08/2016] [Accepted: 11/14/2016] [Indexed: 11/10/2022]
Affiliation(s)
- Suk-Won Ahn
- Department of Neurology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Republic of Korea
| | - Moo-Seok Park
- Department of Neurology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Republic of Korea
| | - Il-Han Yoo
- Department of Neurology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Republic of Korea
| | - Jeong-Min Kim
- Department of Neurology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Republic of Korea
| | - Byung-Nam Yoon
- Department of Neurology, Inha University Hospital, Inha University College of Medicine, Incheon, Republic of Korea
| | - Sang-Beom Kim
- Department of Neurology, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Republic of Korea
| | - Jae Yoon Kim
- Department of Orthopaedic Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Republic of Korea
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20
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Raptis CA, Sridhar S, Thompson RW, Fowler KJ, Bhalla S. Imaging of the Patient with Thoracic Outlet Syndrome. Radiographics 2016; 36:984-1000. [PMID: 27257767 DOI: 10.1148/rg.2016150221] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Patients with symptoms from compression of the neurovascular bundle in the thoracic outlet are described as having thoracic outlet syndrome (TOS), which is best thought of as three conditions classified according to which structures are involved. The purpose of this article is to review the role of imaging in evaluation of patients with TOS, beginning with diagnosis and extending through postoperative management. While diagnosis of TOS still rests on the patient's presenting history and physical examination, imaging examinations are helpful in supporting the diagnosis, delineating abnormal anatomy, determining which structures are compressed, identifying the site of compression, and excluding other diagnoses. Magnetic resonance imaging is the noninvasive imaging modality of choice in evaluating patients with suspected TOS, but computed tomography also plays an important role, particularly in delineating bone anatomy. Evidence of vascular damage is required to make the diagnosis of TOS at imaging. Dynamic compression of the axillosubclavian vessels at the thoracic outlet can be a finding supportive of the diagnosis of TOS but is not a stand-alone diagnostic criterion, as it can be seen in patients without TOS. As diagnosis and treatment of TOS increase, radiologists will increasingly encounter the TOS patient after decompression surgery. Recognition of the expected postoperative appearance of these patients is critical, as is an understanding of the imaging findings of potential short- and long-term complications. (©)RSNA, 2016.
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Affiliation(s)
- Constantine A Raptis
- From the Mallinckrodt Institute of Radiology (C.A.R., S.S., K.J.F., S.B.) and Division of Surgery, Vascular Surgery Section (R.W.T.), Washington University School of Medicine, 510 S Kingshighway Blvd, Campus Box 8131, St Louis, MO 63110
| | - Sreevathsan Sridhar
- From the Mallinckrodt Institute of Radiology (C.A.R., S.S., K.J.F., S.B.) and Division of Surgery, Vascular Surgery Section (R.W.T.), Washington University School of Medicine, 510 S Kingshighway Blvd, Campus Box 8131, St Louis, MO 63110
| | - Robert W Thompson
- From the Mallinckrodt Institute of Radiology (C.A.R., S.S., K.J.F., S.B.) and Division of Surgery, Vascular Surgery Section (R.W.T.), Washington University School of Medicine, 510 S Kingshighway Blvd, Campus Box 8131, St Louis, MO 63110
| | - Kathryn J Fowler
- From the Mallinckrodt Institute of Radiology (C.A.R., S.S., K.J.F., S.B.) and Division of Surgery, Vascular Surgery Section (R.W.T.), Washington University School of Medicine, 510 S Kingshighway Blvd, Campus Box 8131, St Louis, MO 63110
| | - Sanjeev Bhalla
- From the Mallinckrodt Institute of Radiology (C.A.R., S.S., K.J.F., S.B.) and Division of Surgery, Vascular Surgery Section (R.W.T.), Washington University School of Medicine, 510 S Kingshighway Blvd, Campus Box 8131, St Louis, MO 63110
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21
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High resolution neurography of the brachial plexus by 3Tesla magnetic resonance imaging. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.rxeng.2016.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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22
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Cejas C, Rollán C, Michelin G, Nogués M. High resolution neurography of the brachial plexus by 3 Tesla magnetic resonance imaging. RADIOLOGIA 2016; 58:88-100. [PMID: 26860655 DOI: 10.1016/j.rx.2015.12.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 09/23/2015] [Accepted: 12/16/2015] [Indexed: 12/23/2022]
Abstract
The study of the structures that make up the brachial plexus has benefited particularly from the high resolution images provided by 3T magnetic resonance scanners. The brachial plexus can have mononeuropathies or polyneuropathies. The mononeuropathies include traumatic injuries and trapping, such as occurs in thoracic outlet syndrome due to cervical ribs, prominent transverse apophyses, or tumors. The polyneuropathies include inflammatory processes, in particular chronic inflammatory demyelinating polyneuropathy, Parsonage-Turner 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.
