MR IMAGING ON BRACHIAL PLEXOPATHY : A CASE SERIES

Sukmaningtyas, H.1, Yashinta, MA2

1
Radiologist Consultant, Radiology Departemen Faculty of Medicine Diponegoro University/Kariadi
General Hospital
2
Radiology Resident, Radiology Departemen Faculty of Medicine Diponegoro University/Kariadi General
Hospital

ABSTRACT
Objectives : Brachial plexopathy is a form of peripheral neuropathy, involving different
pathological processes. We aimed to describe abnormality in 5 patient causing brachial plexus
dysfunction include traumatic injuries, mass involving or compressing the brachial plexus, and
brachial plexitis.
Material and Methods : MR images in 5 patients with brachial plexopathy were reviewed. We
used 1.5T GE MR machine to acquire multiplanar MR sequences.
Result : MR imaging revealed right brachial plexus injury grade IV (Sunderland classification)
involving trunk, division, and cord of right brachial plexus on 26-year-old man after motorcycle
crash. Second case on 31-year-old trauma patient showed high signal intensity masses at the root
of left brachial plexus at the level C6-7 and Th1-4, most likely pseudomeningocele. MR imaging
on 56-year-old woman with history of breast carcinoma depicted compression on C4 and C5
vertebral body, mildly compressing thecal sac and abnormal T2 signal and enhancement of
divisions and cords of right brachial plexus. A brachial plexus MRI on 57-year-old woman showed
no abnormality and the other on 44-year-old woman depicted well circumscribe high T2 signal
intensity mass arising from division of right brachial plexus. Biopsy revealed schwannoma.
Conclusion : MRI is a valuable technique for identifying and differentiating between pre- and
postganglionic lesions, crucial for surgical management.

Keyword : brachial plexus, brachial plexopathy, MRI

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INTRODUCTION
Brachial plexopathy is a form of peripheral neuropathy that may be involved in different
pathological processes. The causes of brachial plexus dysfunction include traumatic injuries, mass
involving or compressing the brachial plexus, brachial plexitis or thoracic outlet syndrome.
Wiltenberg and Adkins reported that radiation, primary and metastatic lung cancer, and breast
metastasis account for 75% of cases of brachial plexopathy. (1, 2)
Diagnosing brachial plexus pathology can be clinically challenging, often necessitating
further evaluation with MRI. Owing to its vague symptomatology, uncommon nature, and complex
anatomy, the brachial plexus presents a diagnostic dilemma to clinicians and radiologists and has
been the subject of many prior reviews offering various perspectives on its imaging and pathology.
MR imaging is a most valuable technique for lesion identification and differentiation between pre-
and postganglionic lesions, which is crucial for surgical management. (1)
On this case series, we report 5 cases of brachial plexopathy MR imaging with different
causes.

CASE REPORT
Case 1. An 26-year-old man suffered weakness on right upper extremity for four months
after a motorcycle crash along with pain from shoulder to right hand. MR imaging depicted a right
brachial plexus injury grade IV (Sunderland classification) involving trunk, division, and cord of
right brachial plexus which is appear as a high signal intensity on T2-weighted imaging and
thickening of cord and brachial plexus fiber. Muscle groups on shoulder appeared atrophy.
Case 2. An 31 year-old man with history of trauma 4 months prior the examination
complained weakness on left arm and hand. Electroneuromyography showed a brachial plexopathy
with sign of severe axonal degeneration. MR imaging depicted high signal intensity masses at the
root of left brachial plexus at the level C6-7 and Th1-4, most likely a pseudomeningocele.
Case 3. An 56-year-old woman with history of breast carcinoma complained pain dan
stiffness on right upper extremity. MR imaging revealed a compression on cervical 4 and 5
vertebral body that mildly compress the thecal sac. T2-weighted imaging also demonstrated
abnormal T2 signal and enhancement of the divisions and cords of the right brachial plexus.

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Figure 1. Case 1. MR imaging of 26-year-old man suffered weakness on right upper extremity after
motorcycle crash. (a) Coronal STIR image (b) Proton Density image (c) T2 weighted image and (d)
sagital STIR image depicted high signal intensity lesion and thickening of trunk, division and cord of
right brachial plexus reflecting right brachial plexus injury grade IV (Sunderland classification)

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 Figure 2. Case 2. 31 year-old man with history of trauma 4 months prior the examination complained
weakness on left arm and hand. Electromyography showed brachial plexopathy with sign of severe axonal
degeneration. Coronal T2 weighted images (a,b), coronal STIR images (c,d), axial proton density image
(g) and fat saturation proton density image (h) showed lesion at the root of left brachial plexus at the level
C6-7 and Th1-4. Coronal contrast enhanced T1weighted images (e,f) did not showed any enhancement
after contrast administration. Most likely this lesions are pseudomeningocele.

