Peripheral Nerve Imaging

A review of anatomy, imaging techniques, and

selected pathologies

Ryan P. Joyce, MD Megan K. Mills, MD

Patrick H. Kobes, DO Sarah E. Stilwill, MD
Richard L. Leake, MD DEPARTM ENT OF RADIOLOGY
Hailey Allen, MD
AND IMAGING SCIENCES
Nothing to Disclose
 Learning Objectives
After review of this exhibit, the learner will:

 Be familiar with the key anatomic landmarks and structures

relevant to the most commonly imaged peripheral nerves

 Understand the morphologic features of normal and

abnormal peripheral nerves on MRI and US

 Have developed a succinct and relevant differential diagnosis

for abnormal findings
 Outline
 MRI protocol considerations for peripheral neurography

 Normal and abnormal appearance of nerves on both MRI and US

 Practical tips for the sonographic evaluation of peripheral nerves

 Anatomic review of commonly imaged nerves

 Case-based review of pathology affecting peripheral nerves:

• Entrapment/Compressive Neuropathy
• Trauma
• Tumor and Tumor-Like Conditions
• Infectious and Inflammatory Pathology
 MRI Protocol Considerations
Axial T1 Fat Suppressed (FS) Axial Proton Density (PD)
Used for assessment of: Sequence with highest signal-to-noise ratio
 Nerve caliber and course  Fascicular architecture
 Compressive bands or accessory muscles  Muscle atrophy/fatty infiltration Used for assessment of:
 Perineural fibrosis  Nerve caliber and course  Fascicular architecture
 Compressive bands or accessory muscles  Muscle edema

*
Normal elbow with preserved perineural fat Normal fascicular pattern and signal intensity

*
(arrow) about the ulnar nerve. associated with the ulnar nerve (chevron) in the
cubital tunnel.

Calf MRI (above and below) shows posterior and lateral

compartment fatty atrophy (asterisks) in a patient with
Charcot-Marie-Tooth syndrome. MRI of proximal calf in patient with Charcot-Marie-
Tooth syndrome demonstrates enlarged fascicles
of the tibial nerve (arrow) and common peroneal
nerves (arrowhead).

*
Perineural fibrosis, seen as bands of hypointense Denervation edema involving the thenar musculature (arrowheads) in a patient with
tissue (arrowheads) around the median nerve worsening weakness following a complicated carpel tunnel release.
(chevron) in a patient with worsening weakness Coronal T1 imaging can also be useful in
following a complicated carpal tunnel release. characterizing patterns of muscle atrophy.
 MRI Protocol Considerations
Coronal or Sagittal STIR Post-Contrast Imaging
Used for assessment of:  Not necessary for routine
 Denervation muscle edema; STIR is more sensitive than PD or T2 nerve imaging
 Denervated muscles should be downstream to the nerve injury  Can be added on in cases of
tumor, infection, acute
inflammation
 Normal nerves demonstrate
minimal or no enhancement in
the setting of an intact blood-
nerve barrier
 Can demonstrate enhancement
Homogeneousl y enhancing oval mass (a rrow) along
of denervated muscles the course of the left common peroneal nerve,
compa tible with a peripheral nerve sheath tumor.

3D Nerve Imaging
Excellent for assessment of:
 Nerve architecture, caliber,
fascicular pattern
 Nerve-selective and
maximum intensity
projection techniques can be
utilized
Coronal STIR image of the thighs demonstrates Sagittal STIR image of the elbow demonstrates
subtle edema involving the muscles within the normal bulk and signal intensity of the muscles.
 Can be acquired with variable
left femoral nerve distribution (arrowheads) in a weighting; fat suppressed T2
patient with a history of progressive weakness. is the most common
3D Coronal STIR SPACE ima ge ma ximum intensity projection (MIP)
i ma ge demonstrating normal architecture of the lumbosacral plexus.
 MRI Appearance of Peripheral Nerves
Normal Abnormal
T1 On T1 weighted imaging, the left
T1 On T1 weighted sequences, the sciatic nerve (arrows) is markedly
median nerve (arrow) appears enlarged compared to the right in a
isointense to muscle with a patient with left sciatic
peripheral hyperintense halo, mononeuropathy.
representing the epineural fat
(circle). High resolution MRI allows
isointense nerve bundles to be
distinguished within the
Ax PD FS On T2 fat saturated imaging, the left
hyperintense connective epi- and
perineural tissue (arrowhead). sciatic nerve is markedly enlarged
with fascicular edema (arrowhead)
compared to the right (arrowhead).

