AJR Integrative Imaging

LIFELONG LEARNING
FOR RADIOLOGY

Castillo
Imaging the Brachial Plexus
Neuroradiology
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Mauricio Castillo1
Imaging the Anatomy of the
Brachial Plexus: Review and
Self-Assessment Module*
Abstract
1

SAM and CME available online at www.arrs.org.
*To complete the self-assessment module and for an
extended and more detailed review of brachial
plexus imaging, visit www.arrs.org and complete the
accompanying Webcast.
WEB
CAST
Objective
The educational objectives of this continuing medical education activity are to de-
scribe the normal anatomy of the brachial plexus, to name the most common symptoms
associated with a brachial plexopathy, to describe the most common imaging findings re-
sulting from trauma to the brachial plexus, to describe the imaging manifestations of
common neoplasias affecting the brachial plexus, and to also describe the imaging find-
ings and symptoms related to irradiation-induced brachial plexopathies.
Conclusion
In this article, I have illustrated and described the normal anatomy of the brachial
plexus; the most common symptoms related to brachial plexopathy; and imaging find-
ings related to trauma, tumors, and irradiation affecting the brachial plexus.

Scenario 1
Clinical History
An 26-year-old man arrives at the emergency department after a motorcycle crash
with weakness and pain in an upper extremity. An injury to the corresponding brachial
plexus is highly suspected.

DOI:10.2214/AJR.05.1014 Description of the Images

Received June 13, 2005; accepted after revision
August 18, 2005.
1Department of Radiology, University of North Carolina
School of Medicine, Campus Box 7510, Chapel Hill, NC
27599-7510. Address correspondence to M. Castillo
(castillo@med.unc.edu).
AJR 2005;185:S196S204
0361803X/05/1856S196
American Roentgen Ray Society
T2-weighted MR images depict pseudomeningoceles, which appear as a tear in the
meningeal sheath that surrounds the nerve roots with extravasation of CSF in the neighbor-
ing tissues. Because pseudomeningoceles are filled with fluid, they are easily identifiable on
T2-weighted MR images (Figs. 1 and 2).
MR myelography is helpful in depicting pseudomeningoceles in a fashion similar to
conventional myelography, but it is a supplemental method because most of the lesions
are identifiable on MRI. In addition, MRI may show edema of the brachial plexus in
stretching injuries (Fig. 3).

S196 AJR:185, December 2005

 Castillo

Fig. 1Avulsion injuries in 26-year-old man with weakness and pain in upper extremity
after motorcycle crash. Coronal fat-suppressed T2-weighted image shows bright fluid-
filled pseudomeningoceles (arrows) in course of C8 and T1 nerve roots.
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A B

Fig. 2Avulsion injuries in 26-year-old man.

A and B, Coronal postgadolinium T1-weighted image (A) and parasagittal T2-weighted image (B) show posttraumatic pseudomeningoceles (arrows) involving C7 and C8 nerve roots.

