(Radiographics. 2000;20:1023-1032.)
© RSNA, 2000
MR Imaging of Nontraumatic Brachial Plexopathies: Frequency and Spectrum of Findings1
Keith H. Wittenberg, MD and
Mark C. Adkins, MD
1 From the Department of Diagnostic Radiology, Mayo Clinic and Foundation, 200 First St SW, Rochester, MN 55905. Recipient of a Certificate of Merit for a scientific exhibit at the 1998 RSNA scientific assembly. Received April 5, 1999; revision requested May 14 and received July 6; accepted July 12. Address correspondence to M.C.A. (e-mail: wittenberg.keith@mayo.edu).
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Abstract
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Magnetic resonance imaging is the method of choice for evaluating patients with a nontraumatic brachial plexopathy. Although there is a wide range of disease processes that may cause a brachial plexopathy, radiation fibrosis, primary and metastatic lung cancer, and metastatic breast cancer account for almost three-fourths of the causes. Radiation fibrosis, the most common cause in our series, may occur several months to years after the completion of therapy. Findings of radiation fibrosis include (a) thickening and diffuse enhancement of the brachial plexus without a focal mass and (b) soft-tissue changes with low signal intensity on both T1- and T2-weighted images. Lung cancer arising in the lung apex may invade the lower portion of the brachial plexus. Many tumors may metastasize to the brachial plexus, causing a brachial plexopathy. Breast cancer is the most likely to metastasize because major lymphatic drainage routes for the breast course through the apex of the axilla.
Index Terms: Brachial plexus, 276.121412 • Brachial plexus, MR, 276.121412 • Lung neoplasms, metastases, 276.33 • Radiations, injurious effects, complications of therapeutic radiology, 276.47
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Introduction
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The brachial plexus is a major neural structure, providing motor and sensory innervation to the upper extremity. Although a number of modalities are available for imaging of the brachial plexus—including magnetic resonance (MR) imaging, computed tomography (CT) (1–5), and most recently ultrasonography (US) (6)—MR imaging is the modality of choice because of its multiplanar capabilities and exquisite soft-tissue contrast. MR imaging also allows visualization of the branches of the brachial plexus from their origin at the cervical spinal cord to the trunks and cords as they traverse the axillary and supraclavicular regions (7). Brachial plexopathies are challenging diagnostic problems, especially in tertiary hospitals in which large numbers of oncology and trauma patients are seen (8). Clinically, evaluation of the brachial plexus is very challenging because it is inaccessible to palpation and localization of lesions along the course of the plexus is difficult. Although electromyography may help clarify whether a lesion is central (epidural space or neural foramen) or peripheral on the basis of the pattern of involvement, it cannot help further localization.
Brachial plexopathies develop when lesions occur anywhere along the course of the brachial plexus. These lesions are often due to primary or secondary tumors, radiation fibrosis, or trauma. Trauma accounts for more than half the cases (9). Although the numerous origins of diseases that affect the brachial plexus are well recognized, the frequency with which each is encountered is unknown. Furthermore, to our knowledge, the entire spectrum of diseases has never been fully illustrated. To better understand the diseases that might cause a brachial plexopathy, we systematically reviewed all cases occurring in patients without a history of trauma who underwent MR examination of the brachial plexus at our institution between 1993 and 1997.
Herein, we present our observations about the frequency and types of these conditions as they appear on MR images. Our discussion includes a brief summary of the normal brachial plexus anatomy, as well as a review of the MR imaging appearance of radiation fibrosis, primary and metastatic lung cancer, metastatic breast cancer, neurogenic tumors, other metastatic tumors, and benign tumors.
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Normal Brachial Plexus Anatomy
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The brachial plexus is formed in the majority of individuals by the anterior divisions of the spinal nerves of C5 through T1, with variable contribution from C4, which form the roots. The roots of the brachial plexus course between the anterior and middle scalene muscles adjacent to the subclavian artery. The roots then combine to form the three trunks: upper, middle, and lower (Fig 1). The roots of C5 and C6 combine to form the upper trunk, whereas the roots of C8 and T1 combine to form the lower trunk (10). The middle trunk is formed solely from the C7 root (11). The three cords are formed by means of a combination of anterior or posterior divisions of the trunks. The individual cords are named according to their relationship to the adjacent subclavian artery: lateral, posterior, and medial. The cords divide into individual branches providing motor and sensory innervation to the upper extremity.
