Evaluation of Serum Neurofilament Light Chain and Nerve Ultrasound in Diabetic Neuropathy

OBJECTIVE

To assess the role of serum neurofilament light chain (NfL) levels in individuals with diabetic polyneuropathy (DPN) compared with controls, as well as to highlight the different sonographic changes in DPN and determine if NfL correlates with sonographic, clinical, and functional parameters.

METHODS

Diabetic individuals with signs or symptoms consistent with peripheral nerve involvement were recruited. They were evaluated by examination, functional neuropathy severity scores, laboratory assessments (including NfL), nerve conduction studies (NCS), and ultrasound. Ultrasound was performed of the bilateral median, ulnar, tibial, fibular, sural, and vagus nerves, and cervical roots 5 and 6. Results were compared with age, sex, and body mass index matched healthy controls.

RESULTS

A total of 320 nerves from 20 patients and 480 nerves from 30 controls were evaluated. NfL was significantly elevated in those with diabetes with a mean and standard deviation of 6.95 ± 2.95 pg/mL in the diabetic group and 2.83 ± 0.77 pg/mL in controls (P < .001). Nerve cross-sectional area and serum NfL levels correlated significantly with clinical and functional parameters and with each other (P < .05).

CONCLUSION

Individuals with DPN have significantly higher NfL levels than healthy controls, and NfL levels correlate with ultrasonographic parameters. These findings may be useful for the diagnosis, prognosis, and disease monitoring of those with DPN, though further exploration is needed.

Exploration of Neurofilament Light Chain and Nerve Ultrasound in Leprotic Neuropathy

OBJECTIVES

To explore neurofilament light chain (NfL) levels in leprotic neuropathy compared to controls, and to determine if the changes correlate with ultrasonographic nerve findings.

METHODS

Individuals with leprosy with signs or symptoms suggestive of peripheral nerve involvement were recruited. They were evaluated by clinical examination, functional scores, laboratory assessments (including NfL), nerve conduction studies (NCS), and ultrasound. Ultrasound was conducted in bilateral median, ulnar, tibial, fibular, sural, and vagus nerves as well as cervical roots 5 and 6. Results were compared to age, sex, and body mass index matched healthy controls.

RESULTS

A total of 320 nerves from 20 patients and 480 nerves from 30 controls were evaluated. NfL was significantly elevated in those with leprosy with a mean and standard deviation of 7.50 + 2.83 compared with 3.42 + 1.18 in controls (P < .001). Ultrasound showed focal enlargement of the nerves, particularly at entrapment sites. Additionally, there were noticeable changes in neural Doppler signal, echogenicity, and epineural thickness among the measured nerve sites. NfL levels in those with leprosy correlated closely with nerve cross-sectional area at all sites (P < .05). Functional and clinical assessment scores correlated with NfL and sonographic cross-sectional area as well (P ≤ .05).

CONCLUSIONS

NfL is elevated in leprotic neuropathy. Ultrasound showed specific morphological changes in individuals with leprosy, and nerve enlargement correlated with NfL levels. Thus, both modalities may be useful for the diagnosis, prognosis, and disease monitoring in those with leprotic neuropathy, and further investigations are warranted.

Role of High-Resolution Ultrasonography With Colour and Duplex Doppler in the Evaluation of Acute Scrotal Diseases

Introduction The term 'acute scrotum' denotes the sudden initiation of pain in the scrotal region. Acute scrotum is a frequent medical condition in children and adults. Ultrasound facilitates precise diagnosis and differentiation of numerous causes of acute scrotum. The objective of our research was to assess the utility of ultrasonography in the identification and prevalence determination of causes of acute scrotum. Materials and methods Patients with acute scrotal pain referred to the Department of Radiodiagnosis at Great Eastern Medical School & Hospital (GEMS), Srikakulam, India, were added in the research. This is a prospective observational study. High-frequency linear transducer (4-15 MHz) was used for imaging. Grey scale, colour and duplex Doppler were performed routinely. The ultimate diagnosis was established by considering the clinical results, follow-up observations, intraoperative observations and, when accessible, histopathological analysis. For the statistical analysis, IBM SPSS Statistics for Windows, version 22 (released 2013; IBM Corp., Armonk, New York, United States). was used. Descriptive analysis was conducted. The Kendall rank correlation coefficient was used to evaluate the non-parametric association between side and torsion. Results A total of 120 patients were included for statistical analysis. Inflammatory pathology was the most common cause of acute scrotum, followed by testicular torsion and torsion of testicular appendage. Testicular torsion and side of pain did not show a significant association. Conclusion High-resolution ultrasonography with colour and duplex Doppler sonography is an excellent imaging modality exhibiting exceptional sensitivity and specificity for the accurate diagnosis of acute scrotal diseases. Inflammatory pathology was the most common cause of acute scrotum, followed by testicular torsion and torsion of the testicular appendage.

