Low interrater reliability of brachial plexus MRI in chronic inflammatory neuropathies.
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ABSTRACT:
SUBMITTER: van Rosmalen MHJ
PROVIDER: S-EPMC7317832 | biostudies-literature | 2020 Jun
REPOSITORIES: biostudies-literature
Publications
Low interrater reliability of brachial plexus MRI in chronic inflammatory neuropathies.
van Rosmalen Marieke H J MHJ Goedee H Stephan HS van der Gijp Anouk A Witkamp Theo D TD Froeling Martijn M Hendrikse Jeroen J van der Pol W Ludo WL
Muscle & nerve 20200221 6
<h4>Introduction</h4>Magnetic resonance imaging of the brachial plexus shows nerve thickening in approximately half of the patients with chronic inflammatory demyelinating polyneuropathy (CIDP) and multifocal motor neuropathy (MMN). The reliability of qualitative evaluation of brachial plexus MRI has not been studied previously.<h4>Methods</h4>We performed an interrater study in a retrospective cohort of 19 patients with CIDP, 17 patients with MMN, and 14 controls. The objective was to assess in ...[more]
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Project description:ObjectiveThis study aimed at developing a quantitative approach to assess abnormalities on MRI of the brachial plexus and the cervical roots in patients with chronic inflammatory demyelinating polyneuropathy (CIDP) and multifocal motor neuropathy (MMN) and to evaluate interrater reliability and its diagnostic value.MethodsWe performed a cross-sectional study in 50 patients with CIDP, 31 with MMN and 42 disease controls. We systematically measured cervical nerve root sizes on MRI bilaterally (C5, C6, C7) in the coronal [diameter (mm)] and sagittal planes [area (mm2)], next to the ganglion (G0) and 1 cm distal from the ganglion (G1). We determined their diagnostic value using a multivariate binary logistic model and ROC analysis. In addition, we evaluated intra- and interrater reliability.ResultsNerve root size was larger in patients with CIDP and MMN compared to controls at all predetermined anatomical sites. We found that nerve root diameters in the coronal plane had optimal reliability (intrarater ICC 0.55-0.87; interrater ICC 0.65-0.90). AUC was 0.78 (95% CI 0.69-0.87) for measurements at G0 and 0.81 (95% CI 0.72-0.91) for measurements at G1. Importantly, our quantitative assessment of brachial plexus MRI identified an additional 10% of patients that showed response to treatment, but were missed by nerve conduction (NCS) and nerve ultrasound studies.ConclusionOur study showed that a quantitative assessment of brachial plexus MRI is reliable. MRI can serve as an important additional diagnostic tool to identify treatment-responsive patients, complementary to NCS and nerve ultrasound.
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Project description:Background and purposeBrachial plexus birth injury is caused by traction on the neck during delivery and results in flaccid palsy of an upper extremity commonly involving C5-C6 nerve roots. MR imaging and MR myelography help to assess the anatomic location, extent, and severity of brachial plexus injuries which influence the long-term prognosis along with the surgical decision making. Recently, sonography has been increasingly used as the imaging modality of choice for brachial plexus injuries. The aim of this study was to assess the degree of correlation among brachial plexus sonography, MR imaging, and surgical findings in children with brachial plexus birth injury.Materials and methodsThis prospective study included 55 consecutive patients (girls/boys = 32:23; mean age, 2.1 ± 0.8 months) with brachial plexus birth injury between May 2014 and April 2017. The patients were classified according to the Narakas classification and were followed up at 4- to 6-week intervals for recovery by the Modified Mallet system and sonography without specific preparation for evaluation. All patients had MR imaging under general anesthesia. Nerve root avulsion-retraction, pseudomeningocele, and periscalene soft tissue were accepted brachial plexus injury findings on imaging. Interobserver agreement for MR imaging and the agreement between imaging and surgical findings were estimated using the κ statistic. The diagnostic accuracy of sonography and MR imaging was calculated on the basis of the standard reference, which was the surgical findings.ResultsForty-three patients had pre- and postganglionic injury, 12 had only postganglionic injury findings, and 47% of patients underwent an operation. On sonography, no patients had preganglionic injury, but all patients had postganglionic injury findings. For postganglionic injury, the concordance rates between imaging and the surgical findings ranged from 84% to 100%, and the diagnostic accuracy of sonography and MR imaging was 89% and 100%, respectively. For preganglionic injury, the diagnostic accuracy of MR imaging was 92%. Interobserver agreement and the agreement between imaging and the surgical findings were almost perfect for postganglionic injury (κ = 0.81-1, P < .001).ConclusionsHigh-resolution sonography can identify and locate the postganglionic injury associated with the upper and middle trunks. The ability of sonography to evaluate pre- and the postganglionic injury associated with the lower trunk was quite limited. Sonography can be used as a complement to MR imaging; thus, the duration of the MR imaging examination and the need for sedation can be reduced by sonography.