Figure 3. Case 3. 56-year-old woman with history of breast carcinoma complained pain and stiffness on
right upper extremity. Sagital proton density image (a) revealed compression on C4, C5, Th4 vertebral
body, mildly compressing thecal sac. Coronal proton density image (b) and fat saturation proton density
image demonstrated abnormal T2 signal and enhancement of divisions and cords of right brachial plexus

Case 4. An 57-year-old woman complained weakness on right arm, no history of trauma

or malignancy. MR imaging showed no abnormality on right brachial plexus.
Case 5. An 44-year-old woman with lump on her right neck for 5 years. MR imaging
depicted a well circumscribe mass arising from the division of the right brachial plexus which is
appear as a high signal intensity on T2-weighted imaging. Biopsy revealed a schwannoma.

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 Figure 4. Case 4. 57-year-old woman complained weakness on right arm, no history of trauma or
malignancy. Coronal proton density (a,c) and fat saturation proton density (b,d) images showed no
abnormality on right brachial plexus.

Figure 5. Case 5. 44-year-old woman with lump on right neck and right upper extremity weakness for 5
years. Coronal proton density (a) and axial fat saturated proton density (c) images depicted high signal
well circumscribe mass arising from division of right brachial plexus. Coronal (b) and axial (d) contrast
enhanced T1 weighted images showed inhomogen contrast enhancement. Biopsy revealed schwannoma.

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DISCUSSION
Brachial plexus is a part of the peripheral nervous system, responsible for innervation of
the shoulder, upper extremity and upper chest muscles, and cutaneous nerves of the skin and hand,
with branches to the phrenic nerve (C3-C5) for diaphragm movement and to the sympathetic
ganglia via the C8 and T1 nerves. (3)
The brachial plexus (BP) provides sensory and motor innervation to the ipsilateral
shoulder, chest, arm, and hand. Arising from the C5-T1 ventral rami of the spinal cord, the brachial
plexus is divided anatomically into 5 segments: roots, trunks, divisions, cords, and terminal
branches. (1, 3)
In the cervicothoracobrachial region, the BPL courses superior and posterior to the
subclavian artery and vein. The supraclavicular plexus includes roots and trunks. Through the
neural foramina, roots of the BPL extend into the interscalene region, forming the superior (C5
and C6), middle (C7), and inferior (C8 and T1) trunks at the lateral border of middle scalene
muscles. The retroclavicular plexus is located in the costoclavicular space, posterior to the clavicle
and above the subclavian artery and vein, including the anterior and posterior division of the
trunks. The infraclavicular plexus is situated in the retropectoralis minor space, lateral to the first
rib, posterior to pectoralis muscles, and above the axillary artery and vein, including the 3 (medial,
lateral, and posterior) cords and terminal branches (median, ulnar, musculocutaneous, axillary, and
radial nerves).(3, 4)

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 Figure 6. Illustration of the brachial plexus and branches.(2)

Figure 7. A, Coronal drawing demonstrates the basic anatomy of the BPL. B-D, Oblique sagittal drawings
(B-D from medial to lateral) demonstrate 3 parts of the BPL. The supraclavicular plexus is composed of
roots and trunks. Roots are seen at the interscalene triangle between the anterior and middle scalene
muscles. The subclavian artery forms the floor of the interscalene triangle (B). Roots then form the trunks
at the lateral border of the middle scalene muscles. The retroclavicular plexus is composed of divisions
situated in the costoclavicular space between the first rib and clavicula, and the BPL is seen in the
superior and posterior aspect of the subclavian artery (C). The infraclavicular plexus is composed of cords
and terminal branches located in the retropectoralis minor space. The BPL is situated in the posterior and
superior aspect of axillary artery (D). The subclavian artery and vein take the name of axillary artery and
vein at the lateral border of first rib. (3)

The goal of imaging the BP is to visualize the entire course of the neural network from its
preganglionic segments (eg, nerve rootlets and intraforaminal nerve segments) and the
postganglionic segments from the dorsal root ganglion (DRG) to the terminal branches. (1)

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 Figure 8. (a) Normal anatomy of rootlets and roots. (b) Avulsive preganglionic injury. (c, d)
Postganglionic injury. (5)