High-Resolution Ultrasonography of Renal Oncocytoma Presenting with Symptomatic Hematuria and Urinary Bladder Clot Retention-A Rare Occurrence

Renal oncocytomas are asymptomatic, benign tumors often encountered incidentally on various imaging modalities. Renal oncocytomas comprise 5–7% of primary renal neoplasms and are derived from cells of the distal renal tubule. We present a case report of renal oncocytoma in a 22-year-old male having right-sided flank pain and symptomatic gross hematuria with a giant urinary bladder clot retention. The tumor was excised, and the patient underwent laparoscopic partial nephrectomy. Typical features of renal oncocytoma were observed upon histopathological examination of the resected specimen. The patient was catheterized, and bladder irrigation with clot retraction was performed.

Primary Undifferentiated Pleomorphic Sarcoma of the Biceps Femoris Muscle Complicated by Hemorrhage: An Underrecognized Entity

Malignant fibrous histiocytoma currently known as undifferentiated pleomorphic sarcoma is the commonest soft tissue sarcoma of mesenchymal origin. Undifferentiated pleomorphic sarcoma is commonly located in the extremities, trunk, head and neck in decreasing order of frequency. We report a case of primary undifferentiated pleomorphic sarcoma of the biceps femoris muscle in a 50-year-old male complicated by hemorrhage. Diagnostic workup included ultrasonography, magnetic resonance imaging (MRI), histopathology and positive results on immunohistochemistry especially CD-68. High-grade liposarcoma and rhabdomyosarcoma were regarded as differential diagnoses of undifferentiated pleomorphic sarcoma. Demonstration of spontaneous hemorrhage within the lesion on follow-up ultrasonography done at one month from the time of diagnosis deserves a special mention in this report. Radical excision with tumor-free margins of the biceps femoris and tendon reconstruction was undertaken. MRI at six months follow-up did not reveal tumor recurrence at the site of surgery and CT chest did not reveal metastases.

Reference values for the cross-sectional area of the normal sciatic nerve using high-resolution ultrasonography

Aim

High-resolution ultrasonography is a new and promising technique to evaluate peripheral and spinal nerves. Its validity as a diagnostic tool in neurological diseases has been demonstrated in adults. The aims of study were to establish the reference values for the cross-sectional area of the normal sciatic nerve on high-resolution ultrasonography, and to determine the relationship between the cross-sectional area of the normal sciatic nerve and the subjects' age, gender, height (in cm), weight (in kg), and body mass index.

Material and methods

Two hundred subjects of both genders and above 18 years of age were studied with high-resolution ultrasonography. The subjects had no history of peripheral neuropathy or trauma to the lower limb. The cross-sectional areas of the normal sciatic nerves were obtained at two different levels in both lower limbs. The mean cross-sectional areas of the sciatic nerves were measured at two different levels, one located at 1 cm above the bifurcation of the sciatic nerve into the tibial and common peroneal nerves, and the other 4 cm above the bifurcation of the sciatic nerve into the tibial and common peroneal nerves.

Results

A positive correlation of the mean cross-sectional area was established with height, weight, and body mass index. Women had smaller cross-sectional areas of the normal sciatic nerves than men at both measuring sites. No significant relationship was established with the age of the subjects.

Conclusions

The established reference values of the cross-sectional area of the sciatic nerve can facilitate the analysis of pathological nerve conditions.

Cross-sectional area reference values for high-resolution ultrasonography of the upper extremity nerves in healthy Asian adults

In this study, multiple-site, cross-sectional area (CSA) reference values were established for major peripheral nerves, including small branches, in the upper extremity of a healthy Asian population.This study included 107 prospectively recruited age-matched, healthy subjects with a mean age of 46 years (range, 24-75 years). All subjects underwent standardized nerve conduction studies for the median, ulnar, peroneal, posterior tibial, and sural nerves. CSA was measured unilaterally at 21 sites of the median, ulnar, radial, posterior interosseous, superficial radial sensory, musculocutaneous, lateral antebrachial cutaneous, and medial antebrachial cutaneous nerves.According to their age, the subjects were assigned to the younger group (20-40 years, n = 40), the middle group (40-59 years, n = 40), and the older group (60-80 years, n = 27). The significant differences of CSA values between age groups were found only at certain sites, such as the median (wrist, P = .003), ulnar (medial epicondyle, P = .031; forearm, P = .022), radial (antecubital fossa, P = .037), and superficial radial sensory nerve (P = .028). The CSA significantly correlated with gender, height, weight, and body mass index.This study provides CSA reference values for nerves, including small sensory nerves in the upper extremity, which can be useful in the ultrasonographic investigation of various peripheral neuropathies in the upper extremity.