AJR:185, December 2005 S197

 Imaging the Brachial Plexus
QUESTION 1
Regarding the utility of different imaging tech-
niques to evaluate traumatic injuries of the bra-
chial plexus, which of the following is true?
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A) CT myelography is superior to MRI.
B) MRI is superior to CT myelography.
C) CT and MRI are probably equivalent.
D) T2-weighted MR myelography is the method of
choice.
E) Radiography has no role.
QUESTION 2
The brachial plexus is formed by which of the
following?
A) The posterior cervical sensory rootlets of C5
through T1.
B) The anterior rami of C5 through T1.
C) The anterior and posterior rami of C5 through T1.
D) All of the nerve roots arising in the cervical spinal
cord.
QUESTION 3
Which of the following statements regarding
the symptoms of a brachial plexopathy is true?
A) Most symptoms are discrete and specific for
brachial plexopathy.
B) Purely or mostly motor symptoms are usually seen
in young patients.
C) Purely or mostly sensory symptoms are usually
seen in older patients.
D) Irradiation results in mostly motor symptoms.
QUESTION 4
Regarding the goals of treatment of the brachial
plexus, which of the following statements is
false?
A) It includes rehabilitation, grafting, and anastomotic
procedures.
B) Pain control is important.
C) Restoration of biceps function is important.
D) Reanimation of the shoulder is important.
E) Prolonged immobilization of the involved arm and
shoulder is necessary.
S198
Fig. 3Stretching (burning) injury of right brachial plexus in 35-year-old man. Coronal
fat-suppressed T2-weighted image shows that there is high signal, indicating edema, and
thickening of divisions and cords (straight arrows) of right brachial plexus. Note effusion
(curved arrow) in ipsilateral shoulder joint due to traction injury of upper extremity.
Solution to Question 1
A recent study evaluated 35 patients with a total of 175 trau-
matic brachial plexus avulsions [1]. All patients were evaluated
with CT and MRI after undergoing myelography, and both tech-
niques were found to have a sensitivity of approximately 93% for
the detection of these injuries. When evaluated prospectively, both
imaging methods performed equally (thus, Options A and B are
not true and Option C is true). This is true only for traumatic avul-
sions, of which more than 80% will develop pseudomeningoceles.
These pseudomeningoceles represent a tear in the meningeal
sheath that surrounds the nerve roots and extravasation of CSF
into the neighboring tissues. Because they are filled with fluid,
they are easily identifiable on T2-weighted MR images (Figs. 1 and
2). They also fill with contrast material on myelography, a fact
that facilitates their identification on postmyelography CT [2].
In infants, the use of MRI is recommended because postmyelo-
graphy CT is a minimally invasive procedure and adequate infor-
mation is generally provided by noninvasive MRI. MR
myelography is helpful in depicting pseudomeningoceles in a
fashion similar to conventional myelography, but it is a supple-
mental method because most of the lesions are identifiable on
MRI (thus, Option D is not true). In addition, MRI may show
edema of the brachial plexus in stretching injuries (Fig. 3).
In another recent study, neurosurgeons were asked which
method they prefer and use to evaluate the avulsed brachial
plexus before surgery [3]. Eighty percent prefer postmyelogra-
phy CT, 20% prefer MRI, and 41% use both methods, whereas
the remaining participants expressed no preference. In addition,
all agree that chest radiographs are indispensable in evaluating
for diaphragmatic paralysis, which generally implies an irrepa-
rable lesion of the brachial plexus (Option E is not true).
AJR:185, December 2005
 Castillo

