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British Journal of Healthcare and Medical Research - Vol. 10, No. 2

Publication Date: April 25, 2023

DOI:10.14738/jbemi.102.14206.

Vieira, C. G. M., Silveira, C. R. S., Pereira, B. M., Holanda, I. C., Santos Jacinto, A. S. S., Carvalho Filho, F.F. L., Távora, D. G. F., &

Chhabra, A. (2023). Magnetic Resonance Imaging in Traumatic Brachial Plexus Injuries: A 6-Year Experience. British Journal of

Healthcare and Medical Research, Vol - 10(2). 50-64.

Services for Science and Education – United Kingdom

Magnetic Resonance Imaging in Traumatic Brachial Plexus

Injuries: A 6-Year Experience.

Clarissa Gadelha Maia Vieira,MD

São Carlos Imaging/São Carlos Hospital, Fortaleza, CE, Brazil.

Cláudio Régis Sampaio Silveira, MD

Musculoskeletal Radiology Division,

São Carlos Imaging/São Carlos Hospital, Fortaleza, CE, Brazil.

Brenda Machado Pereira,MD

São Carlos Imaging/São Carlos Hospital, Fortaleza, CE, Brazil.

Ingrid Carvalho de Holanda,MD

São Carlos Imaging/São Carlos Hospital, Fortaleza, CE, Brazil.

Ariana Sorah Serra dos Santos Jacinto,MD

São Carlos Imaging/São Carlos Hospital, Fortaleza, CE, Brazil.

Francisco Flávio Leitão de Carvalho Filho, MD

Neurosurgery Division, Doutor José Frota Institute, Fortaleza, CE, Brazil.

Daniel Gurgel Fernandes Távora, MD

Neuroradiology Division, São Carlos Imaging /

São Carlos Hospital, Fortaleza, CE, Brazil.

Avneesh Chhabra, MD

Chief of Musculoskeletal Radiology Division,

UT Southwestern Medical Center, Dallas, Texas.

Abstract

Background and Purpose: There is limited information in the literature on

epidemiology of high-energy brachial plexus injuries evaluated with MR

neurography (MRN). The aim of the present study is to describe the demographic

characteristics of brachial plexus injuries secondary to motorcycle accident

patients in the city of Fortaleza-Ceara, Brazil, and analyze the association of those

data with the features of the brachial plexus lesions observed on MRN findings.

Materials and Methods: A review of sixty medical charts and MRN findings of victims

of motor vehicle accidents (MVA) in northeast, from November 2011 to November

2017. Demographic and imaging data collected included age, sex, laterality and

level of the lesion and time interval between trauma and MRN examination. The

MRN examinations were carried out on a GE 1.5T MR unit (Signa HDxT- General

Electric, Milwaukee, USA) or on a Phillips 3T MR unit (Philips Achieva X-series -

Philips Medical Systems, Best, The Netherlands). Dedicated multichannel phased-

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Vieira, C. G. M., Silveira, C. R. S., Pereira, B. M., Holanda, I. C., Santos Jacinto, A. S. S., Carvalho Filho, F.F. L., Távora, D. G. F., & Chhabra, A. (2023).

Magnetic Resonance Imaging in Traumatic Brachial Plexus Injuries: A 6-Year Experience. British Journal of Healthcare and Medical Research, Vol -

10(2). 50-64.

URL: http://dx.doi.org/10.14738/jbemi.102.14206

array coils. Results: The longest time interval from trauma to imaging was 330 days

and between trauma and surgery was 692 days. Preganglionic lesions (avulsion)

predominated, consisting of 52 patients (86.6%) reflecting the high energy trauma

with upper limb traction from the neck. The lesions were most prevalent at the C6-

C8 levels. Pseudomeningocele was identified in 62.9% of the preganglionic lesions

and in only 1.6% of the postganglionic lesions. Regional muscle denervation

changes were seen in all pre-ganglionic injuries and most of post-ganglionic

injuries. Conclusions: MRN of the brachial plexus provides important insights into

the distribution of neuromuscular lesions in high energy MVA trauma and these

findings enrich the literature for researchers and clinicians focused on managing

such patients and/or defining prognostic strategies.

Keywords: Brachial plexus, Magnetic Resonance Imaging (MRI), Magnetic Resonance

Neurography (MRN), Brachial Plexus Injury (BPI), Epidemiology, Motorcycle accident,

Traffic accident

INTRODUCTION

According to data from the Traffic Department in northeast of Brazil, motorcycle accidents

account for about 40% of total traffic accidents in the state and were responsible for 31.9% of

fatal cases and 43.8% non-fatal victims between the years 2004 and 2015. Traffic accidents,

especially by motorcycle, are the most common cause of brachial plexus injury (BPI) [1]. Some

authors report that brachial plexus injuries occur in up to 5% of polytrauma cases involving

motorcycle accidents, which can result in severe functional impairment of the upper limb [2-

4].