Isolated Intramuscular Cysticercosis of the Biceps Diagnosed on High-Resolution Ultrasonography

High-resolution ultrasound clinches the diagnosis of intramuscular cysticercosis which is a rare finding. Here, we present a case of isolated intramuscular cysticercosis diagnosed on high-resolution ultrasonography in a 46-year-old gentleman who presented with a linear swelling in the flexor aspect of the left arm in the long head of the biceps.

Successful treatment of idiopathic knuckle pads with a combination of high-dose salicylic acid and urea topical keratolytics: A case report

Knuckle pads are benign subcutaneous and usually hyperkeratotic fibromas for which no specific treatments exist. Unspecific treatments are, most of the time, ineffective and a wait-and-see policy is often recommended to patients. However, especially in adolescents, knuckle pads are often poorly tolerated for cosmetic reasons, potentially causing embarrassment and social anxiety. Here we present the case of a young adult successfully treated with a combination of high-dose salicylic acid and urea topical keratolytics. In addition, we provide ideal diagnostic images obtained via high-resolution ultrasonography and histological features that can be used by medical practitioners to better distinguish knuckle pads from other proximal interphalangeal/ metacarpophalangeal joint diseases as also from other diseases inducing swelling of periarticular soft tissues.

Graft vasculopathy in upper extremity allotransplantation: Results of a retrospective high-resolution ultrasonographic study

Graft vasculopathy (GV) is the most severe pathologic change of chronic rejection in vascularized composite allotransplantation. Since 2012, the intimal media thickness (IMT) of radial and ulnar arteries was annually monitored by high-resolution ultrasonography in seven bilateral upper extremity transplant (UET) patients. We also investigated the IMT of seven matched healthy subjects (controls). No significant difference between IMT values of controls and UET patients was found. The median IMT values of recipient radial and ulnar arteries were 0.23 mm and 0.25 mm, respectively, while the median IMT values of grafted radial and ulnar arteries were 0.27 mm and 0.30 mm, respectively. There was a statistically significant difference in the IMT values of the grafted and recipient ulnar arteries (p = .043), but this difference was no longer significant when patient #2 was excluded. He showed a significant difference between recipient and grafted arteries and significantly higher IMT values (p = .001) of his grafted arteries compared with those of all transplanted patients. This patient developed GV leading to graft loss 11 years after the transplantation. In conclusion, this study showed a significant IMT increase in an UET recipient who developed GV.

Sonoanatomy of the deep branch of the ulnar nerve

INTRODUCTION

This study evaluated the sonoanatomy of the deep motor branch of the ulnar nerve (DBUN) using high-resolution ultrasonography (HRUS).

METHODS

In 60 wrists of 30 healthy adults, the gross course, cross-sectional area (CSA), and diameter of the DBUN were observed by HRUS (frequency band 3-16 MHz). Its course was assessed by using the distance from anatomical landmarks and depth from the skin.

RESULTS

The DBUN was found in all subjects with HRUS, and it branched off from the ulnar nerve before reaching the hamate bone. At the hook-of-hamate level, the mean DBUN CSA was 1.5 ± 0.2 mm² , and the mean diameter was 1.5 ± 0.2 mm. The mean distance from the hamate hook to the DBUN was 5.4 ± 1.0 mm, and the mean depth from the skin was 8.6 ± 1.6 mm.

DISCUSSION

Sonoanatomy of the DBUN obtained from HRUS may be useful in detecting or preventing DBUN lesions.