anterior rootlets of C6 through T2 (termed a postfixed brachial

plexus). The brachial plexus is never formed by all the cervical
nerve roots (Option D is not correct). The slight variations regard-
ing the formation of the brachial plexus may slightly affect the pa-
tients physical examination, but these variations are of little
importance in the imaging evaluation of the brachial plexus [7].
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Fig. 4Diagram illustrates basic anatomy of brachial plexus. Brachial plexus is
formed by anterior rami of C5T1 nerve roots. Roots are located in neural foramina
and trunks between scalene muscles. Divisions are posterior to clavicle, and cords
are inferior to it. LC = lateral cord, PC = posterior cord, MC = middle cord. (Reprinted
with permission from Royal College of Radiologists [10])
Solution to Question 2
The anterior spinal rootlets are motor, whereas the posterior
rootlets are sensory; both arise from the spinal cord [4]. After the
level of the dorsal root ganglia (which are in the neural foramina),
the anterior and posterior rootlets merge and immediately split
into anterior and posterior rami, both of which contain a mix-
ture of motor and sensory elements. Thus, the anterior rami are
located just beyond the neural foramina and will continue to
form trunks of the brachial plexus. The posterior rami do not
form the brachial plexus and innervate the paraspinal muscles.
The brachial plexus is a network of nerves innervating the muscles
of the shoulder, upper chest, and arm. The brachial plexus is formed
by the anterior rami of C5 through T1 (Option B is the correct answer)
[4, 5] (Fig. 4). The brachial plexus is not formed by just the posterior
cervical sensory rootlets (Option A is not correct). Because the ante-
rior rami contain a mixture of motor and sensory fibers, many pa-
tients with brachial plexus lesions present with mixed symptoms.
Although the brachial plexus nearly always arises from C5 through
T1, it is composed of only the anterior rami arising from these nerves
and not the posterior rami (thus, Option C is not correct).
The levels of the nerve roots from which the brachial plexus is
formed may vary slightly [46]. In some patients, the brachial
plexus is formed by the anterior rootlets of C4 through C7 (termed
a prefixed brachial plexus), while in others it is formed by the
Solution to Question 3
As a general rule, most brachial plexopathies present with vague
and nonspecific symptoms (Option A is not correct) [8]. For this rea-
son, lesions affecting the brachial plexus may remain undiagnosed
in many patients for long periods of time. There are, however, some
general rules regarding symptoms due to a brachial plexus lesion
that can be helpful when assessing patients with brachial plexopa-
thies. Purely or mostly motor symptoms are generally seen in young
patients (Option B is correct). These symptoms are commonly due
to stretching injuries or avulsions. Associated findings may help to
localize the site of injury (Table 1). Stretching, also called neuro-
praxia, injuries are commonly seen in neonates, particularly after
breech deliveries with shoulder dystocia [8, 9]. Stretching injuries are
also common after vehicular crashes, particularly motorcycle
crashes, which are also common in young male patients.
Complete flaccid paralysis of an upper extremity is seen after
avulsion of a brachial plexus [10]. Although 8090% of patients
with neuropraxia injuries will recover some function, the loss of
function is permanent in patients with avulsions. In adults, pri-
mary and secondary tumors are the most common cause of a
brachial plexopathy [11]. These tumors infiltrate the brachial
plexus and commonly extend into the spinal column and neural
foramina, resulting in both sensory and motor symptoms (Op-
tion C is not correct). Indeed, in older patients, a brachial plex-
opathy is most often mixed (sensory and motor).
Prior radiation therapy, particularly for breast or lung cancer,
is a common cause of brachial plexopathy. In most of these pa-
TABLE 1: Site of Injury Related to Brachial Plexopathies
with Associated Specific Symptoms
Brachial Plexopathy and
Specific Symptom Site of Injury
Brown-Squards syndrome Spinal cord ipsilateral to avulsion
Ipsilateral phrenic nerve involvement Supraclavicular brachial plexus
involving roots, trunks, or both
Ipsilateral scapular winging Proximal branches of C5 through C7
Ipsilateral Horners syndrome Infraclavicular plexusa
aC8T1 contribute to stellate ganglion.

TABLE 2: Motor Innervation Provided by the Different Components of the Brachial Plexus and General Anatomic Regions
Brachial Plexus Component Structure Innervated by Brachial Plexus Component Anatomic Region
Trunks Supraspinatus, infraspinatus, and teres major muscles Shoulder
Posterior cord Latissimus dorsi, subscapularis, teres minor muscles Shoulder
Lateral cord Pectoralis major, biceps, coracobrachialis muscles Upper chest
Medial cord Cutaneous structures Skin, hand