The various divisions of the brachial plexus appear as linear structures with low signal intensity on MR images obtained with all sequences (12). The brachial plexus can be identified on images obtained in both the axial and coronal planes, but images obtained in the sagittal plane are often the most helpful in demonstrating divisions and cords adjacent to the subclavian artery (Fig 2).
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Figure 2a. Normal anatomy at MR imaging in one patient. (a) Axial T1-weighted image through the apex of the lung shows the trunks of the brachial plexus (arrowheads) posterior to the subclavian artery (solid black arrow) and vein (open arrow) and just anterior to the serratus anterior muscle (white arrow). (b) Oblique sagittal T1-weighted image shows the individual cords of the brachial plexus (arrowheads) adjacent to the subclavian artery (straight arrow) and vein (curved arrow). (c) Coronal T1-weighted image demonstrates the cords of the brachial plexus (arrowheads) adjacent to the subclavian artery (solid arrow) and just superior to the subclavian vein (open arrow).
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Figure 2b. Normal anatomy at MR imaging in one patient. (a) Axial T1-weighted image through the apex of the lung shows the trunks of the brachial plexus (arrowheads) posterior to the subclavian artery (solid black arrow) and vein (open arrow) and just anterior to the serratus anterior muscle (white arrow). (b) Oblique sagittal T1-weighted image shows the individual cords of the brachial plexus (arrowheads) adjacent to the subclavian artery (straight arrow) and vein (curved arrow). (c) Coronal T1-weighted image demonstrates the cords of the brachial plexus (arrowheads) adjacent to the subclavian artery (solid arrow) and just superior to the subclavian vein (open arrow).
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Figure 2c. Normal anatomy at MR imaging in one patient. (a) Axial T1-weighted image through the apex of the lung shows the trunks of the brachial plexus (arrowheads) posterior to the subclavian artery (solid black arrow) and vein (open arrow) and just anterior to the serratus anterior muscle (white arrow). (b) Oblique sagittal T1-weighted image shows the individual cords of the brachial plexus (arrowheads) adjacent to the subclavian artery (straight arrow) and vein (curved arrow). (c) Coronal T1-weighted image demonstrates the cords of the brachial plexus (arrowheads) adjacent to the subclavian artery (solid arrow) and just superior to the subclavian vein (open arrow).
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Patient Studies
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We retrospectively reviewed the clinical information for 195 patients who underwent a total of 247 MR imaging studies between 1993 and 1997 at our institution. All patients had clinical or electromyographic evidence of a brachial plexopathy. Any patient with a history of trauma or whose imaging studies were unavailable for review or whose imaging findings did not explain their clinical symptoms were excluded. Of the 195 patients, 91 were excluded. The remaining 104 patients underwent a total 136 imaging studies, all of which were reviewed and findings correlated with available clinical information. All brachial plexus studies were reviewed by two radiologists (K.H.W., M.C.A.), and all diagnoses were determined by consensus. The final diagnoses were correlated with any available clinical follow-up information.
MR imaging was performed with a 1.5-T unit (Signa; GE Medical Systems, Milwaukee, Wis). All patients underwent T1-weighted axial and oblique sagittal imaging (repetition time msec/echo time msec of 450–700/20 with a field of view of 28), followed by axial proton-density– and T2-weighted imaging (2,000/30,60) covering the axilla to the middle of the neck. Some patients underwent coronal T1-weighted imaging (400–600/14). All images were obtained with use of a body coil and a section thickness of 7 mm with 3-mm intersection gaps. A 256 x 256 matrix was used for the T1-weighted images, and a 256 x 192 matrix for the proton-density– and T2-weighted images.
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Nontraumatic Brachial Plexopathies
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The distribution of causes is summarized in the Table. Overall, radiation fibrosis was the most common cause of brachial plexopathy, accounting for 32 (31%) of 104 cases. Metastatic breast cancer (25 cases [24%]) and primary or metastatic lung cancer (20 cases [19%]) were the next two most common causes. These three processes together accounted for almost 75% of the explainable causes of brachial plexopathies. The remaining one-fourth of the cases were caused by a wide variety of benign and malignant tumors.