The brachial plexus is a difficult area to image with most radiographic techniques. CT has
significant limitations, including restriction of imaging planes and artifacts from the shoulder. In
addition, it is more difficult to distinguish neurovascular structures from nodes in the brachial
plexus region using conventional CT techniques. The superior soft tissue contrast and multiple
image planes available with MRI provide significant advantages in this regard. (1,2)
MR imaging is a most valuable technique for lesion identification and differentiation
between pre- and postganglionic lesions, which is crucial for surgical management. Focused
multiplanar, multisequence MRI is required to completely image the brachial plexus and offers
superior contrast resolution compared to computed tomography (CT). Additionally, scanning
coverage should include the C4-T2 levels for pre-fixed (C4-C8) and post-fixed (C6-T2) BP
anatomic variation, and extend out to the axilla to include the proximal terminal branches. (1,3,6)
Individual ventral rami or roots are often best seen on axial images. Roots are also well
seen on sagittal images. Because sagittal images are perpendicular to the plane of the plexus, in
our practice, this is the favored plane for following the elements from the spine to the axilla. The
coronal plane also depicts the plexus elements to good advantage, as the plexus courses within this
plane paralleling the subclavian/axillary arteries.(4)
There are concept of 5 key sagittal locations correlating with the 5 levels of organization
that is helpful: roots, trunks, divisions, cords, and branches. The 5 key sagittal locations are as
follows: (4)
1. Intervertebral foramina: Roots (C5–T1). Plexus is formed by ventral rami only.

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 2. Scalene muscles, anterior and middle: Trunks (upper trunk, C5–C6; middle trunk, C7;
lower trunk, C8/T1). The plexus travels between the anterior and middle scalene muscles
and the very short trunks form at approximately the lateral border of the scalene triangle.
3. Supraclavicular triangle: Divisions (anterior and posterior). The supraclavicular triangle is
above the middle third of the clavicle. The trunks divide into anterior and posterior
divisions just before the brachial plexus passes posterior to the clavicle and go from the
lateral aspect of the anterior scalene muscle to the lateral border of the first rib.
4. Axilla: Cords (lateral, medial, and posterior). The subclavian artery becomes the axillary
artery at the lateral border of the first rib. Cords run from the mid-clavicle to the
inferomedial coracoid process, and are named according to location relative to the axillary
artery. Typical arrangement anterior to posterior on a lateral view is lateral, posterior, and
medial cords.
5. Coracoid/pectoralis minor muscle: Branches. Terminal branches include the radial,
axillary, musculocutaneous, median, and ulnar nerves.

Figure 9. Important anatomic relationships of the brachial plexus. The plexus arises from C5–C8 nerve
roots and passes between the anterior and middle scalene muscles. Identification of the
subclavian/axillary artery is the key to localization of the plexus, which generally travels along with the
artery.(4)

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 Figure 10. Normal anatomy of the brachial plexus on sagittal images. Images of sagittal STIR (left, TR,
6000 ms; TE, 45 ms; TI, 170 ms; slice thickness and spacing, 4 and 1 mm, respectively) and T1-weighted
FSE (right, TR, 800 ms; TE, 10 ms; slice thickness and spacing, 4 and 1 mm, respectively) demonstrate
(A) the roots (white arrows) of the brachial plexus formed by the ventral rami of C5–T1 just exiting the
intervertebral foramina. (B) The interscalene region, where the brachial plexus (white arrows) travels
between the anterior (white arrowheads) and middle scalene muscles. This is the level just before the
roots merge into the short trunks. Brachiocephalic vein (V) and subclavian artery (asterisk).(4)

The preganglionic segments include the cervical spinal cord root entry zone of the ventral
and dorsal nerve rootlets, the intrathecal course of these rootlets, and their intraforaminal course
up until the DRG. Three-dimensional T2-weighted techniques using steady state free procession
(SSFP) can help visualize the intrathecal and intraforaminal segments with high contrast and
spatial resolution. The normal orientation of the BP (medial-superior to lateral-inferior) makes
traditional sagittal, axial and coronal images difficult to interpret, as the plane of imaging is not
aligned with the course of the brachial plexus structures. Consequently, oblique sagittal and
coronal sequences are preferred techniques to capture the anatomy of the brachial plexus and its
relationship to critical surrounding structures. In the setting of unilateral injury, bilateral coronal
T2 sequences provide effective comparison between the affected side and the normal contralateral
side. (1)

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Figure 11. (C) The supraclavicular triangle above the middle third of the clavicle where the trunks (white
arrows) divide into anterior and posterior divisions just before the brachial plexus passes posterior to the
clavicle and go from the lateral aspect of the anterior scalene muscle in front of the middle scalene muscle
(white arrowhead) to the lateral border of the first rib. Subclavian vein (V) and subclavian artery
(asterisk). (D) The divisions merging into cords (lateral, medial, and posterior) at the level where the
subclavian artery becomes the axillary artery (asterisk) at the lateral border of the first rib. Axillary vein
(V).(4)

Figure 12. (E) The change from divisions (white arrows) into terminal branches at the level of the
pectoralis minor muscle just medial to the coracoid (white arrowhead), axillary vein (V), and axillary
artery (asterisk).(4)