Sonographic assessment of the anatomy and common pathologies of clinically important bursae

High-resolution ultrasonography has many advantages in the imaging of the musculoskeletal system, when compared to other imaging methods, particularly in superficial, easily accessible parts of the body. It is a perfect diagnostic tool for visualizing the most common pathologies of the musculoskeletal system, including the bursae. Inflammation of bursae is frequent, and it can mimic other diseases of the musculoskeletal system. Therefore, knowledge of normal ultrasound anatomy of the bursae, their exact location in the human body, and the sonographic signs of their most common pathologies is essential for establishing a quick and accurate diagnosis by ultrasound. Common conditions affecting bursae, leading to bursitis, include acute trauma, overuse syndromes, degenerative diseases, inflammatory conditions (rheumatoid arthritis, psoriatic arthritis, gout etc.), infections such as tuberculosis, synovial tumors and tumor-like conditions (pigmented villonodular synovitis, osteochondromatosis), and many more. This review article presents and explains ultrasound examples of the most frequent pathological conditions affecting bursae. Images include normal and pathological conditions of bursae around the shoulder joint, elbow, hip, knee, and ankle joint.

Ultrasonographic Reference Values for Assessing Normal Sciatic Nerve Ultrasonography in the Normal Population

Objective:

High-resolution ultrasonography (HRUS) has been used recently to characterize median and ulnar nerves but is seldom used to characterize the lower extremity nerves. The reference standard for normal the lower extremity nerves has not been established. Thus, this study measured the cross-sectional areas (CSAs) of the sciatic nerve of 200 healthy male or female volunteers, aged 18–80 using HRUS. These data provide basic clinical data for the use of high-resolution ultrasound for the future diagnosis, treatment, and prognostic evaluation of peripheral neuropathies.

Methods:

Two hundred healthy volunteers with 400 lower extremities were studied with HRUS. According to their age, the subjects were assigned to young group (18-30 years, n = 75), middle group. (31-60 years, n = 70), and old group(61-80 year, n = 55). Age, sex, height, weight were recorded and CSAs of sciatic nerve were obtained at every predetermined sites.

Results:

The mean CSAs of sciatic nerves at GS and MGPF were 0.527 ± 0.028 cm² and 0.444 ± 0.026 cm² respectively. Pearson's correlation analysis showed that the mean CSAs were correlated with height and weight. There was no difference in mean CSAs among the three groups (P > 0.05). Women had smaller CSAs of the normal Sciatic nerves than men in two measuring sites (GS, MGPF) (P < 0.05).

Conclusion:

Peripheral nerve ultrasonography is a reliable and reproducible diagnostic method in the hands of experienced examiners. Normal values for the sciatic nerve nerves are provided by our study. Thus, reference values of Sciatic nerve CSA of the lower extremity can facilitate the analysis of abnormal nerve conditions.

The feasibility of using high-resolution ultrasonography to assess ulnar nerve in patients with diabetes mellitus

OBJECTIVE

The aim of this study was to investigate the usefulness of high-resolution ultrasonography for the diagnosis of polyneuropathy in diabetes mellitus patients by the examination of the ulnar nerves.

METHOD

We recruited 100 healthy age-matched volunteers (50 women and 50 men) with 200 arms without diabetes or cubital tunnel syndrome as the control group. We assessed the upper limbs of 100 diabetes mellitus patients (45 women and 55 men), 40 of whom had electrophysiologically confirmed diabetic peripheral neuropathy and 60 had no diabetic peripheral neuropathy in the upper limbs. Age, sex, height and weight were recorded and the cross-sectional area of the ulnar nerve was measured at every predetermined site.

RESULTS

The cross-sectional area of the ulnar nerve was measured at six sites (mid-humerus, inlet of the cubital tunnel, outlet of the cubital tunnel, upon the medial epicondyle, 6 cm upon the wrist crease and Guyon tunnel). The ulnar nerve in two measuring sites (mid-humerus, upon the medial epicondyle) in the control group showed a statistical difference between men and women (p < 0.05). There was no statistical difference in the cross-sectional area in the control group when dominant and non-dominant arms were compared. The cross-sectional area was larger in the diabetic peripheral neuropathy group in three sites (inlet of the cubital tunnel, outlet of the cubital tunnel, Guyon tunnel) compared with those in the control group.

CONCLUSION

High-resolution ultrasonography may be helpful in the early diagnosis of peripheral neuropathy in diabetic patients.

High-resolution transbulbar ultrasonography helping differentiate intracranial hypertension in bilateral optic disc oedema patients

PURPOSE

The enlargement of optic nerve sheath diameter (ONSD) has been proven to be related with raised intracranial pressure (ICP). No prospective study has been focused on utilizing retrobulbar ultrasonography in optic disc oedema patient presented to ophthalmologist.