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Project description:Diffusion Tensor MRI (DT-MRI) is a promising tool for the evaluation of brachial plexus pathology. Therefore, we introduce and evaluate a fast DT-MRI protocol (8min33s scanning with 5-10 min postprocessing time) for the brachial plexus.Thirty healthy volunteers within three age-groups (18-35, 36-55, and > 56) received DT-MRI of the brachial-plexus twice. Means of fractional-anisotropy (FA), mean-diffusivity (MD), axial-diffusivity (AD), and radial-diffusivity (RD) for the individual roots and trunks were evaluated. A stepwise forward approach was applied to test for correlations with age, sex, body-mass-index (BMI), bodysurface, height, and bodyweight. Within-subject, intra-rater, and inter-rater repeatability were assessed using Bland-Altman analysis, coefficient of variation (CV), intraclass-correlation (ICC), and minimal detectable difference (MDD).No differences between sides and root levels were found. MD, AD, and RD correlated (P < 0.05) with bodyweight. Within-subject quantification proved repeatable with CVs for FA, MD, AD, and RD of 16%, 12%, 11%, and 14%, respectively.The DT-MRI protocol was fast and repeatable. Found correlations should be considered in future studies of brachial plexus pathology.
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Project description:OBJECTIVE:To study the impact of brachial plexus 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 collection included-patient demographics, clinical history, pre-imaging diagnostic impression, pre-imaging treatment plan, post-imaging diagnosis, post-imaging treatment plan, surgical notes and electrodiagnostic (ED) results. Impact of imaging on the pre-imaging clinical diagnosis and therapeutic management were classified as no change, mild change or substantial change. RESULTS:Final sample included 121 studies. The common aetiologies included inflammatory in 31 (25.6%) of 121 patients, trauma in 29 (23.9%) of 121 patients and neoplastic in 26 (21.5%) of 121 patients. ED tests were performed in 47 (38.8%) of 121 patients and these showed concordance with MRN findings in 31 (66.0%) of 47 patients. Following MRN, there was change in the pre-imaging clinical impression for 91 (75.2%) of 121 subjects, with a mild change in diagnosis in 57 (47.1%) of 121 patients and a substantial change in 34 (28.0%) of 121 patients. 19 (15.7%) of 121 patients proceeded to therapies that would not have been performed in the same manner without the information obtained from MRN. CONCLUSION:MRN of the brachial plexus significantly impacts clinical decision-making and should be routinely performed in suspected brachial plexopathy. Advances in knowledge: MRN significantly impacts the diagnostic thinking and therapeutic management of patients with suspected brachial plexopathy. MRN not only provides concordant information to ED tests in majority of cases, but also supplements with additional diagnostic data in patients who are ED negative.