Ax PD FS On fluid sensitive sequences (T2 FS,

PD FS), the nerve demonstrates mild
fluid signal. The fascicles
Ax T1 FS Post Gad On T1 fat saturated post gadolinium
(arrowheads) within the large nerve
imaging, the left sciatic nerve is
trunks exhibit a more pronounced
markedly enlarged with diffuse
hyperintensity secondary to the
fascicular enhancement (arrowhead)
endoneural fluid.
compared to the right (arrowhead)
which shows normal enhancement.
 US Appearance of Peripheral Nerves
Normal Abnormal
 Normal nerve fascicles are homogenously  Abnormal nerve fascicles are enlarged, can be
round and mildly hypoechoic on short axis heterogeneous in size, and are often more
imaging, with surrounding hyperechoic hypoechoic than normal nerves. Occasionally
perineural fat. bands of hypointense perineural tissue,
representing perineural fibrosis, can be seen.

Distal
Short axis US image of the ulnar nerve in the distal forearm (arrows) with a Humerus
normal fascicular pattern and normal perineural fat. The normal median
nerve is partially included on this image (arrowhead).

Short axis and longitudinal US

images of an ulnar nerve, status
post transposition due to severe
ulnar neuropathy.

The fascicles are enlarged (arrows)

and abnormally hypoechoic
(arrowheads). Perineural fat in this
case is preserved (chevrons).
Longitudinal US image of the tibial nerve in the popliteal fossa (arrowheads)
demonstrates a normal fascicular pattern.
 Nerve Ultrasound: Practical Tips
 For most nerves, a high-frequency linear transducer will  Use short axis imaging for the evaluation of nerve caliber,
provide the best image quality fascicular pattern, and presence/absence of perineural fibrosis

Tibial Nerve

Common Peroneal Nerve

Common Peroneal Nerve
 Long axis imaging is good for measuring segment length of
abnormal nerves and for delineating the relationship of masses
 Optimize depth and focal zone settings for the nerve of interest and adjacent nerves.

 Scanning the contralateral side for comparison can be  Cine clips acquired in short axis are often better
useful for problem solving than static images for identifying and
characterizing small nerves

Left Median Nerve

Right Median Nerve
Anatomic Review of Commonly Imaged Nerves
 The Radial Nerve
Ax T1 images of the right upper extremity, from proximal to distal, from the mid-humerus to the elbow joint

Superficial Superficial
RN Branch RN
Biceps Branch RN

Posterior
Interosseous
RN Nerve (PIN)
HUM
HUM RAD RAD
ULN SUP
Common ULN
Triceps Extensor
Deep ULN
Muscle
Group Branch RN

The radial nerve (RN) passes It then courses anteriorly At the level of the radial head The deep branch of the RN
posterior to the mid humerus within the lateral aspect of the (RAD), the nerve splits into continues as the Posterior
(HUM) at the level of the spiral arm, deep to the common superficial and deep Interosseous Nerve (PIN),
groove. extensor muscles. branches. ULN = Ulna. coursing between the
superficial and deep fibers of
the supinator muscle (SUP).

Origin Motor Function Sensory Function Associated Pathology

• Arises from the posterior cord • Triceps Brachii • Dorsum of the upper arm • Nerve injury associated with
of the brachial plexus • Anconeus • Dorsum of the forearm mid-shaft humerus fractures
• Extensors of the hand/wrist • Back of the thumb, index
• Contributions from the C5, C6, (mostly PIN) finger, long finger, and ½ the • Posterior interosseous nerve
C7, C8, and T1 nerve roots ring finger (PIN) syndrome
 The Ulnar Nerve
Ax T1 images of the elbow and wrist
UN

Ax T1 Ax T1

At the level of the At the level of the

elbow, the nerve wrist, the nerve
passes through the passes through
cubital tunnel. Guyon’s canal,
also known as
the ulnar tunnel.