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Affiliation(s)
- C Cejas
- Departamento de Imágenes, Fundación para la lucha de las enfermedades neurológicas de la infancia Dr. Raúl Carrea (FLENI), Buenos Aires, Argentina.
| | - C Rollán
- Departamento de Imágenes, Fundación para la lucha de las enfermedades neurológicas de la infancia Dr. Raúl Carrea (FLENI), Buenos Aires, Argentina
| | - G Michelin
- Departamento de Imágenes, Fundación para la lucha de las enfermedades neurológicas de la infancia Dr. Raúl Carrea (FLENI), Buenos Aires, Argentina
| | - M Nogués
- Departamento de Neurología, Fundación para la lucha de las enfermedades neurológicas de la infancia Dr. Raúl Carrea (FLENI), Buenos Aires, Argentina
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Upadhyaya V, Upadhyaya DN, Kumar A, Pandey AK, Gujral R, Singh AK. Magnetic resonance neurography of the brachial plexus. Indian J Plast Surg 2015; 48:129-37. [PMID: 26424974 PMCID: PMC4564494 DOI: 10.4103/0970-0358.163045] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Magnetic Resonance Imaging (MRI) is being increasingly recognised all over the world as the imaging modality of choice for brachial plexus and peripheral nerve lesions. Recent refinements in MRI protocols have helped in imaging nerve tissue with greater clarity thereby helping in the identification, localisation and classification of nerve lesions with greater confidence than was possible till now. This article on Magnetic Resonance Neurography (MRN) is based on the authors’ experience of imaging the brachial plexus and peripheral nerves using these protocols over the last several years.
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Affiliation(s)
- Vaishali Upadhyaya
- Department of Radiodiagnosis, Vivekananda Polyclinic and Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Divya Narain Upadhyaya
- Department of Plastic Surgery, King George Medical University, Lucknow, Uttar Pradesh, India
| | - Adarsh Kumar
- Department of Plastic Surgery, Vivekananda Polyclinic and Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Ashok Kumar Pandey
- Department of Neurology, Vivekananda Polyclinic and Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Ratni Gujral
- Department of Radiodiagnosis, Vivekananda Polyclinic and Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Arun Kumar Singh
- Department of Plastic Surgery, King George Medical University, Lucknow, Uttar Pradesh, India
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24
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Moriarty JM, Bandyk DF, Broderick DF, Cornelius RS, Dill KE, Francois CJ, Gerhard-Herman MD, Ginsburg ME, Hanley M, Kalva SP, Kanne JP, Ketai LH, Majdalany BS, Ravenel JG, Roth CJ, Saleh AG, Schenker MP, Mohammed TLH, Rybicki FJ. ACR Appropriateness Criteria Imaging in the Diagnosis of Thoracic Outlet Syndrome. J Am Coll Radiol 2015; 12:438-43. [DOI: 10.1016/j.jacr.2015.01.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 01/23/2015] [Indexed: 10/23/2022]
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25
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Upadhyaya V, Upadhyaya DN, Kumar A, Gujral RB. MR neurography in traumatic brachial plexopathy. Eur J Radiol 2015; 84:927-32. [PMID: 25740699 DOI: 10.1016/j.ejrad.2015.02.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 01/30/2015] [Accepted: 02/04/2015] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Imaging of the brachial plexus has come a long way and has progressed from plain radiography to CT and CT myelography to MRI. Evolution of MR imaging sequences has enabled good visualization of the small components of the plexus. The purpose of our study was to correlate the results of MR neurography (MRN) in patients with traumatic brachial plexopathy with their operative findings. We wanted to determine the usefulness of MRN and how it influenced surgical planning and outcome. METHODS Twenty patients with features of traumatic brachial plexopathy who were referred to the MRI section of the Department of Radiology between September 2012 and January 2014 and subsequently underwent exploration were included in the study. MR neurography and operative findings were recorded at three levels of the brachial plexus-roots, trunks and cords. RESULTS Findings at the level of roots and trunks were noted in 14 patients each and at the level of the cords in 16 patients. 