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Project description:Axillary plexus blocks are usually guided by ultrasound, but alternative methods may be used when ultrasound equipment is lacking. For a nonultrasound-guided axillary block, the need for three injections has been questioned.Could differences in block success between single, double and triple deposits methods be explained by differences in local anaesthetic distribution as observed by MRI?A blinded and randomised controlled study.Conducted at Oslo University Hospital, Rikshospitalet, Norway from 2009 to 2011.Forty-five ASA 1 to 2 patients scheduled for surgery were randomised to three equally sized groups. All patients completed the study.Patients in the single-deposit group had an injection through a catheter parallel to the median nerve. In the double-deposit group the patients received a transarterial block. In the triple-deposit group the injections of the two other groups were combined. Upon completion of local anaesthetic injection the patients were scanned by MRI, before clinical block assessment. The distribution of local anaesthetic was scored by its closeness to terminal nerves and cords of the brachial plexus, as seen by MRI. The clinical effect was scored by the degree of sensory block in terminal nerve innervation areas.Sensory block effect and MRI distribution pattern.The triple-deposit method had a higher success rate (100%) than the single-deposit method (67%) and the double-deposit method (67%) in blocking all cutaneous nerves distal to the elbow (P?=?0.04). The patients in the triple-deposit group most often had the best MRI scores. For any nerve or cord, at least one of the single-deposit or double-deposit groups had a similarly high MRI score as the triple-deposit group.Distal to the elbow, the triple-deposit method had the highest sensory block success rate. This could be explained to some extent by analysis of the magnetic resonance images.ClinicalTrials.gov identifier: NCT01033006.
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Project description:Cellular therapy is being actively pursued as a therapeutic modality in many of the neurological diseases. A variety of stem cells from diverse sources have been studied in detail and have been shown to exhibit angiogenetic and immunomodulatory properties in addition to other neuroprotective effects. Published clinical data have shown bone marrow mononuclear cell (BMMNC) injection in neurological disorders is safe and possesses regenerative potential. We illustrate a case of 27-year-old male with traumatic brachial plexus injury, administered with autologous BMMNCs intrathecally and intramuscularly, followed by multidisciplinary rehabilitation. At the follow-up assessment of 3 and 7 months after first cell transplantation, improvements were recorded in muscle strength and movements. Electromyography (EMG) performed after the intervention showed a response in biceps and deltoid muscles suggesting the process of reinnervation at the site of injury. In view of the improvements observed after the treatment, the patient underwent second cell transplantation 8 months after the first transplantation. Muscle wasting had completely stopped with an increase in the muscle girth. No adverse effects were noted. Improvements were maintained for 4 years. A comprehensive randomized study for this type of injury is needed to establish the therapeutic benefits of cellular therapy.
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Project description:Background and purposeChronic inflammatory demyelinating polyneuropathy (CIDP) is an uncommon demyelinating disorder. Although treatable, it is difficult to diagnose. The purpose of this study was to evaluate the diagnostic performance and abnormalities of plexus via quantitative multisequence magnetic resonance neurography (MRN) for CIDP.MethodsBrachial and lumbosacral (LS) plexus of 37 CIDP patients and 37 age- and gender-matched controls were examined by using multisequence MRN. Nerve diameter, nerve-to-muscle T2 signal intensity ratio (nT2), contrast-enhanced ratio (CR), fractional anisotropy (FA), and apparent diffusion coefficient (ADC) were determined in both plexus, and tractographies were performed. The disease histories and the Inflammatory Rasch-built Overall Disability Scale (I-RODS) questionnaire scores were documented before MRI scans.ResultsThe sizes of nerve roots were larger in CIDP (p < 0.01). CR, nT2, and ADC were significantly higher, while FA was lower in CIDP than in controls (p < 0.01). FA had the highest sensitivity (0.809) and area under the curve (AUC) (0.925), while the highest specificity was 0.961 for CR in single parameters. The combination of FA and CR has the highest sensitivity, specificity, accuracy, and AUC in the LS plexus. CR only had a weak correlation with nT2 (p < 0.05). ADC and diameter had a positive correlation with nT2, and the diameter and nT2 had a negative correlation with FA in CIDP (p < 0.05). FA had a negative correlation with the duration in the CIDP (r's = -0.404, p < 0.05). There was no significant correlation between the I-RODS scores and MR multiparameters (p < 0.05).ConclusionMultisequence MRN possesses a high diagnostic performance in the LS plexus. Sampling perfection with application-optimized contrasts using different flip angle evolutions (SPACE) combined with DTI and contrast enhancement serves as a recommended composite protocol for CIDP.
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