Radiation Fibrosis
In patients who undergo radiation therapy to the axillary region, most commonly for breast cancer, the distinction between recurrent or residual disease and radiation-induced neuropathy can be difficult. Neurologic damage after radiation therapy may be observed several months to years after therapy (13), and it is most likely to occur in patients who have received radiation doses in excess of 60 Gy (14). This damage generally occurs 5–30 months after completion of radiation therapy, with a peak at 10–20 months. Common symptoms include parathesias, hyperthesias, pain, and weakness. These symptoms typically occur in an upper trunk distribution with weakness of the arm flexors and shoulder abductors (15).
The findings of radiation fibrosis include (a) diffuse thickening and enhancement of the brachial plexus without a focal mass (11,16,17) and (b) soft-tissue changes with low signal intensity (similar to muscle) on both T1- and T2-weighted images (18–20) (Fig 3). T2-weighted images help differentiate changes of radiation fibrosis from early tumor infiltration. Radiation fibrosis demonstrated low signal intensity on T2-weighted images, whereas tumor showed a higher signal intensity (18,21). Few reports have specifically addressed the usefulness of gadolinium-based contrast material in differentiating radiation fibrosis from early tumor infiltration. One report described a case of diffuse gadolinium enhancement 21 years after the completion of radiation therapy (21). In our experience, routine administration of gadolinium-based contrast material does not help differentiate radiation fibrosis from metastatic disease, because both may show some degree of enhancement.
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Figure 3a. Radiation fibrosis. (a, b) Invasive ductal carcinoma in a 51-year-old woman who had undergone radiation therapy to the axilla. Oblique sagittal T1-weighted (a) and axial fat-saturated gadolinium-enhanced T1-weighted (b) images show soft-tissue stranding (arrows in a) about the brachial plexus (arrowheads in b) with diffuse gadolinium enhancement. These findings had been stable for 6 years. In b, solid arrow = subclavian vein, open arrow = subclavian artery. (c) Breast cancer in a 69-year-old woman who had undergone radiation therapy. Oblique sagittal T1-weighted image shows diffuse thickening of the cords of the brachial plexus (solid straight arrows). The thickening was clinically stable over 4 years. Open arrow = subclavian artery, curved arrow = subclavian vein.
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Figure 3b. Radiation fibrosis. (a, b) Invasive ductal carcinoma in a 51-year-old woman who had undergone radiation therapy to the axilla. Oblique sagittal T1-weighted (a) and axial fat-saturated gadolinium-enhanced T1-weighted (b) images show soft-tissue stranding (arrows in a) about the brachial plexus (arrowheads in b) with diffuse gadolinium enhancement. These findings had been stable for 6 years. In b, solid arrow = subclavian vein, open arrow = subclavian artery. (c) Breast cancer in a 69-year-old woman who had undergone radiation therapy. Oblique sagittal T1-weighted image shows diffuse thickening of the cords of the brachial plexus (solid straight arrows). The thickening was clinically stable over 4 years. Open arrow = subclavian artery, curved arrow = subclavian vein.
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Figure 3c. Radiation fibrosis. (a, b) Invasive ductal carcinoma in a 51-year-old woman who had undergone radiation therapy to the axilla. Oblique sagittal T1-weighted (a) and axial fat-saturated gadolinium-enhanced T1-weighted (b) images show soft-tissue stranding (arrows in a) about the brachial plexus (arrowheads in b) with diffuse gadolinium enhancement. These findings had been stable for 6 years. In b, solid arrow = subclavian vein, open arrow = subclavian artery. (c) Breast cancer in a 69-year-old woman who had undergone radiation therapy. Oblique sagittal T1-weighted image shows diffuse thickening of the cords of the brachial plexus (solid straight arrows). The thickening was clinically stable over 4 years. Open arrow = subclavian artery, curved arrow = subclavian vein.