UN

Origin Motor Function Sensory Function Associated Pathology

• Arises from the medial cord of • Flexor carpi ulnaris • Dorsal and palmar aspects of • Cubital tunnel syndrome
the brachial plexus • Flexor digitorum profundus the ulnar side of the hand
(medial ½) • Guyon’s canal syndrome
• Contributions from C8 and T1 • Hypothenar muscles • Dorsal and palmar aspects of
nerve roots • Dorsal/Palmar Interossei the small finger and the ulnar
• 3rd/4th Lumbricals ½ of the ring finger
• Adductor Pollicis
 The Sciatic Nerve
Ax T1 images of the pelvis and proximal thigh, from proximal to distal

A) B) C)

* *
AM

BF ST

AM = Adductor magnus, ST = Semitendinosus, BF = Biceps Femoris

A-C) The sciatic nerve (circles) courses inferolaterally from the pelvis through the gluteal region. It is easiest to identify at the greater
sciatic foramen (white circles) and as it courses over the ischial tuberosity (asterisks). It continues inferiorly within the posterior
compartment of the thigh.
Origin Motor Function Sensory Function Associated Pathology
• Arises from the L4-S3 nerve • Biceps femoris • No direct sensory function • Piriformis syndrome
roots • Semimembranosus
• Semitendinosus • Indirect sensory function via • Stump neuroma in BKA/AKA
• Contains fibers from the • Adductor magnus the tibial and peroneal nerves
anterior and posterior • Indirect motor function to the • Sciatica (typically related to
divisions of the lumbosacral lower leg via the tibial and compression or irritation at
plexus peroneal nerves the nerve root level)
 The Femoral Nerve
Ax T1 images of the pelvis and proximal thigh, from proximal to distal

A) B)

*
A) Proximal segment of the femoral nerve (arrowhead) and obturator nerve B) The femoral nerve (arrowhead) is easiest to identify
(arrow) within the pelvis. From here, the femoral nerve will course partly within the femoral canal (white circle) just distal to the
within and/or along the psoas muscle and is difficult to visualize for several inguinal ligament. From lateral to medial, one can
centimeters. identify the femoral nerve (arrowhead), artery, vein,
and lymphatics (white dashed outline) within the canal.

Origin Motor Function Sensory Function Associated Pathology

• Derived from the anterior • Pectineus • Anteromedial thigh (via • Compression at the femoral
rami of the L2-L4 nerve roots • Iliacus anterior cutaneous branches) canal/inguinal ligament
• Sartorius • Medial leg and foot (via
• Quadriceps femoris saphenous n.) • Trauma (saphenous vein
stripping)
 The Obturator Nerve
Ax T1 images of the pelvis and proximal thigh, from proximal to distal

A) B) C)

A-B) Proximal origin of the femoral nerve (arrowhead) and obturator nerve (arrow) within the pelvis. From here, the
obturator nerve can be followed along the pelvic sidewall to the obturator canal (circle). C) Small branches (arrowheads) of the anterior and posterior
divisions of the obturator nerve are faintly seen within the fat plane
between adductor magnus, adductor brevis, and pectineus.

Origin Motor Function Sensory Function Associated Pathology

• Arises from the anterior • Adductor longus • Medial mid-thigh • Iatrogenic injury during
divisions of the L2-L4 nerve • Adductor brevis abdominopelvic surgery
roots • Adductor magnus • Injury during childbirth
• Gracilis • Entrapment within the canal
• Obturator externus or obturator externus muscle
 The Tibial Nerve
Ax T1 images of the distal thigh and proximal lower leg, from proximal to distal

A) B)

C) D) E)

A-B) As the sciatic nerve (dashed circle) travels down the posterior thigh compartment, it D) Tibial nerve interposed between
bifurcates as it enters the popliteal fossa into the tibial (arrow) and common peroneal popliteus and the medial and lateral
(arrowhead) nerves. The tibial nerve then courses medially and deeper to travel inferiorly heads of gastrocnemius, partially seen E) Tibial nerve seen posterior
in close proximity to the posterior tibia. on this image. to the tibia.

