Oleh :

Elizabeth Amanda
Maria Cindy
Ian Pranadi
Jevon Andra Saputra
Theresia Herestuwito
Charlene Alia

ILMU KEPANITERAAN KLINIK RADIOLOGI

PERIODE 24 OKTOBER – 26 NOVEMBER 2016
FAKULTAS KEDOKTERAN UNIVERSITAS KATOLIK
INDONESIA ATMAJAYA
 Objective
• To study the impact of brachial pexus MR Neurography (MRN) in the diagnostic thinking and
therapeutic management of patients with suspected plexopathy.

Methods

• MRN examinations of adult brachial plexuses over a period of 18 months were reviewed.
• Relevant data collections : demographics, clinical history, pre-imaging diagnostic impression, pre-
imaging treatment plan, electrodiagnostic results (ED).
• Impact of imaging on the pre-imaging clinical diagnosis and therapeutic management were
classified : no change, mild change, or substansial change

Results

• Sample included 121 studies. The common aetiologies : inflammatory 31 (25.6%), trauma 29
(23.9%), and neoplastic 26 (21.5%) of 121 patients.
• ED test : 47 (38.8%) of 121 patients
• There were change in the pre-imaging clinical impression for 91 (75.2%), mild change in
diagnosis 57 (47.1%), a substansial change 34 (28.0%)
 Conclusion

• MRN of the brachial plexus significantly impacts clinical decision-making and should
be routinely perfomed in suspected brachial plexopathy.

Advance in
knowledge

• MRN significantly impacts the diagnostic thinking and therapeutic managementof

patients with suspected brachial plexopathy. MRN not only provides concordant
information to ED tests in majority of cases, but also suplements with additional
diagnostic data in patients who are ED negative.
• Brachial Plexus
A complex network of
nerves, which gives
rise to large mixed
peripheral nerves to
the upper extremities.
• Conventional MRI
– has been used for a long time
– evaluation of brachial plexopathy
– useful for the diagnosis of mass lesions, gross
nerve root avulsions, or post-radiation changes.
• MRI in the neck is frequently limited owing to
vascular signal contamination, fat suppression
inhomogeneity, and resolution.
• MR neurography (MRN)
– using a combination of two-dimensional and three-
dimensional imaging
– increasingly being used in the diagnosis of
peripheral neuropathy for a variety of peripheral
nerve disorders
– has been shown to change the decision-making &
therapeutic plans of peripheral nerve surgeons,
thereby leading to better patient care.
• Exquisite evaluation of brachial plexus and its various
segments is also possible on 3.0-T scanners.
• A large-scale assessment of the impact of MRN in
suspected but not established brachial plexopathy is
lacking in literature.
• 1.5-T magnets are more widely available & the role of 1.5-
T MRN in this domain is also not known.
• In this study, we retrospectively analyzed the impact of
brachial plexus MRN performed on 1.5-T scanners in the
clinical diagnosis & therapeutic management of a large
series of consecutive patients who presented for
suspected but not known brachial plexopathy.
• Brachial Plexopathy
 Cause : trauma, neoplasia, inflammation, autoimmune.
 Clinically : commonly mimics the symptoms and signs of cervical
spondylosis-related radiculopathy  important to differentiate these
pathologies (management strategies can differ).
• Plexus lesions  difficult to diagnose, characterize
and treat, often leading to inconclusive
electrodiagnostic (ED) testing.
• Management challenges  surgery / pursue further
work-up / be treated conservatively / receive
treatment for diagnosis unrelated to neuropathy.
Performed between Performed on 1.5-T MR scanners
April 2013 and employing a uniform imaging
October 2014. protocol incorporating a
torsoarray coil with a neck coil for
anterior coverage linked to a spine
coil for posterior coverage

The MRN interpretation

reports were evaluated by
two observers (CM and SF).
• Respective clinical charts were reviewed to
retrieve pertinent data :
– clinical presentation
– pre-imaging
– diagnostic impression
– pre-imaging therapeutic treatment plan
– relevant comorbidities
– referrals related to post-imaging diagnosis
– surgical notes and ED test results
• Classified Effects on the pre-imaging clinical :
– Mild change  difference in disease severity
– Substantial change  a separate disease aetiology,
actionable and previously, unknown incidental
findings, or a large deviation from expected degree
of disease severity.
Total responden  148 orang
Responden inklusi  121 orang
Responden eksklusi  27 orang
dikarenakan :
- tidak dilakukan pengambilan data
- informasi klinis tidak ada
- terhalang oleh protokol penelitian
 USIA RATA-RATA RESPONDEN
Laki-laki Perempuan
46±16 tahun 48±14 tahun

ETIOLOGI JUMLAH (TOTAL 121)

Inflammatory 31 orang (25.6%)
Trauma 29 orang (23.9%)
Neoplasia 26 orang (21.5%)
Cervical spine spondylosis 19 orang (15.7%)
Post radiation changes / surgery 11 orang (9.1%)
Thoracic outlet syndrome 6 orang (5%)
Chiari 1 malformation, spinal cord infarction, 1 orang (0.8%)
carpal tunnel syndrome
 Hasil Sesuai MRN
31 orang (66%)
Dilakukan ED
47 orang (38.8%) Hasil Tidak Sesuai
Dilakukan MRN
MRN
121 orang (100%) Tidak Dilakukan 16 orang (34%)
ED
74 orang (61.2%)
Hasil Tidak
Terdeteksi oleh ED
Susp. Lower Cervical 12 orang (75%) Hasil Tidak Sesuai
Radiculopathy MRN
2 orang (50%) Hasil ED Berbeda 16 orang (34%)
dengan MRN
Non Specific 4 orang (25%)
Brachial Plexopathy
2 orang (50%)
 • Retrospective analysis  impact diagnosis and
& therapeutic management

Inclusion of Senn in may

cervical spine cases 
add evaluation additional
findings
Our analysis considerable (spine, spnal (radiculopathy,
value cord, nerves cord cavitation
and adjacent and wallerian
muscles) degeneration
 Impact patient
MRN management MRN
Performed on 1,5 T Performed on 3,0 T

(50 min to 1 hour) (40 – 45 min)

Andresisek et al
• Moderate to major impact in the evaluation of uper extremity
neuropathies (84%) with MRI
• Negative examination  forgo further expensive work-ups and
surgery can be avoided
 Majority of the
Change in preclinical
This brachial plexus patients with
impression after
study substantial impact in
MRN evaluation
28% patients

Right management
MRN decision and
optimal care
results from this MRN significantly supplements
study and complements the results
from ED tests

•MRN provides direct objective evidence and lesion

localization information  essential for pre-surgical planning

•MRN altered the location and extent of nerve abnormalities in

many cases
• Limitation of this study :
– The degree of subjectivity in the categorization of
mild or substantial change in diagnosis
– Many patients were lost to follow-up
– ED testing was performed for included patients 
results were available prior to imaging almost 55% of
the time  influenced interpretation of the MRN
examinations