METHODS

High-resolution transbulbar ultrasonography was performed in a cohort of patient presented with bilateral optic disc oedema. The subarachnoid space of optic nerve (SAS), ONSD and optic nerve diameter (OND) was measured prior to other ancillaries including lumbar puncture. Subjects were classified into increased intracranial pressure (IIP) and normal intracranial pressure (NIP) group according to the open cerebrospinal fluid pressure more than 200 mm H₂ 0. The SAS, ONSD and OND were compared between groups and with normal control. The sensitivity of SAS or ONSD change for predicating intracranial hypertension was assessed.

RESULTS

A total of 20 IIP, 25 NIP patients and 25 normal controls were evaluated. The mean SAS and ONSD measured in idiopathic intracranial hypertension group was significantly increased than that of NIP and controls (p < 0.001), whereas the OND showed no statistic difference between each group. The sensitivities using the SAS and ONSD for differentiating increased ICP in optic disc oedema patients were 0.99 and 0.97, respectively.

CONCLUSIONS

The enlarged SAS and ONSD measured by high-resolution transbulbar sonography are very sensitive parameters to predicate increased ICP in bilateral optic disc oedema patients.

The thickness of the A2 pulley and the flexor tendon are related to the severity of trigger finger: results of a prospective study using high-resolution ultrasonography

We aimed to investigate the relationship between the pulley-tendon complexes and the severity of trigger finger. The thickness of the A1 and A2 pulleys, and the cross-sectional area of the flexor tendon under the pulleys, were prospectively assessed using 17 MHz high-resolution ultrasonography, in 20 patients with trigger finger (31 fingers). A control group comprised 15 asymptomatic fingers. The thickness of the A1 pulley and the proximal part of the A2 pulley, and the cross-sectional area of the flexor tendon under the A2 pulley, were significantly increased in the patient group. Clinical grade was significantly correlated with the thickness of the A1 pulley, the thickness of the proximal part of the A2 pulley, and the cross-sectional area of the flexor tendon under the proximal part of the A2 pulley. This study confirmed that the thickness of the A2 pulley and flexor tendon under the A2 pulley seems to be related to the severity of trigger finger.

LEVEL OF EVIDENCES

Level III.

The diagnostic value of high-resolution ultrasonography for the detection of anterior disc displacement of the temporomandibular joint: a meta-analysis employing the HSROC statistical model

The study aimed to assess the diagnostic value of high-resolution ultrasonography (HR-US) in the detection of anterior disc displacement (ADD) of the temporomandibular joint. Relevant trials reported in MEDLINE, the Chinese National Knowledge Infrastructure Database, the Chinese Biomedical Literature Database, and Embase were identified. A manual search was also performed. The quality of retrieved data was evaluated using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) criteria. Data were extracted and cross-checked, and a statistically rigorous meta-analysis was performed using a hierarchical summary receiver operating characteristic model (HSROC). The clinical utility of results was assessed using Fagan nomograms (Bayes theory). All data were evaluated using Stata software. A total 11 studies including 1096 subjects were included in the analysis; all reported the utility of HR-US for the diagnosis of ADD with reduction (ADDWR) and without reduction (ADDWoR). For ADDWR, the weighted sensitivity and specificity were 0.83 (95% confidence interval (CI) 0.78-0.88) and 0.85 (95% CI 0.76-0.92) respectively. The lambda value was 3.41 (95% CI 2.37-4.46) and the Fagan nomogram pre-test probability 58%, with a positive likelihood ratio (LR) of 6.01. The positive post-test probability was 89%, with a negative LR of 0.20. The negative post-test probability was 21%. The positive increase in diagnostic utility was 31% and the negative decrement in that value 37%. For ADDWoR, the weighted sensitivity and specificity values were 0.72 (95% CI 0.59-0.81) and 0.90 (95% CI 0.86-0.93), respectively. The lambda value was 3.69 (95% CI 2.39-4.99) and the Fagan nomogram pre-test probability 38%, with a positive LR of 7.00. The positive post-test probability was 82%, with a negative LR of 0.32. The negative post-test probability was 16%. The increase in diagnostic utility was 44% and the negative decrement in that value 22%. HR-US delivers acceptable performance when used to diagnose ADD, being superior for the detection of ADDWoR than ADDWR, and exhibiting a lower negative diagnostic value in the detection of ADDWoR than ADDWR. HR-US may serve as a new method for the rapid diagnosis of ADD. The method has the advantages of simplicity and low cost. Given the uncertainty in some of the estimated values, more high-quality studies are needed to assess that diagnostic efficacy.