Origin Motor Function Sensory Function Associated Pathology

• Arises from the sciatic nerve • Popliteus • Sole of the foot (via medial • Tarsal tunnel syndrome
• Flexor hallicus longus calcaneal branches, medial plantar
(L4-S3) • Flexor digitorum longus
nerve, and lateral plantar nerve) • Trauma
• Tibialis posterior
• Plantaris • Posterolateral leg and lateral foot
• Soleus (via sural nerve)
• Gastrocnemius • Soleal sling syndrome
 The Peroneal Nerve
Ax T1 images of the distal thigh and proximal lower leg, from proximal to distal

A) B)

C) * D) E)

A-C) As the sciatic nerve (dashed circle) travels down the posterior thigh compartment, it D) Common peroneal nerve along the
bifurcates as it enters the popliteal fossa into the tibial (arrow) and common peroneal posterolateral aspect of the fibular
(arrowhead) nerves. The common peroneal nerve then courses laterally along biceps head (asterisk). Here, its superficial E) The common peroneal nerve
positioning predisposes to injury, splits into superficial and deep
femoris, around the lateral aspect of the fibular head (asterisk), and down the peroneal nerves (arrowheads)
anterolateral compartment of the lower leg. including direct trauma or stretch
after wrapping around the fibular
injury secondary to fracture or head and neck.
posterolateral corner injury.
Origin Motor Function Sensory Function Associated Pathology
• Arises from the sciatic nerve • Short head of biceps femoris • Posterolateral leg and lateral foot (via sural • Fibular head fracture - direct
nerve)
(L4-S2) • Peroneus longus and brevis • Upper lateral leg (via lateral sural cutaneous trauma or stretch injury
• Tibialis anterior nerve)
• Extensor digitorum longus • Anterolateral leg and dorsum of foot (via
• Extensor hallicus longus superficial peroneal nerve)
• 1st intermetatarsal web space (via deep
• Several small intrinsic foot muscles peroneal nerve)
 Case Based Review
Entrapment/Compressive Neuropathy
Trauma
Tumor and Tumor-Like Conditions
Infectious and Inflammatory Pathology
 Compressive Neuropathy

Spinoglenoid Notch Cyst: Suprascapular Nerve

32-year old male with right shoulder pain.
Axial PD FS Sag T2 FS Compressive Neuropathies in the Shoulder
Location of Typical Muscle Denervation
Nerve Causes
Compression Pattern

• Pa ra labral cys t
• Fra cture Compression proximal to
• Tumor spinoglenoid notch:
Supra scapular notch
• Hypertrophied or supraspinatus + infraspinatus
(proxi mal)
a nomalous
Suprascapular
s pi noglenoid
Spi noglenoid notch
l i gament or Compression distal to
(di stal)
tra ns verse spinoglenoid notch:
s ca pular l igaments infraspinatus only

• Fi brous band
• Juxta -articular cys t Deltoid
Axillary Qua drilateral s pace
• Fra cture Teres minor
• Tumor

Cor T2 FS

MRI images of the right shoulder shows a nondisplaced posterior-superior labral tear
(arrowhead) with a large paralabral cyst (arrows) extending along the medial glenoid
and into the spinoglenoid notch (yellow arc) and the suprascapular notch (blue arc).
There is denervation atrophy involving the infraspinatus muscle (chevrons) with normal
signal of the supraspinatus muscle, consistent with denervation related to compression
of the distal suprascapular nerve.
Compressive Neuropathy

Posterior Interosseous Nerve (PIN) Syndrome

68-year old man with right elbow weakness, numbness and tingling after an altercation
several months prior to presentation.
Axial PD FS Axial T1 Axial T1 FS Post

There is denervation edema of the supinator muscle (arrowheads), with associated fatty infiltration (chevrons) and mild post-contrast
enhancement (arrows). There is focal enlargement and increased signal of the posterior interosseous nerve (arrow).