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Metastatic Breast Cancer
Because one of the major lymphatic drainage routes of the breast is through the apex of the axilla, it is not uncommon for metastatic breast cancer to invade the brachial plexus. Metastatic lymphadenopathy may surround the neurovascular bundle, resulting in vascular or neural compromise.
Metastatic disease from all causes typically appears as masses with low signal intensity on T1-weighted images and increased signal intensity (greater than that of muscle) on T2-weighted images. Occasionally, however, metastases may demonstrate low signal intensity on T2-weighted images (30) (Fig 4).
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Figure 4a. Metastatic breast cancer in a 58-year-old woman. Axial T1-weighted image (a) and sagittal T1-weighted nonenhanced (b) and gadolinium-enhanced (c) images show an infiltrating mass (arrowheads) encasing the left subclavian vessels and brachial plexus. The subclavian vein (straight arrow) is nearly obliterated with what proved at biopsy to be metastatic breast cancer. Curved arrow = subclavian vein.
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Figure 4b. Metastatic breast cancer in a 58-year-old woman. Axial T1-weighted image (a) and sagittal T1-weighted nonenhanced (b) and gadolinium-enhanced (c) images show an infiltrating mass (arrowheads) encasing the left subclavian vessels and brachial plexus. The subclavian vein (straight arrow) is nearly obliterated with what proved at biopsy to be metastatic breast cancer. Curved arrow = subclavian vein.
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Figure 4c. Metastatic breast cancer in a 58-year-old woman. Axial T1-weighted image (a) and sagittal T1-weighted nonenhanced (b) and gadolinium-enhanced (c) images show an infiltrating mass (arrowheads) encasing the left subclavian vessels and brachial plexus. The subclavian vein (straight arrow) is nearly obliterated with what proved at biopsy to be metastatic breast cancer. Curved arrow = subclavian vein.
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Lung Cancer
Primary lung carcinomas arising in the lung apex can invade the lower portion of the brachial plexus, the upper thoracic ribs and vertebral bodies, and the subclavian vessels. These tumors produce a characteristic syndrome of pain down the arm and eventual numbness and weakness, particularly in the nerve root distributions for T1 and C8. Horner syndrome is seen in about 20% of patients (22–24) owing to involvement of the sympathetic chain. In 1932, Pancoast (25) published a study of patients with this constellation of symptoms and, henceforth, these tumors became known as Pancoast tumors. Histologically, adenocarcinomas account for about two-thirds of Pancoast tumors, with squamous cell carcinomas composing most of the remainder (26,27).
Evaluation of the patient with a suspected superior sulcus tumor should include both sagittal and coronal imaging (28,29). The interface between the tumor and lung parenchyma is useful in predicting the site of origin. Lesions originating in the lung parenchyma usually have an irregular interface with the lung parenchyma, whereas pleural and extrapleural lesions tend to have smooth borders (9) (Fig 5).
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Figure 5a. Lung cancer: Pancoast tumor in a 57-year-old man. Oblique sagittal T1- (a) and T2-weighted (b) images and axial T2-weighted image (c) show a large right apical lung mass that invades and encases the roots of the right brachial plexus. The subclavian vessels and cords of the brachial plexus are not identifiable. The mass has an irregular interface (arrows in a) with the adjacent lung parenchyma. This mass was proved at biopsy to be a non-small cell lung cancer.
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Figure 5b. Lung cancer: Pancoast tumor in a 57-year-old man. Oblique sagittal T1- (a) and T2-weighted (b) images and axial T2-weighted image (c) show a large right apical lung mass that invades and encases the roots of the right brachial plexus. The subclavian vessels and cords of the brachial plexus are not identifiable. The mass has an irregular interface (arrows in a) with the adjacent lung parenchyma. This mass was proved at biopsy to be a non-small cell lung cancer.
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Figure 5c. Lung cancer: Pancoast tumor in a 57-year-old man. Oblique sagittal T1- (a) and T2-weighted (b) images and axial T2-weighted image (c) show a large right apical lung mass that invades and encases the roots of the right brachial plexus. The subclavian vessels and cords of the brachial plexus are not identifiable. The mass has an irregular interface (arrows in a) with the adjacent lung parenchyma. This mass was proved at biopsy to be a non-small cell lung cancer.