10 patients had involvement at all levels. Axillary nerve involvement as a solitary finding was noted in two patients. These patients were subsequently operated and their studies were assigned a score based on the feedback from the operating surgeons. The MRN study was scored as three (good), two (average) or one (poor) depending on whether the MR findings correlated with operative findings at all three levels, any two levels or at any one level, respectively. CONCLUSIONS MR neurography is an extremely useful modality to image the traumatized brachial plexus. It influences both surgical planning and outcome/prognosis.
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Affiliation(s)
- Vaishali Upadhyaya
- Department of Radiology, Vivekananda Polyclinic and Institute of Medical Sciences, Vivekanandapuri, Lucknow 226 007, India.
| | - Divya N Upadhyaya
- Department of Plastic Surgery, King George Medical University, Shah Meena Road, Chowk, Lucknow 226 003, India
| | - Adarsh Kumar
- Department of Plastic Surgery, Vivekananda Polyclinic and Institute of Medical Sciences, Vivekanandapuri, Lucknow 226 007, India
| | - Ratni B Gujral
- Department of Radiology, Vivekananda Polyclinic and Institute of Medical Sciences, Vivekanandapuri, Lucknow 226 007, India
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26
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Brachial Plexus Birth Palsy: Multimodality Imaging of Spine and Shoulder Abnormalities in Children. AJR Am J Roentgenol 2015; 204:W199-206. [DOI: 10.2214/ajr.14.12862] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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27
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Wang KC, Salunkhe AR, Morrison JJ, Lee PP, Mejino JLV, Detwiler LT, Brinkley JF, Siegel EL, Rubin DL, Carrino JA. Ontology-based image navigation: exploring 3.0-T MR neurography of the brachial plexus using AIM and RadLex. Radiographics 2015; 35:142-51. [PMID: 25590394 PMCID: PMC4319494 DOI: 10.1148/rg.351130072] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Revised: 07/11/2014] [Accepted: 07/11/2014] [Indexed: 11/11/2022]
Abstract
Disorders of the peripheral nervous system have traditionally been evaluated using clinical history, physical examination, and electrodiagnostic testing. In selected cases, imaging modalities such as magnetic resonance (MR) neurography may help further localize or characterize abnormalities associated with peripheral neuropathies, and the clinical importance of such techniques is increasing. However, MR image interpretation with respect to peripheral nerve anatomy and disease often presents a diagnostic challenge because the relevant knowledge base remains relatively specialized. Using the radiology knowledge resource RadLex®, a series of RadLex queries, the Annotation and Image Markup standard for image annotation, and a Web services-based software architecture, the authors developed an application that allows ontology-assisted image navigation. The application provides an image browsing interface, allowing users to visually inspect the imaging appearance of anatomic structures. By interacting directly with the images, users can access additional structure-related information that is derived from RadLex (eg, muscle innervation, muscle attachment sites). These data also serve as conceptual links to navigate from one portion of the imaging atlas to another. With 3.0-T MR neurography of the brachial plexus as the initial area of interest, the resulting application provides support to radiologists in the image interpretation process by allowing efficient exploration of the MR imaging appearance of relevant nerve segments, muscles, bone structures, vascular landmarks, anatomic spaces, and entrapment sites, and the investigation of neuromuscular relationships.
