European Radiology

, Volume 24, Issue 3, pp 756–761 | Cite as

Thoracic outlet syndrome in 3T MR neurography—fibrous bands causing discernible lesions of the lower brachial plexus

  • P. Baumer
  • H. Kele
  • T. Kretschmer
  • R. Koenig
  • M. Pedro
  • M. Bendszus
  • M. Pham



To investigate whether targeted magnetic resonance neurography (MRN) of the brachial plexus can visualise fibrous bands compressing the brachial plexus and directly detect injury in plexus nerve fascicles.


High-resolution MRN was employed in 30 patients with clinical suspicion of either true neurogenic thoracic outlet syndrome (TOS) or non-specific TOS. The protocol for the brachial plexus included a SPACE (3D turbo spin echo with variable flip angle) STIR (short tau inversion recovery), a sagittal-oblique T2-weighted (T2W) SPAIR (spectral adiabatic inversion recovery) and a 3D PDW (proton density weighted) SPACE. Images were evaluated for anatomical anomalies compressing the brachial plexus and for abnormal T2W signal within plexus elements. Patients with abnormal MR imaging findings underwent surgical exploration.


Seven out of 30 patients were identified with unambiguous morphological correlates of TOS. These were verified by surgical exploration. Correlates included fibrous bands (n = 5) and pseudarthrosis or synostosis of ribs (n = 2). Increased T2W signal was detected within compressed plexus portion (C8 spinal nerve, inferior trunk, or medial cord) and confirmed the diagnosis.


The clinical suspicion of TOS can be diagnostically confirmed by MRN. Entrapment of plexus structures by subtle anatomical anomalies such as fibrous bands can be visualised and relevant compression can be confirmed by increased T2W signal of compromised plexus elements.

Key Points

MR neurography (MRN) can aid the diagnosis of thoracic outlet syndrome (TOS).

Identifiable causes of TOS in MRN include fibrous bands and bony anomalies.

Increased T2W signal within brachial plexus elements indicate relevant nerve compression.

High positive predictive value allows confident and targeted indication for surgery.


TOS Thoracic outlet syndrome MRI MR neurography Fibrous band 



Thoracic outlet syndrome


Magnetic resonance neurography






Proton density weighted


3D turbo spin echo with variable flip angle


Short tau inversion recovery


Spectral adiabatic inversion recovery



This study was supported by Postdoctoral Fellowships granted to P.B. and M.P. from the Medical Faculty of the University of Heidelberg, and a grant to M.P. and M.B. from the German Osteoarthritis Foundation (Deutsche-Arthrose-Hilfe e.V., Grant number P215-A482).


  1. 1.
    Povlsen B, Belzberg A, Hansson T, Dorsi M (2010) Treatment for thoracic outlet syndrome. Cochrane Database Syst Rev 1, CD007218PubMedGoogle Scholar
  2. 2.
    Thomas HM, Cushing HG (1903) Exhibition of two cases of radicular paralysis of the brachial plexus. One from the pressure of a cervical rib with operation. The other of uncertain origin. Johns Hopkins Hosp Bull (14):315–319Google Scholar
  3. 3.
    Roos DB (1976) Congenital anomalies associated with thoracic outlet syndrome. Anatomy, symptoms, diagnosis, and treatment. Am J Surg 132:771–778PubMedCrossRefGoogle Scholar
  4. 4.
    Wilbourn AJ (2005) Brachial plexus lesions. In: Dyck PJ, Thomas PK (eds) Peripheral neuropathy. Elsevier Saunders, Philadelphia, pp 1359–1360Google Scholar
  5. 5.
    Mackinnon SE, Novak CB (2002) Thoracic outlet syndrome. Curr Probl Surg 39:1070–1145PubMedCrossRefGoogle Scholar
  6. 6.
    Ferrante MA (2012) The thoracic outlet syndromes. Muscle Nerve 45:780–795PubMedCrossRefGoogle Scholar
  7. 7.
    Stanton PE Jr, Vo NM, Haley T, Shannon J, Evans J (1988) Thoracic outlet syndrome: a comprehensive evaluation. Am Surg 54:129–133PubMedGoogle Scholar
  8. 8.
    Bilbey JH, Muller NL, Connell DG, Luoma AA, Nelems B (1989) Thoracic outlet syndrome: evaluation with CT. Radiology 171:381–384PubMedGoogle Scholar
  9. 9.
    Redenbach DM, Nelems B (1998) A comparative study of structures comprising the thoracic outlet in 250 human cadavers and 72 surgical cases of thoracic outlet syndrome. Eur J Cardiothorac Surg 13:353–360PubMedCrossRefGoogle Scholar
  10. 10.
    Brewin J, Hill M, Ellis H (2009) The prevalence of cervical ribs in a London population. Clin Anat 22:331–336PubMedCrossRefGoogle Scholar
  11. 11.
    Filler AG, Howe FA, Hayes CE et al (1993) Magnetic resonance neurography. Lancet 341:659–661PubMedCrossRefGoogle Scholar
  12. 12.
    Filler AG, Kliot M, Howe FA et al (1996) Application of magnetic resonance neurography in the evaluation of patients with peripheral nerve pathology. J Neurosurg 85:299–309PubMedCrossRefGoogle Scholar
  13. 13.
    Bendszus M, Stoll G (2005) Technology insight: visualizing peripheral nerve injury using MRI. Nat Clin Pract Neurol 1:45–53PubMedCrossRefGoogle Scholar
  14. 14.
    Baumer P, Dombert T, Staub F et al (2011) Ulnar neuropathy at the elbow: MR neurography—nerve t2 signal increase and caliber. Radiology 260:199–206PubMedCrossRefGoogle Scholar
  15. 15.
    Baumer P, Weiler M, Ruetters M et al (2012) MR neurography in ulnar neuropathy as surrogate parameter for the presence of disseminated neuropathy. PLoS One 7:e49742PubMedCentralPubMedCrossRefGoogle Scholar
  16. 16.
    Stoll G, Bendszus M, Perez J, Pham M (2009) Magnetic resonance imaging of the peripheral nervous system. J Neurol 256:1043–1051PubMedCrossRefGoogle Scholar
  17. 17.
    Kastel T, Heiland S, Baumer P, Bartsch AJ, Bendszus M, Pham M (2011) Magic angle effect: a relevant artifact in MR neurography at 3T? AJNR Am J Neuroradiol 32:821–827PubMedCrossRefGoogle Scholar

Copyright information

© European Society of Radiology 2013

Authors and Affiliations

  • P. Baumer
    • 1
  • H. Kele
    • 2
  • T. Kretschmer
    • 3
  • R. Koenig
    • 4
  • M. Pedro
    • 4
  • M. Bendszus
    • 1
  • M. Pham
    • 1
  1. 1.Department of NeuroradiologyHeidelberg University HospitalHeidelbergGermany
  2. 2.Centre for Neurology and Clinical NeurophysiologyNeuer WallHamburgGermany
  3. 3.Department of NeurosurgeryOldenburg Evangelical Hospital, Oldenburg UniversityOldenburgGermany
  4. 4.Department of NeurosurgeryUlm University Hospital/Bezirkskrankenhaus GuenzburgGünzburgGermany

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