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 Figure 13. Normal MRI anatomy. (A) Coronal T1 and (B) Coronal T2 FS-DIXON images of normal
brachial plexus and its relationship with the subclavian artery (SA) and vein (SV). (C) Sagittal T1 image
at the level of the yellow dashed line on (A) and (B). Note the trunks (Tr) of the left brachial plexus and
their relationship to the subclavian artery (SA), the anterior scalene muscle (AS), and the middle scalene
muscle (MS), comprising the interscalene triangle. FS, Fat-Saturated; DIXON, Dixon technique water
selective sequence. (1)

Imaging technique
Some investigators recommend using 3.0-T scanners, although those with 1.5-T scanners
can achieve very high-quality imaging with careful technique. Recent investigations have
demonstrated that 3.0 T and 1.5 T units are both satisfactory, but 3.0 T images demonstrate
anatomy slightly better than 1.5 T. (4,2)
Conventional imaging with T1-weighted and T2-weighted or STIR sequences is adequate
in many cases. We also use axial, coronal, and sagittal image planes. Imaging of both sides is
useful for comparison purposes. Subtle cases, specifically following radiation therapy, may require
gadolinium studies (dynamic or static fat-suppressed T1-weighted images) for more optimal
evaluation. (2)

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 The selection of appropriate imaging coils for the brachial plexus is challenging because
of the complex anatomy of the supraclavicular region, neck, and shoulders; we are not aware of
dedicated coils produced specifically for brachial plexus imaging. There are also many interfaces
with soft tissue and air, creating magnetic field inhomogenities that can interfere with adequate fat
suppression. Although the body coil is capable of imaging a large field of view, the signal to noise
of this coil is rarely sufficient to achieve good-quality, high-resolution images covering the
brachial plexus from the spine to the axilla. Better options include a torso-type phased-array coil,
head-neck-spine phased-array coil, or a specialized neurovascular array coil designed for imaging
of the aortic arch and neck vessels. Another reasonable coil selection is a flexi-coil or surface coil;
the drawback of these coils is that they have limited anatomic coverage without repositioning the
coil. (2, 4)

Tabel 1. Suggested MR imaging protocol for brachial plexus imaging at 3T (neurovascular array coil).
(4)

Contrast-enhanced MR imaging with 3D heavily T2WI (MR myelography) easily shows

root avulsions, pseudomeningoceles, postganglionic separations, posttraumatic neuromas,
hematomas, fibrosis, intrinsic and extrinsic masses of the BPL, and inflammatory plexitis

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(idiopathic, infectious, radiation-induced, immune-mediated, and toxic). Findings at conventional
MR imaging provide additional anatomic and physiologic information on injuries. (3,6)
MR myelography should be performed in addition to conventional MR imaging for
evaluation of nerve roots if preoperative preparation does not include CT myelography. MR
myelography has been applied to the cervical region despite little success in initial studies. Fast
imaging employing steady-state acquisition (FIESTA) is one of the steady-state coherent imaging
sequences, and its signal is related to the ratio of T2 to T1. FIESTA achieves a high contrast- to-
noise ratio with fewer flow artifacts; thus, this sequence is suitable for MR myelography. At MR
myelography performed with FIESTA, visualization of nerve roots was excellent in healthy
volunteers and in 60% of patients with BPI. However, visualization of nerve roots was only fair in
the remaining patients because of large traumatic meningoceles and artifacts. (6)

Figure 14. Coronal MR myelographic image obtained with FIESTA clearly demonstrates all of
the nerve roots (arrows). (6)

Diffusion-weighted neurography is a cutting-edge technique for visualizing postganglionic

nerve roots. Diffusion-weighted neurography clearly depicts the postganglionic brachial plexus in
healthy subjects, whereas it demonstrates loss of continuity in injured nerves. (6)

