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Walter U, Sobiella G, Prudlo J, Batchakaschvili M, Böhmert J, Storch A, Hermann A. Ultrasonic detection of vagus, accessory, and phrenic nerve atrophy in amyotrophic lateral sclerosis: Relation to impairment and mortality. Eur J Neurol 2024; 31:e16127. [PMID: 37933884 DOI: 10.1111/ene.16127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 09/01/2023] [Accepted: 10/19/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND AND PURPOSE In amyotrophic lateral sclerosis (ALS), phrenic nerve (PN) atrophy has been found, whereas there is controversy regarding vagus nerve (VN) atrophy. Here, we aimed to find out whether PN atrophy is related to respiratory function and 12-month survival. Moreover, we investigated the relevance of VN and spinal accessory nerve (AN) atrophy in ALS. METHODS This prospective observational monocentric study included 80 adult participants (40 ALS patients, 40 age- and sex-matched controls). The cross-sectional area (CSA) of bilateral cervical VN, AN, and PN was measured on high-resolution ultrasonography. Clinical assessments included the Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised (ALSFRS-R), the Non-Motor Symptoms Questionnaire, and handheld spirometry of forced vital capacity (FVC). One-year survival was documented. RESULTS The CSA of each nerve, VN, AN, and PN, was smaller in ALS patients compared to controls. VN atrophy was unrelated to nonmotor symptom scores. PN CSA correlated with the respiratory subscore of the ALSFRS-R (Spearman test, r = 0.59, p < 0.001), the supine FVC (r = 0.71, p < 0.001), and the relative change of sitting-supine FVC (r = -0.64, p = 0.001). Respiratory impairment was predicted by bilateral mean PN CSA (p = 0.046, optimum cutoff value of ≤0.37 mm2 , sensitivity = 92%, specificity = 56%) and by the sum of PN and AN CSA (p = 0.036). The combination of ALSFRS-R score with PN and AN CSA measures predicted 1-year survival with similar accuracy as the combination of ALSFRS-R score and FVC. CONCLUSIONS Ultrasonography detects degeneration of cranial nerve motor fibers. PN and AN calibers are tightly related to respiratory function and 1-year survival in ALS.
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Affiliation(s)
- Uwe Walter
- Department of Neurology, Rostock University Medical Center, Rostock, Germany
- Deutsches Zentrum für Neurodegenerative Erkrankungen Rostock/Greifswald, Rostock, Germany
- Center for Transdisciplinary Neurosciences Rostock, Rostock University Medical Center, Rostock, Germany
| | - Gretlies Sobiella
- Department of Neurology, Rostock University Medical Center, Rostock, Germany
- Translational Neurodegeneration Section "Albrecht Kossel," Department of Neurology, Rostock University Medical Center, Rostock, Germany
| | - Johannes Prudlo
- Department of Neurology, Rostock University Medical Center, Rostock, Germany
- Deutsches Zentrum für Neurodegenerative Erkrankungen Rostock/Greifswald, Rostock, Germany
| | | | - Jan Böhmert
- Department of Neurology, Rostock University Medical Center, Rostock, Germany
| | - Alexander Storch
- Department of Neurology, Rostock University Medical Center, Rostock, Germany
- Deutsches Zentrum für Neurodegenerative Erkrankungen Rostock/Greifswald, Rostock, Germany
- Center for Transdisciplinary Neurosciences Rostock, Rostock University Medical Center, Rostock, Germany
| | - Andreas Hermann
- Deutsches Zentrum für Neurodegenerative Erkrankungen Rostock/Greifswald, Rostock, Germany
- Center for Transdisciplinary Neurosciences Rostock, Rostock University Medical Center, Rostock, Germany
- Translational Neurodegeneration Section "Albrecht Kossel," Department of Neurology, Rostock University Medical Center, Rostock, Germany
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Niu J, Zhang L, Hu N, Cui L, Liu M. The distribution pattern of nerve enlargement in clinical subtypes of chronic inflammatory demyelinating polyneuropathy. J Neuroimaging 2024; 34:127-137. [PMID: 37823703 DOI: 10.1111/jon.13162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 09/28/2023] [Accepted: 10/02/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND AND PURPOSE We aim to investigate nerve enlargement patterns and their correlation with clinical subtypes and treatment response using nerve ultrasound in chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). METHODS Between March 2015 and December 2021, 135 CIDP patients were recruited. Nerve ultrasound and electrophysiological studies were performed on the median and ulnar nerves. The responses to intravenous immunoglobulin (IVIg) or prednisone were evaluated with the disability score. RESULTS There were 99 typical CIDP cases, 10 Lewis-Sumner syndrome (LSS) cases, 15 distal acquired demyelinating symmetric neuropathy (DADS) cases, nine pure motor CIDP cases, and two pure sensory CIDP cases. Sixty (61%) typical CIDP and seven (78%) pure motor CIDP patients had moderately increased or normal cross-sectional area (CSA), and 10 (67%) DADS and seven (70%) LSS patients had significantly increased CSA. The peripheral nerve showed a diffuse enlargement pattern in 46 (51%) typical CIDP, five (50%) LSS, three (25%) DADS, and three (33%) pure motor CIDP patients and a proximal regional enlargement pattern in 11 (12%) typical CIDP, one (10%) LSS, six (50%) DADS, and four (44%) pure motor CIDP patients. Patients with diffusely moderate enlargement patterns and those with proximal regional enlargement showed a higher response rate to glucocorticoids than to IVIg. CONCLUSIONS Various distribution patterns of nerve enlargement existed in CIDP. Although almost all patterns could be detected in each CIDP subtype, diffusely moderate enlargement was more common in typical CIDP and LSS, while proximal regional enlargement was more common in DADS and pure motor CIDP. Different enlargement patterns might indicate different treatment responses.
