 Good morning all. I took to SAPNA with present a paper on the spectrum of amazing finding in the brachial plexus injury under the guidance of Dr. Alka Agarwal ma'am, head of the department of radio diagnosis MGM-MY Medical College, Indore. See the brachial plexus injury the most common cause is the trauma and the clinical investigation for the peripheral nerve injury routinely include the nerve conduction study and electromyography. And the amazing study is limited to extending focal mass lesion and external compression. MRI identify changes in the peripheral nerve secondary neurogenic alteration in the skeletal muscle. MRI is also helpful in diagnosing localizing the site of injury on which the prognosis depend. And the contrast study is usually done in patient with tumor or mass lesion. Gerolinium is not administered in patient with traumatic brachial plexopathy. Here you can see in the schematic diagram the nerve fiber are torn due to stretching between the neck and the shoulder. Here nerve fiber torn due to outstretching of the hand. Now let's discuss the categorization of the nerve injury plexopathy. See the first degree neuroprexia. Here you can see only impaired nerve conduction with intact axon and the connective tissue layers. In the second degree axonal disruption with intact endopathy and perineural. Third degree include the axonal and endonural disruption with intact perineural and epineural. Fourth degree include the axonal endopathy and perineural disruption with intact only epineural. In the fifth degree complete nerve disruption. If there is any combination then it will come under the sixth degree. Here you can see in the schematic diagram in the first you can see the pre-ganglionic fiber tears where the surgical repair impossible. In the second postganglionic tear here surgical repair possible in the third axonal message and then the neuroprexia. Let's discuss if there is which nerve fibers are routinely affected in case of any lesion. If the lesion is supraclavicular then the C5, C6, C7, C8 and T1 roots are mainly involved. Phyranic nerve, long thoracic nerve, trunk may upper middle and lower trunks are involved. Now to the subclavius or supra scapular nerve. If there is any clavicular lesion then division of upper middle or lower trunk include. Then intraclavicular lesion cases later it involve they involve lateral cord and its terminal branches like lateral pectoral nerve, medial pectoral nerve, lateral root of median nerve and the median cord and ulnar nerve posterior cord and its branches. Then let's discuss technique and sequence we use mainly 1.5 tesla and 3 tesla MRI for optimal imaging specialized RF receiver coil are used surface coil or phase dairy coil which provide high signal to noise ratio with the small field of view. And the protocol mainly we use T1 weighted sequence in the coronal cell and axial shows detailed anatomy and is used to define the bony structure and tissue plant tissue planes surrounding the nerve. T2 weighted sequence and the star sequence in the coronal sagittal axial images provide uniform and reliable fat suppression over the curved surface and large field of view. And the post contrast T1 fat set sequences in case of neoplasm infection and polyneuropathies. Then let's discuss preganglionic brachial plexopathy. First common finding here we get the edema of the spinal cord, hemorrhage in the nerve root on GRE and the pseudo meningo seal and preganglionic injury usually have poor prognosis. See ideally amazing of suspected preganglionic injury is performed at least 3 to 4 week after the injury as this allow the resolution of acute edema and subarachnoid hemorrhage and formation of pseudo meningo seal. Then let's discuss few cases of the preganglionic injury. Case 1 patient present with the symptom of right sided partial ptosis and meiosis likely clinical diagnosis, Horner syndrome. There was history of six month back trauma. Here you can see pseudo meningo seal formation noted at the C7C8 T1 at the level of neural foramina. Suggestive preganglionic nerve root avulger injury. Then another case is six year old child present with weakness in the left hand side birth with left hand since birth with poor reflexes, sensory loss, mild stiffness, joint and muscle weakness and atrophy, clover hand and fingers. There was history of assisted delivery at local PHC. Now conduction study should deficit in the motor function along the ulnar nerve distribution. Here you can see well defined dumbbell, well defined dumbbell shape cystic lesion in the left C7 and T1 and left T1 T2 neural foramina, which is extra dural and extend just beyond the neural foramina. The right C8 and T1 nerve root are not visualized suggestive of pseudo meningo seal and preganglionic brachial plexus injury. Let's discuss postganglionic injury. Here the nerve roots usually seen at the origin normal and the thickening of T2 hyper intensity of the nerve root trump cord and associated edema. Associated finding you can get clavicular fracture or adjacent neoplasm. Let's discuss few cases. Here the patient present with history of trauma followed by weakness in the right upper limb. In the MRI you can see the T2 strut hyper intensity is noted in the upper trunco brachial plexus suggestive of exonotemesis that is great 3 injury of the upper trunco brachial plexus. Another case invasive ductal carcinoma in a 51 year old woman who had undergo radiation therapy to the axilla. Neurological damage after radiation therapy may be observed several months to years after therapy and it is most likely to occur in patient who have received radiation dose in excess of 60 gallon. Here you can see diffuse thickening of the cord of bilateral brachial plexus suggestive of post radiation plexopathy. See the most common DD of the radiation plexopathy is the tumor recurrence. How we can differentiate both these? After radiation plexopathy usually we get few months to 20 years spatially dose exceeding 60 graze. Usually involve the infraclavicular plexus and on the EMG we can get the myocymic discharges in the 30% cases. On MRI diffuse uniform symmetrical swelling and the bright T2 signal within the radiation film and mild post contrast enhancement. In the tumor recurrence cases usually it would occur within one year after the treatment and the lower supraclavicular plexus specially CA T1 and lower drunken volt. On EMG we get no changes and the MRI we get on MRI non uniform asymmetric focal enlargement with focal enhancing mass leisure. On the let's discuss few non-traumatic brachial plexopathies. Here you can see the patient known case of CA lung with symptom of neural deficit in the right upper limb. MRI was performed and here you can get the soft tissue mass in the right lung apex. Soft tissue mass in the right lung apex and extension of this mass into the C7 D1 and D1 D2 neural vertebral foreman. Invasion and encasement of the subclavian and right vertebral artery and lower trunk of the right brachial plexus. Another case patient present with left neck mass lesion associated with symptom of neural deficit. Here MRI goes performed a well defined peripherally enhancing lesion showing multiple thin internal septation in the left supraclavicular, located along the cord and division of left brachial plexus showing T2 and flare hyper intense signal suggestive of neural edema and closely abutting the subclavian vessels. Another case known case of CA breast present with symptom of neural deficit in the left upper limb. MRI goes performed. Here you can get multiple confluent T2 and star hyper intense soft tissue deposits seen along the trunk and division of left brachial plexus with epicenter of this lesion is seen in the inter-scalinic triangle. The lesion shows significant enhancement on post contrast study with continuous contrast enhancement noted along the thickened root of left brachial plexus and encroaches the cord of brachial plexus in the axillary posa. Now let's come on the conclusion part. See MRI is an invaluable modality for characterization of the brachial plexus lesion and the optimal technique planning is essential for adequate visualization. Their complex amazing anatomy can be simplified by using easily identifiable anatomic landmark. These are my few references. Thank you.