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Traumatic Brachial Plexopathy
Traumatic BPL injury is more common in neonates due to birth trauma and in adolescents
due to traffic crashes. In infants, brachial plexus palsy is often secondary to excessive severe
traction force exerted on the brachial plexus during complicated deliveries. Coincidental presence
of cervical ribs can even increase the risk to develop brachial plexus palsy from complicated
deliveries. In obstetric injury, the supraclavicular BPL is mostly affected, resulting in Erb-
Duchenne paralysis (C5-C7). (3,4)
In adults, however, most plexus palsies are due to traumatic injuries, usually resulting from
high velocity trauma, such as motorcycle accidents. BPI is caused by severe traction force exerted
on the upper limb, resulting in complete or partial motor paralysis. Clinical symptoms include
and/or range from pain to paralysis of the involved limb. Clinical examination alone cannot
reliably distinguish between the preganglionic and postganglionic injuries, but differentiation
between both is important for prognosis and therapeutic management. Nerves may also be
indirectly affected (eg, by compression or injury of nerves by osseous fragments, hematomas, or
compressed by large callus formations in a more chronic phase post fracture). (4,6)
BPI is classified into three categories: preganglionic lesions, postganglionic lesions, and a
combination of the two. A preganglionic lesion signifies avulsion of nerve roots, whereas a
postganglionic lesion involves the nerve structure distal to the sensory ganglion. Postganglionic
lesions are further classified into nerve ruptures and lesions in continuity.(6)
Preganglionic injuries often are associated with spinal cord changes, such as contralateral
displacement of the cord, T2-hyperintensity consistent with cord edema (acute phase),
myelomalacia, syringomyelia (in a more subacute to chronic phase), and susceptibility effects from
hemosiderin accumulation. The observed pathologic changes may be extensive on the affected
side of the spinal cord or localized to the exit zone of the ventral nerve roots. Root avulsion,
pseudomeningocele, enhancement of the root exit zone or intradural roots, spinal cord signal-
intensity changes at the level of root avulsion, avulsion of the spinal cord, and signal intensity
changes of the paraspinal muscles can be seen. Abnormal enhancement of paraspinal muscles is
an accurate indirect sign of root avulsion injury. Denervated muscles show enhancement as early
as 24 hours after a nerve is injured. At unenhanced MR imaging, signal intensity changes and
volume loss are observed in paraspinal muscles in patients with root avulsion injuries, but these
findings have less accuracy and visibility than paraspinal muscle enhancement. Abnormal

15
enhancement in the multifidus muscle is the most accurate of all paraspinal muscle findings, since
the multifidus muscle is innervated by a single nerve root. (3,4,6)

Figure 15. Root avulsion injury. (a) Axial T2-weighted MR image demonstrates areas of hyperintensity
(arrowheads) in the right paraspinal muscles. (b) Axial contrast-enhanced T1-weighted MR image shows
areas of marked enhancement (arrowheads) in the right paraspinal muscles, findings that are compatible
with muscle denervation caused by root avulsion injury. (6)

Figure 16. Avulsion injuries in 26-year-old man with weakness and pain in upper extremity after
motorcycle crash. Coronal fat-suppressed T2-weighted image and coronal post gadolinium T1-weighted
image shows bright fluidfilled pseudomeningoceles (arrows) in course of C8 and T1 nerve roots. (7)

Postganglionic injuries can present as stretch injuries, with the nerve remaining in
continuity, or as an avulsion injury with nerve disruption. In the more common stretch-type
injuries, thickening of T1-hypointense to isointense and T2-hyperintense nerves is seen, with the

16
nerve remaining in contiguity, whereas fibrosis with thickening of the nerves is seen in a more
chronic phase of the injury. Discontinuity and distal nerve retraction is seen in avulsion-type
injuries. Enhancing nodular thickening (posttraumatic neuroma) and hematoma in the vicinity of
the BPL also can be seen. Edema and fibrosis of the brachial plexus can manifest as thickening of
the plexus. (3,4,6)

Figure 17. Root avulsion injury. Coronal contrast- enhanced T1-weighted MR image shows marked
enhancement in the left multifidus muscle (arrowheads). Abnormal enhancement in the multifidus muscle
is the most accurate sign of root avulsion injury among paraspinal muscle findings. (6)

Historically, peripheral nerve injuries are described by the classification systems of Seddon
and Sunderland. The classification proposed by Seddon describes three groups of nerve injuries:
neurapraxia, axonotmesis, and neurotmesis. Neurapraxia is defined as the presence of nerve
dysfunction without macroscopic lesion of the nerve. Transmission of nerve impulses is
interrupted at the site of lesion, which lasts for a short period of time, lasting from a few hours to
few months, depending on the area and the severity of the injury. In axonotmesis, the axial
continuity of some individual nerve fibers is interrupted, but perineurium and epineurium are
preserved. Neurotmesis is defined as a complete disruption of the axon, along with every part of

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the connective tissue of the peripheral nerve. In the classification described by Sunderland, the
group of axonotmesis is graded in three degrees, suggesting that different anatomic disruption
leads to correspondingly different prognosis. (8)

Figure 18. A 28-year-old male patient with left brachial plexus stretch injury after a motorcycle accident.
(A, B) Images of coronal STIR sequence (TR, 600 ms: TE, 45 ms; TI, 170 ms) demonstrate mild
enlargement and hyperintensity of the entire brachial plexus, most pronounced at C5 and C6, from the
roots (A, white arrows) to the branches, with perineural edema as well as curvilinear course of the plexus
at the level of the divisions and cords (B, white arrow). (C) Images of sagittal STIR sequence (TR, 600
ms: TE, 45 ms; TI, 170 ms) with ipsilateral perimuscular edema (white arrowheads) seen surrounding the
entire rotator cuff musculature indicating hyperextensionof the left neck/shoulder region during the
injury.(4)

MR imaging is valuable in differentiation and surgical planning for traumatic injuries.