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Affiliation(s)
- Kenneth C. Wang
- From the Imaging Service, Baltimore VA Medical Center, 10 N Greene St, Room C1-24, Baltimore, MD 21201 (K.C.W., E.L.S.); Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Md (K.C.W., P.P.L.); Department of Computer Science, University of Maryland, Baltimore County, Baltimore, Md (A.R.S.); Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Md (J.J.M., E.L.S.); Departments of Biological Structure (J.L.V.M., L.T.D., J.F.B.) and Biomedical Informatics and Medical Education (L.T.D., J.F.B.), University of Washington, Seattle, Wash; Department of Radiology, Stanford University School of Medicine, Stanford, Calif (D.L.R.); and Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY (J.A.C.)
| | - Aditya R. Salunkhe
- From the Imaging Service, Baltimore VA Medical Center, 10 N Greene St, Room C1-24, Baltimore, MD 21201 (K.C.W., E.L.S.); Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Md (K.C.W., P.P.L.); Department of Computer Science, University of Maryland, Baltimore County, Baltimore, Md (A.R.S.); Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Md (J.J.M., E.L.S.); Departments of Biological Structure (J.L.V.M., L.T.D., J.F.B.) and Biomedical Informatics and Medical Education (L.T.D., J.F.B.), University of Washington, Seattle, Wash; Department of Radiology, Stanford University School of Medicine, Stanford, Calif (D.L.R.); and Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY (J.A.C.)
| | - James J. Morrison
- From the Imaging Service, Baltimore VA Medical Center, 10 N Greene St, Room C1-24, Baltimore, MD 21201 (K.C.W., E.L.S.); Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Md (K.C.W., P.P.L.); Department of Computer Science, University of Maryland, Baltimore County, Baltimore, Md (A.R.S.); Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Md (J.J.M., E.L.S.); Departments of Biological Structure (J.L.V.M., L.T.D., J.F.B.) and Biomedical Informatics and Medical Education (L.T.D., J.F.B.), University of Washington, Seattle, Wash; Department of Radiology, Stanford University School of Medicine, Stanford, Calif (D.L.R.); and Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY (J.A.C.)
| | - Pearlene P. Lee
- From the Imaging Service, Baltimore VA Medical Center, 10 N Greene St, Room C1-24, Baltimore, MD 21201 (K.C.W., E.L.S.); Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Md (K.C.W., P.P.L.); Department of Computer Science, University of Maryland, Baltimore County, Baltimore, Md (A.R.S.); Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Md (J.J.M., E.L.S.); Departments of Biological Structure (J.L.V.M., L.T.D., J.F.B.) and Biomedical Informatics and Medical Education (L.T.D., J.F.B.), University of Washington, Seattle, Wash; Department of Radiology, Stanford University School of Medicine, Stanford, Calif (D.L.R.); and Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY (J.A.C.)
| | - José L. V. Mejino
- From the Imaging Service, Baltimore VA Medical Center, 10 N Greene St, Room C1-24, Baltimore, MD 21201 (K.C.W., E.L.S.); Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Md (K.C.W., P.P.L.); Department of Computer Science, University of Maryland, Baltimore County, Baltimore, Md (A.R.S.); Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Md (J.J.M., E.L.S.); Departments of Biological Structure (J.L.V.M., L.T.D., J.F.B.) and Biomedical Informatics and Medical Education (L.T.D., J.F.B.), University of Washington, Seattle, Wash; Department of Radiology, Stanford University School of Medicine, Stanford, Calif (D.L.R.); and Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY (J.A.C.)
| | - Landon T. Detwiler
- From the Imaging Service, Baltimore VA Medical Center, 10 N Greene St, Room C1-24, Baltimore, MD 21201 (K.C.W., E.L.S.); Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Md (K.C.W., P.P.L.); Department of Computer Science, University of Maryland, Baltimore County, Baltimore, Md (A.R.S.); Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Md (J.J.M., E.L.S.); Departments of Biological Structure (J.L.V.M., L.T.D., J.F.B.) and Biomedical Informatics and Medical Education (L.T.D., J.F.B.), University of Washington, Seattle, Wash; Department of Radiology, Stanford University School of Medicine, Stanford, Calif (D.L.R.); and Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY (J.A.C.)
