Ammar Chaudhry1, Arash Kamali2, Daniel Herzka 3, Kenneth C Wang4, John carrino5, and Ari Blitz2
1Diagnostic Radiology, Johns Hopkins Medical Institute, Elkridge, MD, United States, 2Neuroradiology, Johns Hopkins Medical Institute, Baltimore, MD, United States, 3Radiology, Johns Hopkins Medical Institute, Baltimore, MD, United States, 4Radiology, Johns Hopkins, Baltimore, MD, United States, 5Radiology, Hospital of Special Surgery, New York, NY, United States
Synopsis
Thoracic sympathetic chain ganglia can be readily seen and
well characterized on pre-contrast 3D-CISS MRI. This technique can aid in
initial evaluation of potential stellate and/or SCG pathology as well allow for
post-treatment follow-up. Spine
Target Audience:
Radiologists (especially neuroradiologist, musculoskeletal
radiologists and interventional radiologists).
Purpose:
Three-dimensional constructive interference in steady
state (3D-CISS) refocused-gradient-echo magnetic resonance imaging (MRI)
sequence is a high spatial resolution imaging technique. The technique
generates images using ratio of T2 relaxation time: T1 relaxation time,
generating what appears to be a heavily T2-weighted images (3). Currently, this
technique is widely being used to evaluate small intracranial structures most
notably the cranial nerves and spinal nerve roots. In our experience, we found
that 3D-CISS provided comprehensive in vivo evaluation of the sympathetic chain
ganglion. In this retrospective study, we aim to evaluate the normal anatomy of
the stellate ganglion as well as thoracic sympathetic chain ganglia and assess
the detectability of each of the thoracic sympathetic chain ganglion (SCG) on pre-contrast
CISS images.
Materials and Methods:
In this IRB-approved HIPPA compliant study, 300 normal
thoracic sympathetic chain
ganglion were evaluated in 25 patients. The detectability of the sympathetic chain ganglion was evaluated using
pre-contrast enhanced 3D-CISS MR imaging. Confirmation of stellate and SCG was
made ensuring connection of the ganglia with spinal nerves and inter-connection
within the SCG chain. Measures of central tendency were performed as well as
t-test were performed for statistical analysis. Additionally, kappa test was
performed to evaluate for inter-rater reliability.
Results:
In our cohort of 13 males and 12 females (mean age 45
years), stellate ganglion and thoracic chain ganglia were successfully
identified in all patients except at T10-T11 and T11-T12 level. Pre-contrast
CISS demonstrated stellate ganglia to be isointense relative to gray-matter
noted in the spinal cord. Stellate
ganglion was found inferomedial to the subclavian artery inferior to the
transverse process of C7 in all patients. Thoracic SCG were identified ventral to
the costovertebral junction. There is strong
interobserver agreement with Kappa-value > 0.80. Mean size of stellate
ganglia was 35.75 mm2 while thoracic SCG ranged from 6.5 mm2 to
17.4 mm2.
Discussion:
Isotropic high resolution imaging provides the
capability of visualizing structures not typically seen with standard spine MRI
techniques due to the constraints of conventional two dimensional imaging. Our study shows that thoracic sympathetic chain
ganglia can be readily and well characterized on pre-contrast 3D-CISS MRI. Knowledge
of precise location of stellate ganglion and thoracic SCG can aid in
identifying pathology and/or treatment planning of various clinical syndromes
that result from sympathetic chain abnormality e.g. primary
hyperhidrosis, reflex sympathetic dystrophy, Raynaud’s phenomenon, etc.
Conclusion:
Thoracic sympathetic chain
ganglia can be readily seen and well characterized on pre-contrast 3D-CISS MRI.
This technique can aid in initial evaluation of potential stellate and/or SCG
pathology as well allow for post-treatment follow-up.
Acknowledgements
N/AReferences
1.
Jinkins, J. (2000). Atlas of neuroradiologic
embryology, anatomy, and variants. Philadelphia: Lippincott Williams &
Wilkins.
2.
Lang, J. (1993). Clinical anatomy of the
cervical spine. Stuttgart New York New York: G. Thieme Verlag Thieme Medical
Publishers.
3.
Saylam CY, et al. Connection types between the
spinal root of the accessory nerve and the posterior roots of the C2-C6 spinal
nerves. Surg Radiol Anat. 2009 Jul;31(6):419-23.
4.
Tubbs RS, et al. Clinical anatomy of the C1
dorsal root, ganglion, and ramus: a review and anatomical study. Clin Anat.
2007 Aug;20(6):624-7.
5.
Karatas A, et al. Microsurgical anatomy of the
dorsal cervical rootlets and dorsal root entry zones. Acta Neurochir (Wien).
2005 Feb;147(2):195-9.
6.
Bozkurt M, et al. Microsurgical anatomy of the
dorsal thoracic rootlets and dorsal root entryzones. Acta Neurochir (Wien).
2012 Jul;154(7):1235-9.
7.
Hung LK, et al. Relationship of cervical spinal
rootlets and the inferior vertebral notch. Clin Orthop Relat Res. 2003
Apr;(409):131-7
8.
Zhou MW, et al. Microsurgical anatomy of
lumbosacral nerve rootlets for highly selective rhizotomy in chronic spinal
cord injury. Anat Rec (Hoboken). 2010 Dec;293(12):2123-8.
9.
Kulkarni M. Constructive interference in
steady-state/FIESTA-C clinical applications in neuroimaging. J Med Imaging
Radiat Oncol. 2011 Apr;55(2):183-90.
10.
Ramli N, Cooper A, Jaspan T. High resolution
CISS imaging of the spine. Br JRadiol. 2001 Sep;74(885):862-73.