Findings at conventional MR imaging provide additional anatomic and physiologic information
on injuries. In a stretching injury, MR imaging reveals asymmetric thickening, irregularities, T2
hyperintensity and diffuse contrast enhancement of the injured BPL. (3,6)

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 Figure 19. A 31-year-old male patient with right upper extremity paralysis due to complete avulsion
injury of the right brachial plexus post car accident. (A) Image of a coronal STIR sequence (TR, 600 ms:
TE, 45 ms; TI, 170 ms), (B) image of a coronal and (C) of a sagittal T1-weighted FSE sequence (TR, 800
ms; TE, 14 ms) show a large supraclavicular hematoma (white arrowheads). In this hematoma,
serpiginous, thickened cordlike structures can be seen that represent ruptured, edematous components of
the brachial plexus (white arrows), which had been completely avulsed off the level of the right trunks.
(D) Maximum intensity projection of a coronal MFAST MR angiography sequence (TR, 4.2 ms; TE, 0.9
ms) demonstrates complete occlusion of the right subclavian artery (small white arrow) and severe
compression of the right brachiocephalic/subclavian vein (large white arrow), the latter likely in the
context of the large adjacent hematoma.(4)

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Tabel 2. The essence of Seddon and Sunderland classifications of peripheral nerve injury, along with the
respective MRN findings. (8)

Mass Involving or Compressing the BPL

Extrinsic masses invading or compressing the BPL are more common than primary tumors.
These are contiguous or noncontiguous spread of breast, lung, and neck cancers; lymphoma;
leukemia; melanoma; gastrointestinal and genitourinary carcinomas; and neurolymphomatosis.
Metastasis from breast cancer is the most common, occurring mainly by lymphatic spread. A
Pancoast tumor (superior sulcus tumor; most are nonsmall cell cancers) easily invades the BPL. In
the setting of primary or metastatic brachial plexus involvement it is important to determine
presence or absence of leptomeningeal enhancement/spread, relation to the ipsilateral vertebral
artery, and extent of nerve root involvement. Neurolymphomatosis of the BPL (diffuse swelling
and hyperintensity on T2WI with enhancement) could be a part of a systemic lymphoma or a
primary central nervous system lymphoma. (1,3)
Intrinsic Brachial Plexus Tumors. Neurogenic tumors are the most common primary
tumors of the BPL, composed of the benign nerve sheath tumors (neurofibroma [50%–65%], and
schwannoma [18%–20%]) and malignant peripheral nerve sheath tumors (14%). Benign nerve
sheath tumors are more common than malignant ones in this region. (3,4)

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Figure 20. Breast cancer metastasis. (A) Coronal T2 FS-DIXON and (B) coronal T2 FS-DIXON images
show abnormal T2 signal and enhancement of the divisions and cords of the left brachial plexus (yellow
arrows) in this patient with metastatic breast cancer. FS, Fat-Saturated; DIXON, Dixon technique water
selective sequence (Siemens). (1)

Peripheral nerve sheath tumors of the brachial plexus may show classic findings on MRN,
such as the target, fascicular, and tail signs on T2-weighted images, split fat sign on T1-weighted
images, and the bag of worms sign for plexiform neurofibromas; however, schwannomas can
occasionally show cystic necrosis and not develop the target sign, which may then hamper
differentiation from malignant nerve sheath tumors. Schwannomas are seen in an eccentric
location and tend to be encapsulated causing fascicular deviation, whereas neurofibromas are not
encapsulated and typically invade the nerve causing the appearance of the nerve running through
the center of the tumor. This differentiation is important for the prognosis, because surgical
resection of schwannomas may be feasible without resulting nerve damage. The contrast-
enhancement pattern of peripheral nerve sheath tumors is typically very avid. (4)
Reliable differentiation between benign and malignant peripheral nerve sheath tumors is
problematic by imaging alone, but features, such as advanced local invasion and poorly defined
margins, absence of the target sign on T2-weighted sequences of larger size (>5 cm), and bone
destruction, suggest malignancy.(4)
The most common non-neurogenic primary brachial plexus tumors are desmoid tumors,
followed by lipomas. 24 In MRN, desmoid tumors will typically be isointense to muscle on T1-
weighted sequences, inhomogeneously hyperintense on T2-weighted sequences (with some low
T2 signal because of increased collagen content in parts of the tumors) with infiltrative margins
and marked contrast enhancement. Lipomas are usually well characterized by MRN as fat-

21
isointense lesions, although well-differentiated liposarcomas can show similar imaging
characteristics. (4)