| | - James F. Brinkley
- From the Imaging Service, Baltimore VA Medical Center, 10 N Greene St, Room C1-24, Baltimore, MD 21201 (K.C.W., E.L.S.); Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Md (K.C.W., P.P.L.); Department of Computer Science, University of Maryland, Baltimore County, Baltimore, Md (A.R.S.); Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Md (J.J.M., E.L.S.); Departments of Biological Structure (J.L.V.M., L.T.D., J.F.B.) and Biomedical Informatics and Medical Education (L.T.D., J.F.B.), University of Washington, Seattle, Wash; Department of Radiology, Stanford University School of Medicine, Stanford, Calif (D.L.R.); and Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY (J.A.C.)
| | - Eliot L. Siegel
- From the Imaging Service, Baltimore VA Medical Center, 10 N Greene St, Room C1-24, Baltimore, MD 21201 (K.C.W., E.L.S.); Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Md (K.C.W., P.P.L.); Department of Computer Science, University of Maryland, Baltimore County, Baltimore, Md (A.R.S.); Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Md (J.J.M., E.L.S.); Departments of Biological Structure (J.L.V.M., L.T.D., J.F.B.) and Biomedical Informatics and Medical Education (L.T.D., J.F.B.), University of Washington, Seattle, Wash; Department of Radiology, Stanford University School of Medicine, Stanford, Calif (D.L.R.); and Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY (J.A.C.)
| | - Daniel L. Rubin
- From the Imaging Service, Baltimore VA Medical Center, 10 N Greene St, Room C1-24, Baltimore, MD 21201 (K.C.W., E.L.S.); Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Md (K.C.W., P.P.L.); Department of Computer Science, University of Maryland, Baltimore County, Baltimore, Md (A.R.S.); Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Md (J.J.M., E.L.S.); Departments of Biological Structure (J.L.V.M., L.T.D., J.F.B.) and Biomedical Informatics and Medical Education (L.T.D., J.F.B.), University of Washington, Seattle, Wash; Department of Radiology, Stanford University School of Medicine, Stanford, Calif (D.L.R.); and Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY (J.A.C.)
| | - John A. Carrino
- From the Imaging Service, Baltimore VA Medical Center, 10 N Greene St, Room C1-24, Baltimore, MD 21201 (K.C.W., E.L.S.); Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Md (K.C.W., P.P.L.); Department of Computer Science, University of Maryland, Baltimore County, Baltimore, Md (A.R.S.); Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Md (J.J.M., E.L.S.); Departments of Biological Structure (J.L.V.M., L.T.D., J.F.B.) and Biomedical Informatics and Medical Education (L.T.D., J.F.B.), University of Washington, Seattle, Wash; Department of Radiology, Stanford University School of Medicine, Stanford, Calif (D.L.R.); and Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY (J.A.C.)
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Singh VK, Jeyaseelan L, Kyriacou S, Ghosh S, Sinisi M, Fox M. Diagnostic value of magnetic resonance imaging in thoracic outlet syndrome. J Orthop Surg (Hong Kong) 2014; 22:228-31. [PMID: 25163962 DOI: 10.1177/230949901402200224] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE. To evaluate the diagnostic value of magnetic resonance imaging (MRI) in thoracic outlet syndrome (TOS). METHODS. Medical records of 30 women and 10 men aged 18 to 68 (mean, 38) years who presented with unilateral (n=35) and bilateral (n=5) TOS and underwent 42 surgical decompressions of the right (n=23) and left (n=19) sides were reviewed. MRI findings were compared with intra-operative findings to evaluate the diagnostic value of MRI. RESULTS. MRI findings correlated poorly with intra-operative findings. Of the 42 cases, MRI and intra-operative findings were matched in 17 and not matched in 25. MRI appeared normal but intra-operative findings were in fact positive for TOS in 23 of 24 cases. The sensitivity and specificity of MRI in diagnosing TOS were 41% and 33%, respectively, whereas its positive and negative predictive values were 89% and 4%, respectively. CONCLUSION. Sensitivity and specificity of MRI in diagnosing TOS are low. Diagnosis should be based on a holistic approach including history, clinical examination, and radiological findings.