The deep branch of the radial There are numerous described causes of compression of the
nerve, also known as the PIN, although not all are appreciated by imaging:
posterior interosseous nerve, • Leash of Henry: A fan-shaped network of branches of the radial artery
courses between the two heads • Arcade of Frohse: a fibrous band located between the heads of the supinator muscle
of the supinator muscle • Distal edge of the supinator or edge of the extensor carpi radialis
Compressive Neuropathy

Peroneal Neuropathy: Compressing Ganglion Cyst

25-year old man with progressive right leg numbness and paresthesias along the proximal lateral lower leg
and along the dorsum of the foot.
Axial PD FS Sag T2 FS Cor T1 Cor T2 FS

*
*
There is a multiloculated ganglion cyst located at the lateral margin of the fibular head (arrowheads). The common peroneal nerve
(arrows) takes an elongated course around the cyst. The nerve itself is increased in caliber and increased in signal intensity, but its
normal fascicular pattern is preserved. There is denervation edema of the peroneus longus muscle (asterisks). The cyst was surgically
resected and the patient’s symptoms improved.
Trauma
Traumatic Axonotmesis: Radial Nerve
52-year old woman with right wrist extensor weakness and intermittent numbness in the distribution of the radial nerve, status post
ORIF for humeral diaphysis fracture incurred from a ground level fall.

AP View of R Humerus Short Axis US – Level of Spiral Groove

Humerus radiograph demonstrates stabilization plate and screws
associated with a comminuted humeral diaphysis fracture (chevrons).
Diagnostic US reveals enlargement of the radial nerve (arrows) beginning at
the level of the spiral groove adjacent to the surgical plate (asterisk).
Distally, the posterior interosseous nerve (arrowhead) is identified as it
courses between the deep and superficial heads of the supinator muscle
(dashed lines). The nerve is markedly enlarged and has lost its normal
fascicular pattern.

*
Short Axis US – Level of Proximal Radius
Class
Sunderland Classification of Nerve Injuries*
Description MRI Findings
Recovery
Potential

Nerve stretch injury Normal nerve caliber but with abnormally

I (neurapraxia) increased T2 signal.
Full

Axonal injury (axonotmesis) Nerve is enlarged and abnormally T2

II with intact endoneurium hyperintense. Fascicular pattern preserved.
Full

Axonal injury (axonotmesis) Enlarged, hyperintense nerve with enlarged or Slow

III with disrupted endoneurium effaced fascicles. + Denervation changes. Partial

Endoneurium + perineurium
Focally enlarged nerve with disrupted
IV disrupted; epineurium intact
fascicles. + Denervation changes.
Poor
(neuroma-in-continuity)

Complete nerve discontinuity. Over time

V Transected nerve (neurotmesis)
neuroma can develop. +Denervation changes.
None

*Chhabra Indian J Radiol Imaging 2014

Trauma
Traumatic Neurotmesis with Neuroma: Sciatic Nerve
50-year-old male with history of a horse riding accident one year prior, with total loss of sensation
and function of the left lower leg and foot.
Sag T2 Sag T2 Ax T1 FS Post Ax T1 FS Post

The proximal stump neuroma (dashed The distal stump (dashed circle) is shown.
circle) demonstrates homogeneous There is no enhancing stump neuroma at
the distal nerve end, supporting the
enhancement surrounding the distal
philosophy that only the proximal nerve
nerve fascicles (arrowheads). end attempts to regenerate after injury.

There is transection of the sciatic nerve with a

2 cm gap (dashed line) between the torn ends A stump neuroma is a disorganized proliferation of nerve fascicles after injury to a nerve which
(arrows) and a stump neuroma (arrowheads) forms at the proximal nerve ending as it attempts to regenerate. They are most commonly
at the proximal nerve end. encountered in amputees but, as in this case, can be seen after any nerve transection.
Trauma
Traumatic Neurotmesis with Neuroma: Sciatic Nerve
Status post neuroma resection and repair.
Sag T2 Cor T1 FS Post Ax T1 FS Post Ax T2 FS

Ax T1 FS Post

Ax T1 FS Post
Diffuse T2 hyperintense denervation
edema (arrows) throughout the
Both sciatic nerves are shown (dashed Minimal enhancement of the granulation
outline). Interval neuroma resection tissue (arrowhead) surrounding the partially imaged musculature of the
and nerve reapproximation shown on repaired nerve ends. 3 consecutive axial proximal lower leg.
images show the enhancing granulation
the left. Note the T1 hypointense tissue surrounding the otherwise
granulation tissue (arrowhead) at the contiguous repaired sciatic nerve (dashed
site of nerve repair. circle). Several small nerve fascicles
(punctate low signal foci) are seen bridging
the granulation tissue.
Trauma

Traumatic Neurotmesis: Peroneal Nerve

24-year-old male struck by motor vehicle with knee pain and foot drop.