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Neurogenic Tumors
Primary neurogenic tumors of the brachial plexus can be benign or malignant and include neurofibroma, plexiform neurofibroma, schwannoma, and malignant peripheral nerve sheath tumor. Neurofibromas are the most common neural tumor to involve the brachial plexus. Histologically, these lesions are unencapsulated tumors believed to arise from the nerve fascicles (31). One-third of these lesions occur in patients with neurofibromatosis type 1, whereas two-thirds of cases are sporadic. These tumors are characteristically multiple and plexiform in appearance, with diffuse involvement of the brachial plexus in patients with neurofibromatosis (10).
The imaging features of solitary neurofibromas overlap those of schwannomas, and often they are indistinguishable. At CT, both neurofibromas and schwannomas have attenuation similar to that of muscle and both demonstrate variable amounts of enhancement with contrast material. At MR imaging, both lesions are isointense to muscle on T1-weighted images and hyperintense on T2-weighted images and may have central areas with low signal intensity, the so-called target sign (Fig 6). Neurofibromas and schwannomas enhance intensely after administration of gadolinium-based contrast material.
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Figure 6a. Neurogenic tumor: neurofibromatosis type 1 in a 23-year-old man. (a) Oblique sagittal T1-weighted image shows a small mass (solid arrow and arrowheads) involving the inferior aspect of the brachial plexus. Open arrow = axillary artery. (b) Axial T2-weighted image obtained in the proximal arm demonstrates a lobulated mass with areas of central decreased T2 signal intensity typical of a neurofibroma.
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Figure 6b. Neurogenic tumor: neurofibromatosis type 1 in a 23-year-old man. (a) Oblique sagittal T1-weighted image shows a small mass (solid arrow and arrowheads) involving the inferior aspect of the brachial plexus. Open arrow = axillary artery. (b) Axial T2-weighted image obtained in the proximal arm demonstrates a lobulated mass with areas of central decreased T2 signal intensity typical of a neurofibroma.
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Malignant peripheral nerve sheath tumors develop in 3%–13% of patients with neurofibromatosis (32,33). These tumors are also known as neurofibrosarcomas, neurogenic sarcomas, malignant neurofibromas, and malignant neurilemomas. These lesions occur most commonly in patients with neurofibromatosis type 1, especially after radiation therapy (34). The imaging features of malignant neural tumors overlap those of their benign counterparts, making differentiation between the two challenging (Fig 7). Findings that favor a malignant neural tumor include large size, irregular margins, and heterogeneity. Clinically, the finding of a progressively enlarging mass in a patient suggests a malignant nerve sheath tumor.
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Figure 7a. Neurogenic tumor: neurofibrosarcoma in a 32-year-old woman. Axial (a) and oblique sagittal (b) T1-weighted images show an irregular mass (solid arrows) abutting the anterior portion of the brachial plexus (arrowheads in b). At surgery, this mass was found to be a neurofibrosarcoma. In b, open arrow = axillary artery.
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Figure 7b. Neurogenic tumor: neurofibrosarcoma in a 32-year-old woman. Axial (a) and oblique sagittal (b) T1-weighted images show an irregular mass (solid arrows) abutting the anterior portion of the brachial plexus (arrowheads in b). At surgery, this mass was found to be a neurofibrosarcoma. In b, open arrow = axillary artery.
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Metastatic Tumors
Metastatic tumors from any primary site may extend into or around the brachial plexus, causing a brachial plexopathy. Although metastatic breast cancer is the most common cancer to affect the brachial plexus, metastasis from many other primary tumors may affect the brachial plexus. In our series, other primary malignancies that were metastatic included a wide range of tumors: lymphoma, melanoma, bronchogenic carcinoma, squamous cell carcinomas of the head and neck, osteosarcomas, eccrine carcinomas, mesotheliomas, and malignant fibrous histiocytomas. Often, the appearance of many of these tumors is nonspecific, although occasionally there may be clues in the imaging characteristics that suggest the diagnosis (Figs 8, 9).