Figure 21. Nerve sheath tumor. (A) Coronal T1 and (B) coronal T1 post-contrast FS-DIXON images
show a well-circumscribed mass (yellow arrows) arising from the divisions of the right brachial plexus, a
neurofibroma. FS, Fat-saturated; DIXON, Dixon technique water selective sequence (Siemens). (1)

22
 Figure 22. A 42-year-old female patient with a malignant peripheral nerve sheath tumor of the right
brachial plexus. (A) Images of coronal STIR sequence (TR, 6000 ms; TE, 45 ms; TI, 170 ms) and (B)
corresponding image of coronal T1-weighted FSE sequence (TR, 800 ms; TE, 14 ms) both demonstrate a
large mass with heterogeneous, predominantly T2-hyperintense signal (white arrowheads) reaching from
the right lateral chest wall to the proximal humerus with proximal spread (white arrows) along the
brachial plexus to the level of the trunks and roots, as indicated by the enlargement and edema of the
more proximal brachial plexus components. (C) Image of a sagittal STIR sequence (TR, 6000 ms: TE, 45
ms; TI, 170 ms) demonstrates encasing of the subclavian artery (black arrowhead) by the tumor (white
arrows), which was occluded slightly more distally and associated soft tissue edema (white arrowheads)
involving the adjacent muscles including pectoralis major and minor, infraspinatus, teres minor, and
latissimus dorsi. (4)

Figure 23. A 30-year-old female patient with desmoid tumor (white arrows) at the left medial lung apex
involving the left brachial plexus. Images of (A) coronal T1-weighted FSE sequences (TR, 800 ms; TE, 4
ms), of (B) coronal STIR sequences and of (C) contrast-enhanced T1-weighted fat-saturated FSE
sequence demonstrate the tumor (white arrows) at the left lung apex with low T1 and high T2 signal and
relatively homogeneous contrast enhancement involving primarily the inferior trunk/medial cord. Mild
pleural thickening/pleural fluid is noted at the lung apex (white arrowheads on images B, C). (D) Image
of a sagittal STIR (TR, 6000 ms: TE, 45 ms; TI, 170 ms) sequence demonstrates the proximal tumor
(white arrows) extent reaching just distal to the inferior brachial plexus roots.(4)

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 Another important entity is lymphoma, which cannot only encase the brachial plexus due
to enlarged lymph nodes, but can also primarily involve the brachial plexus in rare cases.
Lymphoma may affect nerve roots and trunks causing increased signal and neural enlargement of
selected levels. Primary neurolymphoma may present in MRN with diffuse thickening or
multifocal nodularity of the involved neural structures and show diffuse contrast enhancement. (4)

Figure 24. A 56-year-old female patient with non-Hodgkin lymphoma. (A) Images of a coronal STIR
sequence (TR, 6000 ms: TE, 45 ms; TI, 170 ms) and (B) of a coronal T1-weighted FSE sequence (TR,
800 ms; TE, 14 ms) demonstrate a large enhancing mass (white arrows) with moderately increased
heterogeneous T2 signal and intermediate to low T1 signal intensity in the left neck immediately adjacent
to the cervical spine extending out to the midclavicular region encasing the brachial plexus from the roots
to the trunks above the subclavian artery. (C) Image of a coronal T1 IDEAL sequence (TR, 900 ms; TE,
minimum full) demonstrates an area of low-attenuation centrally within the tumor (white arrowhead) that
does not enhance after contrast administration, consistent with necrosis. (D) Image of a sagittal STIR
sequence (TR, 6000 ms: TE, 45 ms; TI, 170 ms) clearly demonstrates involvement of the brachial plexus
by the lymphoma (white arrows) and encasement of the subclavian artery (asterisk) and vein (V).
(Courtesy of Kathryn Stevens, MD, Associate Professor of Radiology, Stanford School of Medicine.). (4)

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Inflammatory Brachial Plexus Pathologies
In cases of inflammatory brachial plexus pathologies, patients may present with sudden
onset of pain, often followed by weakness and paraesthesia, or patients may experience only
sensory abnormalities. Sometimes it is difficult to differentiate acute plexitis from a cervical
radiculopathy or even rotator cuff tears clinically, but virtually all 4cases can be solved by MR
imaging. (4)
The most common inflammatory processes affecting the BPL occur after irradiation, which
usually manifest at 5–30 months after treatment, generally with doses of 6000 cGy. Radiation
plexopathy presents as a uniform, symmetric, diffuse thickening, loss of clarity, distortion of fibers
(particularly the branches, cords, and divisions with sparing of the trunks and roots), T2
hyperintensity, and mild enhancement without a discrete mass within the irradiated region. Often,
the different neural structures can no longer be separated from each other. (3,4)

Figure 25. Radiation plexitis. (A) Coronal and (B) sagittal T1 post-contrast FS-DIXON images show ill-
defined enhancement of the divisions of the right brachial plexus (yellow arrows) in this breast cancer
patient who underwent extensive locoregional radiation therapy. Biopsy confirmed lack of tumor or
infection. FS, Fat-Saturated; DIXON, Dixon technique water selective sequence (Siemens). (1)