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Affiliation(s)
- Jingwen Niu
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Lei Zhang
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Nan Hu
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Liying Cui
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Mingsheng Liu
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
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Kerasnoudis A, Ntasiou E, Tsiami S, Sarholz M, Baraliakos X, Krogias C. Nerve sonography in the diagnostic evaluation of primary and secondary carpal tunnel syndrome in rheumatoid arthritis. J Neuroimaging 2024; 34:120-126. [PMID: 37933219 DOI: 10.1111/jon.13169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 10/25/2023] [Accepted: 10/25/2023] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND AND PURPOSE Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy and extra-articular manifestation of rheumatoid arthritis (RA). However, in patients with RA, it is not always possible to clinically distinguish an actual CTS from other RA-based complaints. METHODS We evaluated the diagnostic role of nerve ultrasound (NUS) as supportive tool in the diagnostic process of CTS in patients with RA and tried to provide etiological clarification in cases of secondary CTS. Fifty-eight patients with RA and clinical suspicion of CTS were enrolled. All patients underwent a standardized clinical-neurological, electrophysiological (nerve conduction studies [NCS]), and NUS examination and completed the Boston CTS Questionnaire (BCTQ). RESULTS In 96 of 116 hands examined, a clinical suspicion of CTS was documented. In 43 of 96 (44.8%) CTS-positive hands, the diagnosis was primarily confirmed by NCS, whereas in another 16 of 96 (30.2%) hands, the diagnosis could only be verified by NUS, leading to a diagnosis of CTS in 59 of 116 (50.8%) hands. In 19 of 59 (32.3%) CTS-positive hands, tenosynovial hypertrophy was observed, and in 7 of 59 (11.8%), a cystic mass was identified as the underlying cause of secondary CTS. A good correlation between NCS and NUS findings was documented, but no significant correlation was found between NCS, NUS, and clinical findings/BCTQ. CONCLUSIONS In people with RA, a diagnosis of CTS purely on a clinical basis is nonspecific and should be supported by NCS and/or NUS. NUS markedly facilitates the diagnosis of CTS in these patients and enables differentiation between primary and secondary causes.
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Affiliation(s)
- Antonios Kerasnoudis
- Department of Neurology, St Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Etfhymia Ntasiou
- Department of Neurology, St Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Styliani Tsiami
- Rheumazentrum Ruhrgebiet, Herne, Ruhr University Bochum, Bochum, Germany
| | - Michael Sarholz
- Department of Rheumatology, St. Marien-Hospital Vreden, Vreden, Germany
| | - Xenofon Baraliakos
- Rheumazentrum Ruhrgebiet, Herne, Ruhr University Bochum, Bochum, Germany
| | - Christos Krogias
- Department of Neurology, St Josef Hospital, Ruhr University Bochum, Bochum, Germany
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Pelosi L, van Alfen N. Neuromuscular ultrasound as a marker for inherited sensory neuronopathy. Muscle Nerve 2023; 68:718-721. [PMID: 37436126 DOI: 10.1002/mus.27934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 06/19/2023] [Accepted: 06/25/2023] [Indexed: 07/13/2023]
Abstract
A review and detailed analysis of the literature over the past two decades has revealed a unique ultrasound feature of pathologically "small" nerves in inherited sensory neuronopathies. Although sample sizes were limited, due to the rarity of these diseases, this characteristic ultrasound finding has been consistently reported across a variety of inherited diseases that affect the dorsal root ganglia. Direct comparisons with both acquired and inherited diseases that primarily affect the axons in the peripheral nerves showed that the ultrasound finding of abnormally "small" cross-sectional areas (CSAs) in mixed nerves of the upper limbs has a high diagnostic accuracy for inherited sensory neuronopathy. Based on this review, ultrasound CSA of the mixed upper limb nerves can be proposed as a marker for inherited sensory neuronopathy.