AJR:185, December 2005 S199

 Imaging the Brachial Plexus
tients, the symptoms are usually sensory (thus Option D is not
correct). The motor innervation provided by the brachial plexus
is described in Table 2.
Solution to Question 4
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Successful treatment of brachial plexus injuries entails a multi-
faceted approach that includes physical rehabilitation and, when
indicated, surgical intervention (Option A is true, and thus not the
correct answer) [12]. The cornerstone of all brachial plexus inju-
ries is physical rehabilitation. Although this type of therapy may
have a significant impact in treating stretching injuries, particu-
larly those in infants, its results are more limited in adults and in
patients in whom the brachial plexus has been avulsed.
For supraganglionic nerve avulsions, there is generally no treat-
ment, but early experience with microanastomoses of the roots and
of the roots to the spinal cord is promising [13]. In most patients,
some nerve regeneration will occur. Although this nerve regenera-
tion leads to useful muscle function in only one third of patients, it
leads to control of pain in most patients (Option B is true).
Juxtaforaminal and more distal avulsions may be treated with
microsurgical grafting and anastomoses [14]. Grafting and anas-
tomoses may be done using the phrenic, spinal accessory, and me-
dial pectoral nerves and the sensory and motor branches of the
intercostal nerves and even the contralateral brachial plexus. In-
juries to the C5 and C6 nerve roots are the most common and re-
sult in abnormalities of glenohumeral abduction, exorotation, and
biceps function. Thus, restoration of biceps and shoulder function
is important in the treatment of brachial plexus injuries (Options
Scenario 2
Clinical History
This scenario involves a 65-year-old man presenting with a
left-sided mixed (i.e., motor and sensory) brachial plexopathy of
2 months duration. The patient also has a history of cigarette
smoking and a persistent cough that developed 3 weeks earlier. A
chest radiograph shows abnormal findings. After CT of the
chest, MRI of the brachial plexus was performed (Fig. 5).
Description of the Images
A coronal T1-weighted image shows a large left tumor (Fig. 5).
Note the normal interscalene fat pad on the right. Obliteration
of this fat by tumor as seen here generally implies invasion of the
brachial plexus at the level of the trunks that normally course
between the scalene muscles in the interscalene fat pad.
Solution to Question 1
Pancoasts tumor is a term used to describe a bronchogenic
neoplasia that arises in the apical pleuropulmonary groove (the su-
perior sulcus); most are nonsmall cell cancers (squamous cell car-
cinomas, adenocarcinomas, or large cell carcinomas) [16]. They
generally progress by direct extension and invasion of the brachial
plexus, intercostal nerves, stellate ganglion, neighboring ribs, and
S200
C and D are true) [15]. Prolonged immobilization of the affected
arm and shoulder needs to be avoided because it may result in a
frozen extremity (thus, Option E is false and is the correct answer).
Injuries to the C7, C8, and T1 nerve roots are relatively less
common and affect the function of the lower arm and hand. He-
matomas can compress the brachial plexus, and some hemato-
mas may be amenable to surgical drainage. Similarly, aneurysms
and pseudoaneurysms of the subclavian artery may result in a
compressive plexopathy and may need to be treated predomi-
nantly with stenting without or with embolization to preserve
the arterys native lumen.
Conclusion
The accurate anatomic identification of the site of injury to
the brachial plexus relies mostly on MRI. It is important to
know the clinical symptoms of brachial plexus injury because
they may help to pinpoint the area of damage. In most infants
and young children, a brachial plexopathy is due to trauma and
most of the symptoms are motor ones; however, in adults, the
most common lesions are related to underlying tumors and to
their treatment. In these patients, the brachial plexopathies
tend to be both motor and sensory (mixed type). Patients with