Cor T2 FS Ax PD FS Ax PD FS

Marked enlargement and hyperintensity of the More proximally, at the level of the tibial Peroneal nerve origin proximal to the transection
peroneal nerve (arrowheads) as it courses over the plateau (asterisk) abnormal anterior course demonstrates mild enlargement and
lateral aspect of the fibular head (asterisk), where it is and redundancy of the transected peroneal hyperintensity (arrowhead). Adjacent normal
most vulnerable to direct impact and stretch injury in nerve (dashed outline) is partially shown. tibial nerve (arrow).
the setting of trauma. The transected nerve stump is well seen
(arrowheads).
Trauma

Traumatic Neurotmesis: Peroneal Nerve (Continued)

24-year-old male struck by motor vehicle with knee pain and foot drop.

Ax PD FS Ax PD FS

Images distal to the nerve transection demonstrate enlargement and hyperintensity of the peroneal nerve (arrowheads) and
denervation edema (arrows) within the tibialis anterior, extensor digitorum longus, and peroneus longus muscles innervated by the
peroneal nerve.
Tumor and Tumor-Like
Peripheral Nerve Sheath Tumor (PNST)
56-year old man presenting with pain and weakness of the left forearm and hand. The patient reports paresthesias in the thumb and
forefinger when carrying a grocery bag looped over his forearm.

Long Axis US Cor T1 Ax PD FS

B)
MRI of the forearm confirms a well

* circumscribed mass (asterisks) arising

from the center of the median nerve

*
* * (arrowheads). The mass is hyperintense
to skeletal muscle on T1 weighted
imaging, homogeneously hyperintense
on T2 weighted imaging, and enhances
homogenously.

Imaging in the area of maximal tenderness

demonstrates a well-circumscribed, Ax T1 FS Post
hypoechoic mass (asterisk) in the volar, radial
aspect of the forearm among the flexor
compartment muscles. The fascicles of the
median nerve (arrowheads) diverge around
the mass. There is a small triangle of fat
* The mass was surgically resected;
(arrow) at the apex of the mass. pathology was consistent with a
schwannoma.
Tumor and Tumor-Like

Malignant Peripheral Nerve Sheath Tumor (MPNST)

22-year old man with a history of neurofibromatosis type I presents with a growing left elbow mass.
Sag T2 FS Ax PD FS Cor T1 FS Post
There is a fusiform mass arising from the ulnar nerve just
above the elbow (asterisks). The mass is T2 hyperintense,
* but with central areas of central hypointensity (arrows).
The mass enhances on post contrast images, but with
peripheral areas of non-enhancement (chevrons). The
mass was resected; histology was consistent with a high-
grade malignant nerve sheath tumor.
Ax T1 FS Post

Additional small T2 hyperintense nodules along the

* course of the brachial plexus near the axilla, consistent
* * with small neurofibromas (arrowheads).

Imaging does not consistently differentiate between benign and malignant nerve sheath tumors. Features more characteristic of malignant tumors include:
 Large tumor size  Peripheral rather than central enhancement  Infiltrative margins
 Rapid growth in size or worsening pain  Central hypointensity on T2 weighting, which is  Larger lesions, history of NF1, and truncal
 Perilesional edema suggestive of central necrosis or hemorrhage location all predict higher mortality
Tumor and Tumor-Like

Lipofibromatous Hamartoma of Median Nerve

28-year-old female with 15-year history of a “bump” on her left wrist, with recent development of numbness
and tingling involving the second and third digits.