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Affiliation(s)
- Luciana Pelosi
- Departments of Neurology and Neurophysiology, Bay of Plenty District Health Board, Tauranga Hospital, Tauranga, New Zealand
| | - Nens van Alfen
- Department of Neurology and Clinical Neurophysiology, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Centre, Nijmegen, The Netherlands
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Antenucci P, Carlucci D, Pugliatti M, Lucchetta M. Considerations about the multidimensional evaluation of a stab wound tibial neuropathy: a case report. J Ultrason 2023; 23:e97-e100. [PMID: 37520750 PMCID: PMC10379840 DOI: 10.15557/jou.2023.0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 01/12/2023] [Indexed: 08/01/2023] Open
Abstract
We present a rare case of a traumatic lesion of the tibial fibers of the sciatic nerve with spared peroneal fibers. A 33-year-old victim of a three month earlier stabbing attack came to our attention with gait impairment and weakened left foot plantar flexion and left foot internal rotation and supination. Based upon clinical signs and neurophysiological investigations we suspected that a traumatic injury of the left tibial nerve had occurred. Ultrasound examination detected a lesion of part of the left sciatic nerve, in a different site than expected. The patient was immediately enlisted for a tailored surgical reconstruction.
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Affiliation(s)
- Pietro Antenucci
- Department of Neurosciences and Rehabilitation, University of Ferrara, Ferrara, Italy
| | - Domenico Carlucci
- Division of Neurology, Santa Maria della Misericordia Hospital, Rovigo, Italy
| | - Maura Pugliatti
- Department of Neurosciences and Rehabilitation, University of Ferrara, Ferrara, Italy
| | - Marta Lucchetta
- Division of Neurology, Santa Maria della Misericordia Hospital, Rovigo, Italy
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Kneer K, Stahl JH, Kronlage C, Bombach P, Renovanz M, Winter N, Grimm A. Nerve Ultrasound of Peripheral Nerves in Patients Treated with Immune Checkpoint Inhibitors. Medicina (Kaunas) 2023; 59:1003. [PMID: 37374207 DOI: 10.3390/medicina59061003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 05/16/2023] [Accepted: 05/18/2023] [Indexed: 06/29/2023]
Abstract
Background and Objectives: Immune checkpoint inhibitors (ICIs) have enriched tumor therapy, improving overall survival. Immunotherapy adverse events (irAEs) occur in up to 50% of patients and also affect the peripheral nervous system. The exact pathomechanism is unclear; however, an autoimmune process is implicated. Thus, the clinical evaluation of irAEs in the peripheral nervous system is still demanding. We retrospectively analyzed nerve ultrasound (NU) data of polyneuropathies (PNPs) secondary to checkpoint inhibitors. Materials and Methods: NU data of patients with PNP symptoms secondary to ICI therapy were retrospectively analyzed using the Ultrasound Pattern Sum Score (UPSS) as a quantitative marker. Our findings were compared with a propensity score match analysis (1:1 ratio) to NU findings in patients with chronic inflammatory demyelinating polyneuropathy (CIDP) and chemotherapy-associated PNP patients. Results: In total, 10 patients were included (4 female, mean age 66 ± 10.5, IQR 60-77), where NU was performed in 80%. The UPSS obtained ranged from 0 to 5 (mean 2 ± 1.6, IQR 1-2.5). The morphological changes seen in the NUs resembled sonographic changes seen in chemotherapy-associated PNP (n = 10, mean UPSS 1 ± 1, IQR 0-2) with little to no nerve swelling. In contrast, CIDP patients had a significantly higher UPSS (n = 10, mean UPSS 11 ± 4, IQR 8-13, p < 0.0001). Conclusions: Although an autoimmune process is hypothesized to cause peripheral neurological irAEs, NU showed no increased swelling as seen in CIDP. The nerve swelling observed was mild and comparable to ultrasound findings seen in chemotherapy-associated PNP.