an avulsion at the root entry zone (seen mostly as pseudomenin-
goceles) have a grave prognosis, and surgery is not feasible in
most of these patients. Lesions distal to the roots may be ame-
nable to grafting and anastomoses. Restoration of the function
of the shoulder and elbow and control of phantom pain are the
most important goals of treatment.
vertebrae. Involvement of the brachial plexus and of the adjacent
vertebrae is seen in fairly advanced cases (thus, Options A and B
are not correct) [17]. Supraclavicular lymphadenopathy denotes
an N3 stage (according to the TNM classification) and also repre-
sents an advanced stage of the disease (Option C is not correct).
Perhaps the earliest sign of extrathoracic and brachial plexus
involvement is invasion of the interscalene fat pad by the tumor
(Option D is correct). This fat pad normally lies between the an-
QUESTION 1
The earliest sign of brachial plexus involvement
by a Pancoasts tumor (superior sulcus tumor) is
which of the following?
A) Thickening of the trunks and divisions of the
brachial plexus.
B) Involvement of the upper thoracic and lower
cervical vertebrae ipsilateral to the tumor.
C) Supraclavicular lymphadenopathy.
D) Effacement of the interscalene fat pad.
AJR:185, December 2005
 Castillo
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Fig. 565-year-old man presenting with left-sided mixed (i.e., motor and sensory)
brachial plexopathy of 2 months duration. Patient also has history of cigarette
smoking and persistent cough that developed 3 weeks earlier. Chest radiography
(not shown) revealed abnormal findings. Coronal T1-weighted image shows large
left tumor (arrow); note normal interscalene fat pad on right. Obliteration of this fat
by tumor as seen here generally implies invasion of brachial plexus at level of trunks
that normally course between scalene muscles in interscalene fat pad.
terior and the middle posterior scalene muscles just cephalad to
the lung apex. The trunks of the brachial plexus are found in this
fat pad. On coronal T1-weighted MR images, the interscalene fat
pads have a triangular appearance and should always be present,
bright in signal intensity, and bilaterally symmetric (Fig. 6).
Obliteration of this normal bright fat signal by a mass arising in
a lung apex generally implies invasion of the brachial plexus, and
surgical resection may no longer be feasible [17].
Tumors that involve the brachial plexus include primary tu-
mors that arise from the brachial plexus (nerve and nerve sheath
Fig. 7Schwannoma in 45-year-old woman. Coronal fat-suppressed T2-weighted
image shows mass with high signal intensity (lower arrow) in region of roots and
trunks of right brachial plexus. Note tail of mass extending into C7T1 right neural
foramen (upper arrows). This finding is typical of nerve sheath tumors.
AJR:185, December 2005
Fig. 6Small left Pancoasts tumor in 60-year-old woman. Coronal T1-weighted
image shows small bilobed mass (white arrow) in left lung apex. Note preservation
of normal interscalene fat pad (black arrow), which on coronal images has triangu-
lar appearance. Left brachial plexus (arrowhead) is nicely seen.
tumors that may be benign or sarcomatous) [18] (Fig. 7). Second-
ary tumors are most common in adults and include Pancoasts tu-
mors, metastases (generally from breast carcinoma), lymphoma,
leukemia, and multiple myeloma (from adjacent bone involve-
ment) (Fig. 8). Lipomas and other tumors may arise outside the
brachial plexus and may compress the brachial plexus (Fig. 9).
Nontumoral masses, such as aneurysms and pseudoaneurysms,
may also result in compressive brachial plexopathies (Fig. 10). The
method of choice in the evaluation of suspected brachial plexus tu-
mors is MRI [19].
Fig. 8Metastases from breast carcinoma in 58-year-old woman. Coronal fat-sup-
pressed T2-weighted image shows two masses (large arrows) that are inseparable
from underlying right brachial plexus. Divisions and cords of brachial plexus (small
arrow) adjacent to tumors are bright and swollen.
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 Imaging the Brachial Plexus
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A B