In the post radiation setting, it is essential to differentiate tumor recurrence from

inflammatory changes of the brachial plexus. Tumor recurrence, on the other hand, will result in a
focal or diffuse heterogeneously enhancing mass. Because of the often extensive and persistent
tissue changes in radiation-induced inflammation, follow-up studies are often needed to reliably
differentiate between tumor recurrence and post radiation treatment changes. Over time, fibrotic
changes of the brachial plexus and surrounding tissue may prevail. (3,4)

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Figure 26. A 52-year-old male patient with bilateral radiation-induced brachial plexus neuritis following
therapy for non-Hodgkin lymphoma. (A) Maximum intensity projection of coronal STIR sequences (TR,
6000 ms: TE, 45 ms; TI, 170 ms) demonstrates symmetric, relatively smooth enlargement and edema of
the bilateral brachial plexuses (white arrows). (B) Image of a sag T1-weighted FSE sequence (TR, 800
ms; TE, 10 ms) and (C) image of a sagittal STIR sequence (TR, 6000 ms: TE, 45 ms; TI, 170 ms) also
show the marked enlargement and edema of the brachial plexus (white arrows) at the level of the roots.
Also seen are the anatomic landmarks brachiocephalic vein (V), subclavian artery (asterisk), and anterior
scalene muscle (white arrowhead). (4)

Other causes of brachial plexitis are idiopathic, viral (cytomegalovirus, Coxsackie, herpes
zoster, Epstein-Barr virus, Parvovirus B19), immune-mediated or toxic (related to previous serum,
vaccine, antibiotic or other drug administration, human immunodeficiency virus serology, recent
surgery, anesthesia, and childbirth), and Lyme disease. (3)

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TOS (Entrapment Syndrome)
TOS results from dynamic compression of the BPL, the subclavian artery, or the subclavian
vein in the cervicothoracobrachial region. Depending on the injured component of the
neurovascular bundles, patients may endure arterial, venous, or neurogenic TOS symptoms
individually or combined. Symptoms are reproduced or aggravated by arm elevation and sustained
use of the arm due to congenital or acquired narrowing in any of the 3 compartments of the thoracic
outlet region. Neurogenic TOS is the most common, comprising 95% of all TOS cases. Causative
agents for TOS are cervical rib, elongated C7 transverse process, exostosis of the first rib or
clavicle, excessive callus of the clavicle or first rib, congenital fibromuscular anomalies, muscle
hypertrophy (scalenus, subclavius, or pectoralis minor muscles), posture, repetitive movements,
and posttraumatic fibrosis of the scalene muscles. Although clinical examinations, including
provocative maneuvers and electrophysiologic examinations, still represent the mainstay of
diagnostic workup, MR imaging has become the imaging modality of choice, especially in the
workup of neural TOS. (3,4)
The 3 compartments of the thoracic outlet include the interscalene triangle most medially
(the subclavian artery travels at the bottom and the trunks of the brachial plexus posteriorly and
superiorly, respectively, to the artery), then slightly more laterally the costoclavicular space (the
subclavian vein travels through this space anteriorly, the subclavian artery right adjacent posterior
to it, and the 3 cords of the brachial plexus are located above and posterior to the vascular
structures), and the most lateral the retropectoralis minor space (the subclavian vein travels through
this space anteriorly, the subclavian artery right adjacent posterior to it, and the 3 cords of the
brachial plexus are located above and posterior to the vascular structures). (4)
Compression of brachial plexus structures is known to be most common in the
costoclavicular space and in the interscalene triangle, but rarely occurs in the retropectoralis minor
space. Acquisition of high-quality images in the sagittal plane is of particular importance in TOS
cases. Some institutions obtain images not only in the arm-down, neutral position, but additionally
also in hyperabduction of the arm. Comparing these images, the width of the anatomic spaces and
the caliber of involved structures can be assessed. (4)

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 Figure 27. Thoracic outlet syndrome. A 55-year-old woman with weakness of the left upper extremity
with tingling in the hand. Coronal T2 SPACE image shows the deviated path of the C8 nerve root with
abnormal flattening (arrow) due to pseudoarthrosis between the left cervical rib and first rib, which was
subsequently proved on the surgery. The patient improved after surgery. (9)

CONCLUSION
MRI is a valuable technique for identifying and differentiating between pre- and
postganglionic lesions on brachial plexopathy, crucial for surgical management. Metastasis from
breast cancer and trauma are the most common cause of brachial plexopathy.

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5. Sakellariou, Vasileios I, Badilas, Nikolaos K. et al. Review Article. Brachial Plexus
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