The brachial plexus (BP) is a network of nerves that combine in terminal branches to supply

the motor and sensory innervation to the upper limb. It is formed by the union of ventral rami

of 5th, 6th, 7th, and 8th cervical nerve roots and 1st thoracic nerve root. It is divided into roots,

trunks, divisions, and cords [1]. Traumatic lesion of the BP is called preganglionic when an

avulsion occurs proximal to the dorsal root ganglion (DRG), and postganglionic when the lesion

affects the spinal nerves distal do the DRG.

The intricate anatomy of the BP and a variety of potential injuries yield a wide array of

pathological entities, with diverse clinical deficits, different treatment strategies, rendering the

management these patients a great challenge [5].

Imaging modalities combined with detailed clinical evaluation play an essential role in

differentiating preganglionic from postganglionic injuries of the brachial plexus. They consist

of standard myelography, computed tomographic (CT) myelography, and Magnetic Resonance

Neurography (MRN). Electrophysiologic examination is useful in confirmation of neuropathy

and evaluation of nerve regeneration [3, 4].

Treatment of BPI can be either conservative or operative (neurotization, nerve or tendon

transfers) [1].

The MRN has become the standard imaging for BP injury evaluation. In our tertiary care

institute, these injuries are not infrequently seen. The aim of the present study was to

systematically evaluate and present the distribution and extent of BP injury lesions in patients

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British Journal of Healthcare and Medical Research (BJHMR) Vol 10, Issue 2, April- 2023

Services for Science and Education – United Kingdom

with motor vehicle accidents (MVA) in northeast-Brazil, and analyze the association of those

data with patient demographics of age and gender [6].

MATERIAL AND METHODS

The study was performed under HIPAA (Health Insurance Portability and Accountability Act)

waiver following the institutional review board guidelines and informed consent was waived.

This study consisted of a retrospective review of medical charts and MRN findings of victims of

MVA in northeast-Brazil, from November 2011 to November 2017. We included a consecutive

series of sixty patients referred for MRN of the BP with suspected traumatic BPI in this interval.

Patients with non-traumatic causes of BP symptoms were not included.

Demographic data were collected by the attending neurosurgeon and included age, sex,

laterality and level of the lesion and time interval between trauma and MRN examination.

Imaging Technique

All examinations were performed in a tertiary care center. The MRN examinations were carried

out on a GE 1.5T MR unit (Signa HDxT- General Electric, Milwaukee, USA) or on a Phillips 3T

MR unit (Philips Achieva X-series - Philips Medical Systems, Best, The Netherlands). Dedicated

multichannel phased-array coils were used (Tables. 1 and 2). Nineteen patients were examined

at 3T (Table 2), and forty-one patients at 1.5T (Table 1). A high field device (General Electric

1.5 T Signa HDxT - MRI System; General Electric Systems, Milwaukee, USA) was used for the

plexus brachial MRN the HeadNeckSpine CoilMR coils with the following protocol: coronal 3D

volumetric short tau inversion recovery (STIR) imaging, coronal three-dimensional (3D)

volumetric T1-weighted imaging, sagittal T1 and T2-weighted imaging, 3D diffusion-weighted

imaging (DWI), axial FIESTA, and sagital 3D fat saturated (Fat-sat) T1-weighted sequences both

without contrast and after intravenous gadolinium injection. A device (Philips Achieva 3.0 T X- series MRI System; Philips Medical Systems, Best, the Netherlands) was used HeadNeckSpine

CoilMR coils with the following protocol: coronal 3D volumetric short tau inversion recovery

(STIR) imaging, coronal three-dimensional (3D) volumetric T1 and T2-weighted imaging,

sagittal T1 and T2-weighted imaging, 3D diffusion-weighted imaging (DWI), axial balanced FFE,

and 3D fat saturated (Fat-sat) T1-weighted sequences both without contrast and after

intravenous gadolinium injection. The images were post-processed at a workstation, and

multiplanar reconstructions (MPRs) were generated using the thick-slab maximum intensity

projection (MIP) technique. The images were post-processed at a workstation, and multiplanar

reconstructions (MPRs) were generated using the thick-slab maximum intensity projection

(MIP) technique.

Imaging Review

Expert consensus reading of the MRN examinations was performed by two radiologists with

more than 10 years of experience in musculoskeletal imaging.