Fig. 9Lipoma in 44-year-old woman.

A and B, Coronal T1-weighted image (A) and corresponding fat-suppressed image (B) show well-defined fatty mass (arrows) that typically loses all signal intensity after fat-
suppression technique is applied.

A B

Fig. 10Traumatic pseudoaneurysm in subclavian artery of 38-year-old man.

A and B, Coronal unenhanced (A) and axial enhanced (B) T2-weighted images show mass (arrows) in region of right subclavian artery compressing brachial plexus. Note
concentric rings of varying signal intensities due to clot that forms walls of this pseudoaneurysm.

S202 AJR:185, December 2005

 Castillo
Conclusion
A variety of masses may affect the brachial plexus primarily
or secondarily. The most common primary tumors are schwan-
nomas. Neurofibromas and sarcomas are rare unless the pa-
tient has underlying neurofibromatosis 1. Of the lung tumors,
the superior sulcus ones (Pancoasts type) tend to involve the
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brachial plexus early; this indicates a grave prognosis and in
many patients makes the tumor not resectable. Metastases
(mostly from breast carcinoma) may invade or compress (or
QUESTION 1
Which one of the following statements is false
regarding this patients disease?
A) The findings are likely to be due to the patients
treatment.
B) The findings are likely to be due to metastases to
the brachial plexus.
C) The symptoms will probably be self-limited and
resolve.
D) The differential diagnosis includes viral neuritis.
Scenario 3
Clinical History
A 56-year-old woman with a history of a left-sided breast car-
cinoma was treated with surgery and irradiation. The patient
was doing well until about 7 months after termination of radia-
tion therapy when she developed weakness and pain in the left
upper extremity. An MRI examination was performed (Fig. 11).
Description of the Images
Coronal fat-suppressed T2-weighted image shows diffuse thick-
ening and increased signal intensity in the region of the left bra-
chial plexus affecting the trunks, divisions, and cords (Fig. 11).
Solution to Question 1
Inflammatory processes affect the brachial plexus relatively
commonly. One of the most common inflammatory processes oc-
curs after irradiation, generally with doses of 6,000 cGy or more
[20]. Unlike carcinomas that tend to present as focal masses, pos-
tradiation plexopathies show loss of clarity and distortion of the
brachial plexus (particularly its branches, cords, and divisions with
sparing of the trunks and roots), high T2 signal intensity, and mild
contrast enhancement. Thus, the findings shown in Figure 11 are
unlikely to be due to the patients primary carcinoma and are most
likely the sequela of treatment (Option A is true). Metastases to the
brachial plexus nearly always present as discreet masses and not as
diffuse thickening (Option B is false and, thus, is the correct answer).
AJR:185, December 2005
both) the brachial plexus. Occasionally, some masses result in
a plexopathy just by compression of the nerves.
Large tumors commonly result in a compressive neuropathy. Lipo-
mas tend to be soft and need to attain a large size before producing
symptoms. Aneurysms and pseudoaneurysms of the subclavian ar-
tery may compress the brachial plexus and also produce symptoms.
It is critical to show involvement or lack of involvement of the brachial
plexus in all patients with tumors in this vicinity because involvement
of the nerves generally places the patients in a nonsurgical category.
Postirradiation brachial plexopathies may be acute and
present within 6 months after initiation of irradiation or be de-
layed and manifest 6 months after termination of treatment. The
former type of plexopathy is believed to be due to vascular is-
chemia and tends to be permanent, whereas the latter is generally
a transient and often reversible process (Option C is true). As a gen-
eral rule, most irradiation-induced brachial plexopathies mani-
fest 530 months after treatment (peak period, 1020 months).
The differential diagnosis for the findings described for the
case presented here includes viral neuritis, allergic (generally
drug-induced) neuritis, and infections (Option D is true) [21, 22].
Viral plexitis is more commonly found in men between the ages
of 30 and 70 years and resolves 612 weeks after presentation
without sequelae (Fig. 12). The brachial plexus may also be in-
volved in heredofamilial plexitis, such as hypertrophic neurop-
athies (the most common probably being Charcot-Marie-Tooth
disease) [23]. In these processes, the brachial plexus will appear
diffusely thick and hyperintense on T2-weighted images (Fig.
13). Chronic inflammatory demyelinating is another of the rel-
atively common hypertrophic polyneuropathies that may
present identical imaging findings. Diffusion nerve thickening in
children may be due to Dejerine-Sottas disease.
Fig. 1157-year-old woman who had undergone surgery and irradiation for treatment of
left-sided breast carcinoma and was doing well until about 7 months after termination of
radiation therapy, when she developed weakness and pain in left upper extremity. Coronal
fat-suppressed T2-weighted image shows diffuse thickening and increased signal inten-
sity (arrow) in region of left brachial plexus affecting trunks, divisions, and cords.
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 Imaging the Brachial Plexus
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Fig. 12Coronal fat-suppressed T2-weighted image shows mild thickening and increased
signal in trunks for left brachial plexus in 45-year-old man who presented with sudden onset
of weakness in ipsilateral upper extremity. Symptoms resolved spontaneously 4 weeks
later; this case was assumed to be a virus-induced plexopathy.
Conclusion
Inflammatory brachial plexopathies are relatively uncom-
mon, and, when found, most are secondary to the effects of prior
therapeutic irradiation. Postirradiation plexopathy may be
acute and irreversible or chronic and reversible. Both have simi-
lar imaging findings: diffuse thickening and high T2 signal inten-
sity. These findings may be at times difficult to separate from
diffuse tumor infiltration, particularly when contrast enhance-
ment is present. Viral plexopathies tend to be a diagnosis of ex-
clusion and generally present acutely and resolve spontaneously
after treatment with just antiinflammatory drugs. If the nerves
of the brachial plexuses are diffusely thickened, the differential
diagnosis needs to include the hypertrophic polyneuropathies.
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