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Affiliation(s)
- Vinay Kumar Singh
- Peripheral Nerve Injury Unit, Royal National Orthopaedic Hospital Stanmore, Brockley Hill, Stanmore, United Kingdom
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Rehman I, Chokshi FH, Khosa F. MR Imaging of the Brachial Plexus. Clin Neuroradiol 2014; 24:207-16. [DOI: 10.1007/s00062-014-0297-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 02/06/2014] [Indexed: 12/26/2022]
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Caranci F, Briganti F, La Porta M, Antinolfi G, Cesarano E, Fonio P, Brunese L, Coppolino F. Magnetic resonance imaging in brachial plexus injury. Musculoskelet Surg 2013; 97 Suppl 2:S181-90. [PMID: 23949940 DOI: 10.1007/s12306-013-0281-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Accepted: 06/13/2013] [Indexed: 12/20/2022]
Abstract
Brachial plexus injury represents the most severe nerve injury of the extremities. While obstetric brachial plexus injury has showed a reduction in the number of cases due to the improvements in obstetric care, brachial plexus injury in the adult is an increasingly common clinical problem. The therapeutic measures depend on the pathologic condition and the location of the injury: Preganglionic avulsions are usually not amenable to surgical repair; function of some denervated muscles can be restored with nerve transfers from intercostals or accessory nerves and contralateral C7 transfer. Postganglionic avulsions are repaired with excision of the damaged segment and nerve autograft between nerve ends or followed up conservatively. Magnetic resonance imaging is the modality of choice for depicting the anatomy and pathology of the brachial plexus: It demonstrates the location of the nerve damage (crucial for optimal treatment planning), depicts the nerve continuity (with or without neuroma formation), or may show a completely disrupted/avulsed nerve, thereby aiding in nerve-injury grading for preoperative planning. Computed tomography myelography has the advantage of a higher spatial resolution in demonstration of nerve roots compared with MR myelography; however, it is invasive and shows some difficulties in the depiction of some pseudomeningoceles with little or no communication with the dural sac.
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Affiliation(s)
- F Caranci
- Department of Advanced Biomedical Sciences, Unit of Neuroradiology, Federico II University of Naples, Via S. Pansini 5, 80131, Naples, Italy.
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Aralasmak A, Cevikol C, Karaali K, Senol U, Sharifov R, Kilicarslan R, Alkan A. MRI findings in thoracic outlet syndrome. Skeletal Radiol 2012; 41:1365-74. [PMID: 22782291 DOI: 10.1007/s00256-012-1485-3] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Revised: 06/14/2012] [Accepted: 06/21/2012] [Indexed: 02/02/2023]
Abstract
We discuss MRI findings in patients with thoracic outlet syndrome (TOS). A total of 100 neurovascular bundles were evaluated in the interscalene triangle (IS), costoclavicular (CC), and retropectoralis minor (RPM) spaces. To exclude neurogenic abnormality, MRIs of the cervical spine and brachial plexus (BPL) were obtained in neutral. To exclude compression on neurovascular bundles, sagittal T1W images were obtained vertical to the longitudinal axis of BPL from spinal cord to the medial part of the humerus, in abduction and neutral. To exclude vascular TOS, MR angiography (MRA) and venography (MRV) of the subclavian artery (SA) and vein (SV) in abduction were obtained. If there is compression on the vessels, MRA and MRV of the subclavian vessels were repeated in neutral. Seventy-one neurovascular bundles were found to be abnormal: 16 arterial-venous-neurogenic, 20 neurogenic, 1 arterial, 15 venous, 8 arterial-venous, 3 arterial-neurogenic, and 8 venous-neurogenic TOS. Overall, neurogenic TOS was noted in 69%, venous TOS in 66%, and arterial TOS in 39%. The neurovascular bundle was most commonly compressed in the CC, mostly secondary to position, and very rarely compressed in the RPM. The cause of TOS was congenital bone variations in 36%, congenital fibromuscular anomalies in 11%, and position in 53%. In 5%, there was unilateral brachial plexitis in addition to compression of the neurovascular bundle. Severe cervical spondylosis was noted in 14%, contributing to TOS symptoms. For evaluation of patients with TOS, visualization of the brachial plexus and cervical spine and dynamic evaluation of neurovascular bundles in the cervicothoracobrachial region are mandatory.
