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So here's a case that I read not too long ago,

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and I think this really tells you the importance

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of trying to evaluate the brachial plexus.

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So this was a patient that had a fatty mass

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involving the right supraclavicular area.

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And the patient underwent a

0:15

partial resection of this.

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And this mass, which I'm outlining

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right here, was a lipoma.

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So it was a benign fatty lesion.

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So the issue was, it's a lipoma.

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And I think we can all make this diagnosis.

0:29

But really to take things to the next

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level, what the surgeon was concerned

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about was that this lipoma was involving

0:36

the right supraclavicular fossa.

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So when they started to do their

0:40

resection, the surgeon noticed that

0:42

this lipoma was extending pretty deeply.

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And he was concerned that the mass

0:48

was actually involving the brachial

0:49

plexus or in close proximity to it.

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So the reason they got the MRI was not

0:54

for us to say, yes, there's a lipoma.

0:56

What they really wanted to do was

0:58

identify the relationship of the

1:00

lipoma with the brachial plexus.

1:02

Because from a surgical standpoint, that's

1:04

one of the big determining factors whether or

1:06

not this lipoma could be completely resected.

1:09

So, when we look at this mass, I've

1:11

already outlined the lipoma, but

1:13

again, what we have to do is identify

1:16

where the brachial plexus is located.

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So, I'm going to draw my line down

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the middle, and I'm going to compare

1:21

one side to the opposite side.

1:23

So, on the left-hand side, we can see the

1:25

anterior scalene muscle here, then we can

1:27

see the posterior scalene muscle, and then

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we can see the supraclavicular portion of

1:33

the brachial plexus extending through the

1:35

planes of the scalene muscles, and that tells

1:38

us where that brachial plexus is located.

1:40

Now, on the patient's right-hand

1:42

side, what we can actually see is

1:44

that this mass is extending medially.

1:48

And look what it's doing to

1:49

the anterior scalene muscle.

1:51

This mass is extending between the

1:52

plane of the anterior scalene muscle

1:54

and the medial scalene muscle.

1:56

So, we have a little strip of fat

1:59

that's extending between the anterior

2:01

and the middle scalene muscles.

2:03

So, when we see that fat extending into that

2:05

area, all of a sudden we know that the brachial

2:08

plexus is now at risk for involvement.

2:12

When we look at the image in the center, again,

2:15

let's draw a line down the middle, compare

2:17

one side to the other side, anterior scalene,

2:19

middle scalene, there's the brachial plexus,

2:22

and on the patient's right-hand side, there's

2:24

that anterior scalene muscle, there's the middle

2:26

scalene muscle, and we can see that this fat

2:29

has not only extended between the plane

2:32

of the anterior and the middle muscles,

2:35

but look what it's doing to the

2:37

supraclavicular portion of the brachial plexus.

2:40

It's surrounding that brachial

2:41

plexus, and in fact, it's actually

2:43

stretching that brachial plexus.

2:45

And then when we look at the sagittal T1

2:48

weighted image, to get ourselves oriented,

2:51

this is anterior, and this is posterior.

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Here's the top of the lung.

2:56

This is the clavicle that's located

2:58

here, so I'll just put a C there.

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And then here's our subclavian artery,

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so there's our subclavian artery.

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So we can see not only is the mass extending

3:07

deeply, it's extending so deeply that it's

3:09

actually encased the subclavian artery and

3:13

it's completely encased the three cords

3:16

of the brachial plexus that we see here.

3:19

So in summary, what we were able

3:20

to do in this case is confirm the

3:22

diagnosis of a lipomatous lesion.

3:25

So this was a lipoma, but we were able to

3:28

inform the surgeon that this thing is not

3:31

only extending deeply but it's encased in the

3:34

subclavian artery and adjacent to the subclavian

3:37

artery are the cords of the brachial plexus.

3:39

And we can see that this fatty lesion is

3:42

actually encasing and directly involving

3:45

the cords of the brachial plexus.

3:47

And therefore, we directly affected

3:49

how this patient was treated.

3:50

And it really was a relative contraindication for

3:53

complete resection of this benign lesion.