Brachial plexus injury with pseudomeningoceles

Case contributed by Dr Utkarsh Kabra

Presentation

Chronic left upper limb weakness with mild weakness in right upper limb also since birth.

Patient Data

Age: 20 years
Gender: Male

Multiple cystic lesions following CSF signal intensity on all sequences are seen along bilateral C5, C6 and left C7 nerve roots. Possible small cystic lesions also seen along right C7 and bilateral C4 nerve roots. These are closely abutting the cord.

Trunks, divisions and cords of bilateral brachial plexus are unremarkable.

Significant fatty atrophy of muscles forming the rotator cuff and possibly deltoid muscle is seen on left side.

Scoliosis of cervical spine is seen with convexity towards left.

Mild inferior descent of cerebellar tonsils seen beyond foramen magnum (~3.5mm).

Mild prominent central canal of cord is seen from C5-6 to C7 levels, likely syrinx.

Case Discussion

Multiple cystic lesions following CSF signal intensity on all sequences are seen along multiple nerve roots on either side suggesting the likelihood of post-traumatic pseudomeningoceles secondary to nerve root avulsion. 

Caution should be exercised to not mistake perineural cysts, that are very common, for pseudomeningoceles. Pseudomeningoceles closely abut the cord whereas perineural cysts are usually seen further laterally along the neural foramina. Furthermore, pseudomeningoceles are seen in the setting of nerve root injury, and therefore, should be primarily considered only if there is a consistent clinical history and examination - as is the case in this instance. 

A small cystic lesion is seen along right C5-6 neural foramina which is likely a perineural cyst. 

 

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