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Brachial Plexus Traction Injury
KEY FACTS
Terminology
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Synonyms: Brachial plexus stretch injury, brachial plexus avulsion, avulsion pseudomeningocele
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Stretch injury or avulsion of ≥ 1 cervical roots, brachial plexus
Imaging
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Stretch injury: Enlargement, abnormal edema of neural elements
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Avulsion: Abnormal cerebrospinal fluid signal intensity within empty thecal diverticulum
Top Differential Diagnoses
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Nerve sheath tumor
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Lateral meningocele
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Nerve root sleeve cyst
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Chronic inflammatory demyelinating polyneuropathy (CIDP); less often acute inflammatory demyelinating polyneuropathy (AIDP)
Pathology
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Adults: Majority posttraumatic injuries secondary to high-energy force
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Infants: Secondary to excessive traction on plexus during difficult delivery (breech or forceps)
Clinical Issues
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Complete brachial plexus avulsion produces useless “flail arm”
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Clinical incomplete paralysis possible with complete root avulsion(s) because of redundant muscle innervation from multiple roots
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EMG/NCS helps differentiate traumatic from immune etiologies
Diagnostic Checklist
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Familiarity with normal brachial plexus anatomy essential for MR interpretation
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Muscle denervation pattern predicts abnormal nerves
Coronal graphic demonstrates posttraumatic avulsion of left C5-C8 nerve roots
, producing local hemorrhage at the site of root injury and associated pseudomeningoceles.
, producing local hemorrhage at the site of root injury and associated pseudomeningoceles.
Coronal T2WI MR in a patient with posttraumatic paralyzed “flail arm” demonstrates an extensive extradural cerebrospinal fluid (CSF) signal intensity collection admixed with blood products
, representing CSF leakage following avulsion of multiple nerve roots, displacing the spinal cord to the right.
, representing CSF leakage following avulsion of multiple nerve roots, displacing the spinal cord to the right.
Coronal STIR MR in a patient with severe brachial plexus traction injury shows avulsion pseudomeningoceles of right C6, C7, and C8 roots
. The C5 root is attenuated with abnormally ↑ signal (incomplete stretch injury)
. The avulsed nerve roots have formed a “retraction ball”
, with abnormal enlargement and T2 hyperintensity of the distal (denervated) plexus
.
. The C5 root is attenuated with abnormally ↑ signal (incomplete stretch injury) . The avulsed nerve roots have formed a “retraction ball” , with abnormal enlargement and T2 hyperintensity of the distal (denervated) plexus .
Axial STIR MR confirms the CSF signal and lack of demonstrable neural elements within the right C7 pseudomeningocele
.
.
TERMINOLOGY
Synonyms
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Brachial plexus stretch injury, brachial plexus avulsion, avulsion pseudomeningocele
Definitions
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Stretch injury or avulsion of ≥ 1 cervical roots, brachial plexus
IMAGING
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