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Affiliation(s)
- Katharina Kneer
- Department of Neurology and Epileptology, University Hospital Tübingen, Eberhard Karls University Tübingen, 72076 Tübingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, 72076 Tübingen, Germany
| | - Jan-Hendrik Stahl
- Department of Neurology and Epileptology, University Hospital Tübingen, Eberhard Karls University Tübingen, 72076 Tübingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, 72076 Tübingen, Germany
| | - Cornelius Kronlage
- Department of Neurology and Epileptology, University Hospital Tübingen, Eberhard Karls University Tübingen, 72076 Tübingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, 72076 Tübingen, Germany
| | - Paula Bombach
- Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, 72076 Tübingen, Germany
- Department of Neurology and Interdisciplinary Neuro-Oncology, University Hospital Tübingen, Eberhard Karls University Tübingen, 72076 Tübingen, Germany
- Center of Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Eberhard Karls University Tübingen, 72076 Tübingen, Germany
| | - Mirjam Renovanz
- Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, 72076 Tübingen, Germany
- Department of Neurology and Interdisciplinary Neuro-Oncology, University Hospital Tübingen, Eberhard Karls University Tübingen, 72076 Tübingen, Germany
- Center of Neuro-Oncology, Comprehensive Cancer Center Tübingen-Stuttgart, University Hospital Tübingen, Eberhard Karls University Tübingen, 72076 Tübingen, Germany
| | - Natalie Winter
- Department of Neurology and Epileptology, University Hospital Tübingen, Eberhard Karls University Tübingen, 72076 Tübingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, 72076 Tübingen, Germany
| | - Alexander Grimm
- Department of Neurology and Epileptology, University Hospital Tübingen, Eberhard Karls University Tübingen, 72076 Tübingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, 72076 Tübingen, Germany
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Tan CY, Yahya MA, Goh KJ, Shahrizaila N. Nerve Ultrasound Score in Chronic Inflammatory Demyelinating Polyneuropathy. Medicina (Kaunas) 2023; 59:medicina59040747. [PMID: 37109705 PMCID: PMC10144993 DOI: 10.3390/medicina59040747] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 04/09/2023] [Accepted: 04/10/2023] [Indexed: 04/29/2023]
Abstract
Background and Objectives: Studies have suggested that, by applying certain nerve ultrasound scores, demyelinating and axonal polyneuropathies can be differentiated. In the current study, we investigated the utility of ultrasound pattern sub-score A (UPSA) and intra- and internerve cross-sectional area (CSA) variability in the diagnostic evaluation of demyelinating neuropathies. Materials and Methods: Nerve ultrasound was performed in patients with chronic inflammatory demyelinating polyneuropathy (CIDP) and acute inflammatory demyelinating polyneuropathy (AIDP) and compared to patients with axonal neuropathies. The UPSA, i.e., the sum of ultrasound scores at eight predefined measurement points in the median (forearm, elbow and mid-arm), ulnar (forearm and mid-arm), tibial (popliteal fossa and ankle) and fibular (lateral popliteal fossa) nerves, was applied. Intra- and internerve CSA variability were defined as maximal CSA/minimal CSA for each nerve and each subject, respectively. Results: A total of 34 CIDP, 15 AIDP and 16 axonal neuropathies (including eight axonal Guillain-Barré syndrome (GBS), four hereditary transthyretin amyloidosis, three diabetic polyneuropathy and one vasculitic neuropathy) were included. A total of 30 age- and sex-matched healthy controls were recruited for comparison. Significantly enlarged nerve CSA was observed in CIDP and AIDP with significantly higher UPSA in CIDP compared to the other groups (9.9 ± 2.9 vs. 5.9 ± 2.0 vs. 4.6 ± 1.9 in AIDP vs. axonal neuropathies, p < 0.001). A total of 89.3% of the patients with CIDP had an UPSA score ≥7 compared to the patients with AIDP (33.3%) and axonal neuropathies (25.0%) (p < 0.001). Using this cut-off, the performance of UPSA in differentiating CIDP from other neuropathies including AIDP was excellent (area under the curve of 0.943) with high sensitivity (89.3%), specificity (85.2%) and positive predictive value (73.5%). There were no significant differences in intra- and internerve CSA variability between the three groups. Conclusion: The UPSA ultrasound score was useful in distinguishing CIDP from other neuropathies compared to nerve CSA alone.