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Affiliation(s)
- Ayse Aralasmak
- Department of Radiology, Bezmialem Vakif University, Fatih/Istanbul, Turkey.
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Chhabra A, Thawait GK, Soldatos T, Thakkar RS, Del Grande F, Chalian M, Carrino JA. High-resolution 3T MR neurography of the brachial plexus and its branches, with emphasis on 3D imaging. AJNR Am J Neuroradiol 2012; 34:486-97. [PMID: 22976233 DOI: 10.3174/ajnr.a3287] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
With advancement in 3D imaging, better fat-suppression techniques, and superior coil designs for MR imaging and the increasing availability and use of 3T magnets, the visualization of the complexity of the brachial plexus has become facile. The relevant imaging findings are described for normal and pathologic conditions of the brachial plexus. These radiologic findings are supported by clinical and/or EMG/surgical data, and corresponding high-resolution MR neurography images are illustrated. Because the brachial plexus can be affected by a plethora of pathologies, resulting in often serious and disabling complications, a better radiologic insight has great potential in aiding physicians in rendering superior services to patients.
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Affiliation(s)
- A Chhabra
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, Maryland 21287, USA.
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Diagnostic accuracy of MRI in adults with suspect brachial plexus lesions: a multicentre retrospective study with surgical findings and clinical follow-up as reference standard. Eur J Radiol 2011; 81:2666-72. [PMID: 22071340 DOI: 10.1016/j.ejrad.2011.10.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2011] [Revised: 10/12/2011] [Accepted: 10/14/2011] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To evaluate brachial plexus MRI accuracy with surgical findings and clinical follow-up as reference standard in a large multicentre study. MATERIALS AND METHODS The research was approved by the Institutional Review Boards, and all patients provided their written informed consent. A multicentre retrospective trial that included three centres was performed between March 2006 and April 2011. A total of 157 patients (men/women: 81/76; age range, 18-84 years) were evaluated: surgical findings and clinical follow-up of at least 12 months were used as the reference standard. MR imaging was performed with different equipment at 1.5 T and 3.0 T. The patient group was divided in five subgroups: mass lesion, traumatic injury, entrapment syndromes, post-treatment evaluation, and other. Sensitivity, specificity with 95% confidence intervals (CIs), positive predictive value (PPV), pre-test-probability (the prevalence), negative predictive value (NPV), pre- and post-test odds (OR), likelihood ratio for positive results (LH+), likelihood ratio for negative results (LH-), accuracy and post-test probability (post-P) were reported on a per-patient basis. RESULTS The overall sensitivity and specificity with 95% CIs were: 0.810/0.914; (0.697-0.904). Overall PPV, pre-test probability, NPV, LH+, LH-, and accuracy: 0.823, 0.331, 0.905, 9.432, 0.210, 0.878. CONCLUSIONS The overall diagnostic accuracy of brachial plexus MRI calculated on a per-patient base is relatively high. The specificity of brachial plexus MRI in patients suspected of having a space-occupying mass is very high. The sensitivity is also high, but there are false-positive interpretations as well.
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Lee PP, Dorsi MJ, Belzberg AJ, Chhabra A. Magnetic resonance neurography-surgical correlation of neurologic thoracic outlet syndrome. Microsurgery 2011; 31:662-5. [DOI: 10.1002/micr.20935] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2011] [Revised: 05/25/2011] [Accepted: 05/31/2011] [Indexed: 11/09/2022]
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