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Figure 8a. Non-Hodgkin lymphoma in a 53-year-old man. Axial (a) and oblique sagittal (b) T1-weighted images show multiple small masses (solid arrows) in the base of the neck and involving the right brachial plexus (arrowheads). Also note the superior mediastinal adenopathy (curved arrow in b). In b, open straight arrow = subclavian artery.
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Figure 8b. Non-Hodgkin lymphoma in a 53-year-old man. Axial (a) and oblique sagittal (b) T1-weighted images show multiple small masses (solid arrows) in the base of the neck and involving the right brachial plexus (arrowheads). Also note the superior mediastinal adenopathy (curved arrow in b). In b, open straight arrow = subclavian artery.
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Figure 9a. Melanoma in a 35-year-old man. Axial T1- (a) and T2-weighted (b) images show a large mass in the right axilla (solid arrows in a) contiguous to and displacing the right brachial plexus (arrowhead in a). Note the subtle areas of increased T1 signal intensity within the mass that are characteristic of melanoma. Open arrow = subclavian artery.
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Figure 9b. Melanoma in a 35-year-old man. Axial T1- (a) and T2-weighted (b) images show a large mass in the right axilla (solid arrows in a) contiguous to and displacing the right brachial plexus (arrowhead in a). Note the subtle areas of increased T1 signal intensity within the mass that are characteristic of melanoma. Open arrow = subclavian artery.
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Benign Tumors
Many benign tumors occur along the course of the brachial plexus and involve or impinge on its various components. In our series, benign tumors included neurofibromas, desmoid tumors, lymphangiomas, and lipomas. A wide range of other benign tumors has been reported in the literature (32,33). Although the appearance of many benign processes is nonspecific, some offer imaging characteristics that suggest the exact diagnosis (Figs 10, 11)
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Figure 10a. Benign tumor: lipoma in a 19-year-old woman. Axial (a) and sagittal (b) T1-weighted images show a large lipoma (straight arrows) displacing the brachial plexus (arrowhead in a) and subclavian vessels. In b, curved white arrow = subclavian artery, curved black arrow = subclavian vein.
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Figure 10b. Benign tumor: lipoma in a 19-year-old woman. Axial (a) and sagittal (b) T1-weighted images show a large lipoma (straight arrows) displacing the brachial plexus (arrowhead in a) and subclavian vessels. In b, curved white arrow = subclavian artery, curved black arrow = subclavian vein.
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Figure 11a. Benign tumor: desmoid tumor in a 27-year-old woman. Oblique sagittal T1-weighted image (a), coronal T2-weighted image (b), and gadolinium-enhanced T1-weighted image (c) of the right brachial plexus demonstrate an irregular enhancing mass (arrowheads) infiltrating the brachial plexus (solid arrows). This mass has the characteristic decreased T2 signal intensity seen in desmoid tumors. In a, open arrow = subclavian vein.
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Figure 11b. Benign tumor: desmoid tumor in a 27-year-old woman. Oblique sagittal T1-weighted image (a), coronal T2-weighted image (b), and gadolinium-enhanced T1-weighted image (c) of the right brachial plexus demonstrate an irregular enhancing mass (arrowheads) infiltrating the brachial plexus (solid arrows). This mass has the characteristic decreased T2 signal intensity seen in desmoid tumors. In a, open arrow = subclavian vein.
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Figure 11c. Benign tumor: desmoid tumor in a 27-year-old woman. Oblique sagittal T1-weighted image (a), coronal T2-weighted image (b), and gadolinium-enhanced T1-weighted image (c) of the right brachial plexus demonstrate an irregular enhancing mass (arrowheads) infiltrating the brachial plexus (solid arrows). This mass has the characteristic decreased T2 signal intensity seen in desmoid tumors. In a, open arrow = subclavian vein.
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Conclusions
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Evaluation of the brachial plexus presents a great challenge to the clinician and radiologist. By being familiar with the appearance of common and uncommon entities affecting the brachial plexus, radiologists can direct important therapeutic decision making. Therefore, it is important for the radiologist to be familiar with the frequency and MR imaging characteristics of a wide variety of benign and malignant processes. Although the imaging features often overlap, there are specific clinical and MR imaging features that can help distinguish particular entities.
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Abstract
Introduction