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Affiliation(s)
- Cheng-Yin Tan
- Division of Neurology, Department of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
| | - Mohd Azly Yahya
- Neurophysiology Laboratory, University of Malaya Medical Centre, Kuala Lumpur 59100, Malaysia
| | - Khean-Jin Goh
- Division of Neurology, Department of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
| | - Nortina Shahrizaila
- Division of Neurology, Department of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
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Dhanapalaratnam R, Issar T, Poynten AM, Milner K, Kwai NCG, Krishnan AV. Diagnostic accuracy of nerve ultrasonography for the detection of peripheral neuropathy in type 2 diabetes. Eur J Neurol 2022; 29:3571-3579. [PMID: 36039540 PMCID: PMC9826521 DOI: 10.1111/ene.15534] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 07/05/2022] [Accepted: 07/13/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND PURPOSE Nerve conduction studies (NCS) are the current objective measure for diagnosis of peripheral neuropathy in type 2 diabetes but do not assess nerve structure. This study investigated the utility of peripheral nerve ultrasound as a marker of the presence and severity of peripheral neuropathy in type 2 diabetes. METHODS A total of 156 patients were recruited, and nerve ultrasound was undertaken on distal tibial and distal median nerves. Neuropathy severity was graded using the modified Toronto Clinical Neuropathy Scale (mTCNS) and Total Neuropathy Score (TNS). Studies were undertaken by a single ultrasonographer blinded to nerve conduction results. RESULTS A stepwise increase in tibial nerve cross-sectional area (CSA) was noted with increasing TNS grade (p < 0.001) and each mTCNS quartile (p < 0.001). Regression analysis demonstrated a correlation between tibial nerve CSA and neuropathy severity (p < 0.001). Using receiver operator curve analysis, tibial nerve CSA of >12.88 mm yielded a sensitivity of 70.5% and specificity of 85.7% for neuropathy detection. Binary logistic regression revealed that tibial nerve CSA was a predictor of abnormal sural sensory nerve action potential amplitude (odds ratio = 1.239, 95% confidence interval [CI] = 1.142-1.345) and abnormal neuropathy score (odds ratio = 1.537, 95% confidence interval [CI] = 1.286-1.838). CONCLUSIONS Tibial nerve ultrasound has good specificity and sensitivity for neuropathy diagnosis in type 2 diabetes. The study demonstrates that tibial nerve CSA correlates with neuropathy severity. Future serial studies using both ultrasound and NCS may be useful in determining whether changes in ultrasound occur prior to development of nerve conduction abnormalities and neuropathic symptoms.
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Affiliation(s)
- Roshan Dhanapalaratnam
- Prince of Wales Clinical School, University of New South WalesSydneyNew South WalesAustralia
- Institute of Neurological Sciences, Prince of Wales HospitalSydneyNew South WalesAustralia
| | - Tushar Issar
- Prince of Wales Clinical School, University of New South WalesSydneyNew South WalesAustralia
| | - Ann M. Poynten
- Prince of Wales Clinical School, University of New South WalesSydneyNew South WalesAustralia
- Department of EndocrinologyPrince of Wales HospitalSydneyNew South WalesAustralia
| | - Kerry‐Lee Milner
- Prince of Wales Clinical School, University of New South WalesSydneyNew South WalesAustralia
- Department of EndocrinologyPrince of Wales HospitalSydneyNew South WalesAustralia
| | - Natalie C. G. Kwai
- School of Medical SciencesUniversity of SydneySydneyNew South WalesAustralia
| | - Arun V. Krishnan
- Prince of Wales Clinical School, University of New South WalesSydneyNew South WalesAustralia
- Institute of Neurological Sciences, Prince of Wales HospitalSydneyNew South WalesAustralia
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Wada S, Hirano H, Uehara N, Kurotobi Y, Tsuzaki K, Takamatsu N, Fujita M, Hamano T. Cervical Root Enlargement in Segmental Zoster Paresis: A Study with Magnetic Resonance Imaging and Nerve Ultrasound. Intern Med 2022; 61:2361-2365. [PMID: 35022345 PMCID: PMC9424074 DOI: 10.2169/internalmedicine.8538-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A 72-year-old woman presented with acute-progressive muscle weakness after a rash in the left upper limb. Muscle weakness was restricted to the left C5 innervated muscles. Short inversion time inversion recovery magnetic resonance imaging (MRI) showed a high-intensity signal in the left C5 nerve root, and nerve ultrasound showed its enlargement. She was diagnosed with segmental zoster paralysis (SZP) and treated with acyclovir and methylprednisolone. Her muscle strength gradually recovered, and the abnormal signal and enlargement in the left C5 nerve root improved. This is the first SZP case of confirmed improvement of abnormal findings on MRI and nerve ultrasound in association with muscle power recovery.