Ax T1 Ax PD FS

Marked enlargement of the median nerve fascicles (arrows) Proton density imaging better demonstrates that the
with increased T1 hyperintense fat (arrowheads) surrounding apparent fascicular enlargement reflects intermediate
each individual fascicle is shown. This appearance has been signal intensity fibrosis (arrow) surrounding each central
likened to a coaxial cable. low signal intensity nerve fascicle (arrowhead). Note the fat
A lipofibromatous hamartoma is a rare and slow growing benign fibro-fatty signal has been suppressed (asterisk). There is mass effect
tumor, characterized by proliferation of mature adipocytes within the as evidenced by volar bulging of the flexor retinaculum
epineurium and the perineurium of the peripheral nerves. The median nerve is (chevrons) and dorsal displacement of the flexor tendons
the most common site of involvement, typically leading to pain, numbness, and
paresthesia within the median nerve distribution of the hand (carpal tunnel within the carpal tunnel (dashed arc).
syndrome).
Tumor and Tumor-Like
Vascular Malformation
8-year old boy presenting with a slowly growing, soft painless mass involving the left forearm.
Ax T1 Ax PD FS Cor T1 FS Post

* *
Key MRI Features of Vascular Malformations
• Transpatial lesions involving multiple muscle

*
compartments, can involve bone
• Venous malformations: phleboliths and progressive
enhancement
Ax T1 FS Post MRI images demonstrate a large • Lymphatic malformations: fluid-fluid levels and
infiltrating mass in the forearm minimal septal/peripheral enhancement
(asterisks) involving both the volar and • Arteriovenous malformation: flow voids indicating
dorsal muscle compartments. There

*
C) fast arterial flow with large draining veins
are areas of interspersed fat (chevrons) • Combination lesions are common (i.e.
and scattered hypointense phleboliths venolymphatic malformation).
(arrowheads). There is progressive • Associated with syndromes: Klippel-Trenaunay,
enhancement between the axial post- Maffucci, Parkes-Weber, etc.
contrast image, acquired early, and the
coronal image, acquired late. No *
associated flow voids are present.
*
The mass encases the superficial branch of the radial nerve (open arrow) DDx
and abuts the deep margin of the median nerve (arrow). Findings are most
compatible with a venous malformation.
Infection/Inflammation
Infectious Ulnar Neuritis
78-year old male with elbow pain, swelling and paresthesias. History of remote elbow fracture fixation, underwent ulnar nerve
transposition 5 months prior to presentation.
Ax T1 Post Sag STIR
The transposed ulnar nerve (arrows)
is markedly enlarged, abnormally
STIR hyperintense, with a thick rind

*
of abnormal enhancement, and is
situated anteromedial to the cubital
tunnel. It is located within a soft
tissue abscess in the posteromedial
arm (arrowheads). Adjacent
susceptibility artifacts (asterisk) are
related to prior fracture repair and
Ax T1 nerve transposition.

Management of Perineural Infection

• Conservative management with IV antibiotics
• Incision/debridement of perineural abscess with stripping of the nerve itself may be indicated, as
was done in this case
Infection/Inflammation

Parsonage-Turner Syndrome: Idiopathic Brachial Neuritis

49-year old female with right shoulder pain and progressive weakness.

Sag T1 Sag T2 FS Nerve Muscles Causes Treatment

Most frequently
Self Limiting.
supraspinatus and
Uncertain. Weakness can last
Suprascapular (97%), infraspinatus
Viral and for years though
axillary and (innervated by
autoimmune majority of
subscapular nerves suprascapular
etiologies patients recover
can also be involved nerve) followed by
postulated to normal
deltoid (innervated
function.
by axillary nerve)

Cor T2 FS

MRI images of the right shoulder show extensive edema in the deltoid
(chevrons), supraspinatus (circle/oval) and infraspinatus (blue ovals) musculature.
There is no corresponding atrophy on T1 weighted imaging.
 Conclusion
 The imaging evaluation of patients who present with
symptoms of peripheral nerve pathology is complex and
requires a targeted, high quality, often multimodal
investigation.
 Knowledge of normal nerve anatomy and imaging
characteristics, sites of common injury, and the expected MR
and US manifestations of pathology are key to accurately
protocoling, localizing, and characterizing nerve
abnormalities.
 A radiologist proficient in multimodal nerve imaging can
prove invaluable for any practice or institution, and can
significantly contribute to the optimal management of these
complicated patients.
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