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Affiliation(s)
- Shinichi Wada
- Department of Neurology, Kansai Electric Power Hospital, Japan
- Division of Clinical Neurology, Kansai Electric Power Medical Research Institute, Japan
| | - Hirohisa Hirano
- Department of Rehabilitation, Kansai Electric Power Hospital, Japan
| | - Naoko Uehara
- Department of Neurology, Kansai Electric Power Hospital, Japan
- Division of Clinical Neurology, Kansai Electric Power Medical Research Institute, Japan
| | - Yuri Kurotobi
- Department of Neurology, Kansai Electric Power Hospital, Japan
| | - Koji Tsuzaki
- Department of Neurology, Kansai Electric Power Hospital, Japan
- Division of Clinical Neurology, Kansai Electric Power Medical Research Institute, Japan
| | | | - Masaaki Fujita
- Department of Clinical Immunology and Rheumatology, Kansai Electric Power Hospital, Japan
| | - Toshiaki Hamano
- Department of Neurology, Kansai Electric Power Hospital, Japan
- Division of Clinical Neurology, Kansai Electric Power Medical Research Institute, Japan
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Issar T, Walker S, Arnold R, Poynten AM, Endre ZH, Krishnan AV. Peripheral nerve morphology and intraneural blood flow in chronic kidney disease with and without diabetes. Muscle Nerve 2022; 65:603-607. [PMID: 35119701 PMCID: PMC9305967 DOI: 10.1002/mus.27513] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 01/24/2022] [Accepted: 01/29/2022] [Indexed: 11/22/2022]
Abstract
Introduction/Aims Sonographic alterations of peripheral nerves in pre‐dialytic kidney disease are yet to be determined. We aimed to assess peripheral nerve cross‐sectional area (CSA) and intraneural blood flow in patients with pre‐dialytic chronic kidney disease (CKD) and diabetic kidney disease (DKD). Methods Subjects with CKD (n = 20) or DKD (n = 20) underwent ultrasound to assess CSA of the median and tibial nerves as well as intraneural blood flow of the median nerve. Blood flow was quantified using maximum perfusion intensity. Neuropathy was assessed using the Total Neuropathy Score. A 6‐m timed walk test was also performed. Healthy controls (n = 28) were recruited for comparison. Results The DKD group had more severe neuropathy (p = .024), larger tibial nerve CSA (p = .002) and greater median nerve blood flow than the CKD group (p = .023). Blood flow correlated with serum potassium in disease groups (r = 0.652, p = .022). Disease groups had larger tibial nerve CSA than controls (p < .05). No blood flow was detected in controls. Tibial nerve enlargement was associated with slower maximal walking speeds in disease groups (r = −0.389, p = .021). Discussion Subjects with DKD demonstrated enlarged tibial nerve CSA and increased median nerve blood flow compared to those with CKD. Elevations in serum potassium were associated with increased blood flow. Sonographic alterations were detectable in pre‐dialytic kidney disease compared to controls, highlighting the utility of ultrasound in the assessment of nerve pathology in these patient groups.
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Affiliation(s)
- Tushar Issar
- Prince of Wales Clinical School, UNSW Sydney, NSW, Australia
| | - Susan Walker
- Prince of Wales Clinical School, UNSW Sydney, NSW, Australia
| | - Ria Arnold
- School of Medical Sciences, UNSW Sydney, NSW, Australia
| | - Ann M Poynten
- Department of Endocrinology, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Zoltan H Endre
- Department of Nephrology, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Arun V Krishnan
- Prince of Wales Clinical School, UNSW Sydney, NSW, Australia
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Pelosi L, Ghosh A, Leadbetter R, Lance S, Rodrigues M, Roxburgh R. Nerve ultrasound detects abnormally small nerves in patients with Spinal and Bulbar Muscular Atrophy. Muscle Nerve 2022; 65:599-602. [PMID: 35092036 DOI: 10.1002/mus.27509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 01/20/2022] [Accepted: 01/22/2022] [Indexed: 11/11/2022]
Abstract
Nerve ultrasound detects abnormally small nerves in patients with Spinal and Bulbar Muscular Atrophy.
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Affiliation(s)
- Luciana Pelosi
- Departments of Neurology and Neurophysiology, Bay Of Plenty District Health Board, Tauranga Hospital, Tauranga, New Zealand
| | - Avroneel Ghosh
- Department of Neurology, Auckland District Health Board, Auckland, New Zealand
| | - Ruth Leadbetter
- Department of Neurology, Wellington Hospital, Wellington, New Zealand
| | - Sean Lance
- Department of Neurology, Wellington Hospital, Wellington, New Zealand
| | - Miriam Rodrigues
- Department of Neurology, Auckland District Health Board, Auckland, New Zealand
| | - Richard Roxburgh
- Department of Neurology, Auckland District Health Board, Auckland, New Zealand.,Centre of Brain Research Neurogenetics Research Clinic, University of Auckland, New Zealand
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12
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Hsieh WJ, Chang KC, Hsueh HW, Chao CC, Hsieh ST. Bilateral widespread segmental swelling on nerve sonography in multifocal acquired demyelinating sensory and motor neuropathy: Two case reports. Medicine (Baltimore) 2021; 100:e27900. [PMID: 34797343 PMCID: PMC8601274 DOI: 10.1097/md.0000000000027900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 11/03/2021] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Multifocal acquired demyelinating sensory and motor neuropathy (MADSAM) is an asymmetric immune-related neuropathy with conduction block. We report 2 MADSAM cases with detailed clinical, electrophysiological, and sonography profiles. PATIENT CONCERNS AND DIAGNOSIS Two cases presented with patchy sensorimotor impairment in both clinical and electrophysiological findings. Notably, nerve ultrasound demonstrated multifocal nerve enlargement not only at sites of conduction blockade but also at the unaffected contralateral sites. Interestingly, in our first case, focal radial nerve enlargement was observed prior to the clinical manifestations, suggesting nerve dynamic pathogenesis with variable clinical significance. INTERVENTIONS AND OUTCOMES The first patient was initially treated with prednisolone, however, 3 months after steroid therapy, her symptoms progressed. After treatment with intravenous immunoglobulin for 3 months, the symptoms stabilized. The second patient showed improvement after 2 months of prednisolone treatment. CONCLUSION These observations suggest a more widespread pathomechanism underlying MADSAM, and ultrasound may detect nerve lesions earlier than clinical electrophysiology studies, and is warranted for early detection and thorough documentation of nerve pathology.
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Affiliation(s)
- Wan-Jen Hsieh
- Department of Neurology, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Kai-Chieh Chang
- Department of Neurology, National Taiwan University Hospital Yunlin Branch, College of Medicine, National Taiwan University, Yunlin, Taiwan
| | - Hsueh-Wen Hsueh
- Department of Neurology, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chi-Chao Chao
- Department of Neurology, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Sung-Tsang Hsieh
- Department of Neurology, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
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13
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Philipps J, Mork H, Katz M, Knaup M, Beyer K, Spies K, Corbach J, Schellinger PD. Assessment of Operator Reliability in Ultrasound of the Median and Ulnar Nerve Using Bland-Altman Analysis. Diagnostics (Basel) 2021; 11:2134. [PMID: 34829481 DOI: 10.3390/diagnostics11112134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 11/10/2021] [Accepted: 11/16/2021] [Indexed: 11/23/2022] Open
Abstract
Currently, there is no standardized method to evaluate operator reliability in nerve ultrasound. A short prospective protocol using Bland–Altman analysis was developed to assess the level of agreement between operators with different expertise levels. A control rater without experience in nerve ultrasound, three novices after two months of training, an experienced rater with two years of experience, and a reference rater performed blinded ultrasound examinations of the left median and ulnar nerve in 42 nerve sites in healthy volunteers. The precision of Bland–Altman agreement analysis was tested using the Preiss–Fisher procedure. Intraclass correlation coefficients (ICC), coefficients of variation, and Bland–Altman limits of agreement were calculated. The sample size calculation and Preiss–Fisher procedure showed a sufficient precision of Bland–Altman agreement analysis. Limits of agreement of all trained novices ranged from 2.0 to 2.9 mm2 and were within the test’s maximum tolerated difference. Ninety-five percent confidence intervals of limits of agreement revealed a higher precision in the experienced rater’s measurements. Operator reliability in nerve ultrasound of the median and ulnar nerve arm nerves can be evaluated with a short prospective controlled protocol using Bland–Altman statistics, allowing a clear distinction between an untrained rater, trained novices after two months of training, and an experienced rater.
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14
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Tan CY, Razali SNO, Goh KJ, Shahrizaila N. Influence of Demographic Factors on Nerve Ultrasound of Healthy Participants in a Multiethnic Asian Population. J Med Ultrasound 2021; 29:181-186. [PMID: 34729327 PMCID: PMC8515621 DOI: 10.4103/jmu.jmu_105_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 08/31/2020] [Accepted: 10/27/2020] [Indexed: 12/02/2022] Open
Abstract
Background: High-resolution nerve ultrasound provides morphological information of peripheral nerves. We aimed to determine the normal ultrasonographic reference values of nerve cross-sectional area (CSA) in multiethnic Malaysian healthy participants. Methods: Nerve ultrasound of the median, ulnar, radial, tibial, fibular, and sural nerves was performed in 84 healthy participants at anatomical-defined locations. The CSA at each scanned site was measured by tracing circumferentially inside the hyperechoic rim of each nerve. Comparisons were made between genders and ethnic groups. Correlations with age, ethnicity, gender, height, weight, and body mass index (BMI) were evaluated. Results: CSA values and reference ranges in healthy participants were generated. Nerve CSA was significantly different in different gender (P = 0.002–0.032) and ethnic groups (P = 0.006–0.038). Men had larger nerve CSA than women, and Malay participants had larger nerve CSA compared to other ethnic groups. Nerve CSA had significant correlations to age, height, weight, and BMI (r = 0.220–0.349, P = 0.001–0.045). Conclusion: This study provides normative values for CSA of peripheral nerves in a multiethnic Malaysian population, which serves as reference values in the evaluation of peripheral nerve disorders. The ethnic differences in nerve CSA values should be considered during nerve ultrasound.
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Affiliation(s)
- Cheng-Yin Tan
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Siti Nur Omaira Razali
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Khean-Jin Goh
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Nortina Shahrizaila
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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15
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Fargeot G, Maisonobe T, Vandendries C, Le Garff-Tavernier M, Leblond V, Viala K. Neurolymphomatosis related to direct epineural invasion of the superficial peroneal nerve from subcutaneous B-cell lymphoma. Clin Neurol Neurosurg 2021; 210:106992. [PMID: 34700275 DOI: 10.1016/j.clineuro.2021.106992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 10/08/2021] [Accepted: 10/12/2021] [Indexed: 11/25/2022]
Abstract
Neurolymphomatosis is a rare complication of systemic lymphomas, and is classically related to hematogenous spread or intraneural spread of tumor cells from the leptomeninges. Here we report a case of neurolymphomatosis related to direct epineural invasion of the superficial peroneal nerve from subcutaneous localization of B-cell lymphoma. Nerve biopsy revealed striking histological features suggestive of contiguous infiltration of the superficial peroneal nerve by subcutaneous lymphoma. We think this case report sheds new light on neurolymphomatosis pathophysiology with an unreported mechanism in B-cell lymphoma. It also points out that the clinical spectrum in neurolymphomatosis is really variable, pure sensory mononeuritis being a rare presentation. Finally, our case is also strongly illustrative of the contribution of early nerve ultrasonography in the patient diagnosis and in guidance of the nerve biopsy.
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Affiliation(s)
- G Fargeot
- Department of Clinical Neurophysiology, Sorbonne Université, Hôpital Pitié Salpêtrière, APHP, Paris, France.
| | - T Maisonobe
- Department of Clinical Neurophysiology, Sorbonne Université, Hôpital Pitié Salpêtrière, APHP, Paris, France; Department of Neuropathology, Sorbonne Université, Hôpital Pitié Salpêtrière, APHP, Paris, France
| | - C Vandendries
- RMX-medical center, 80, avenue Felix-Faure, 75015 Paris, France
| | - M Le Garff-Tavernier
- Service d'hématologie biologique, APHP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - V Leblond
- Hematology Department, Sorbonne Université, Hôpital Pitié Salpêtrière APHP, Paris, France
| | - K Viala
- Department of Clinical Neurophysiology, Sorbonne Université, Hôpital Pitié Salpêtrière, APHP, Paris, France
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16
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Mul K, Pesser N, Vervaart K, Teijink J, van Nuenen B, van Alfen N. Variability in electrodiagnostic findings associated with neurogenic thoracic outlet syndrome. Muscle Nerve 2021; 65:34-42. [PMID: 34378193 PMCID: PMC9292757 DOI: 10.1002/mus.27395] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 07/28/2021] [Accepted: 07/31/2021] [Indexed: 01/18/2023]
Abstract
Introduction/Aims Neurogenic thoracic outlet syndrome (NTOS) is a heterogeneous and often disputed entity. An electrodiagnostic pattern of T1 > C8 axon involvement is considered characteristic for the diagnosis of NTOS. However, since the advent of high‐resolution nerve ultrasound (US) imaging, we have encountered several patients with a proven entrapment of the lower brachial plexus who showed a different, variable electrodiagnostic pattern. Methods In this retrospective case series, 14 patients with an NTOS diagnosis with a verified source of compression of the lower brachial plexus and abnormal findings on their electrodiagnostic testing were included. Their medical records were reviewed to obtain clinical, imaging, and electrodiagnostic data. Results Seven patients showed results consistent with the “classic” T1 axon > C8 pattern of involvement. Less typical findings included equally severe involvement of T1 and C8 axons, more severe C8 involvement, pure motor abnormalities, neurogenic changes on needle electromyography in the flexor carpi radialis and biceps brachii muscles, and one patient with an abnormal sensory nerve action potential (SNAP) amplitude for the median sensory response recorded from the third digit. Patients with atypical findings on electrodiagnostic testing underwent nerve imaging more often compared to patients with classic findings (seven of seven patients vs. five of seven respectively), especially nerve ultrasound. Discussion When there is a clinical suspicion of NTOS, an electrodiagnostic finding other than the classic T1 > C8 pattern of involvement does not rule out the diagnosis. High resolution nerve imaging is valuable to diagnose additional patients with this treatable condition. See Editorial on pages 4‐6 in this issue.
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Affiliation(s)
- Karlien Mul
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Niels Pesser
- Department of Vascular surgery, Catharina Hospital, Eindhoven, The Netherlands.,CAPHRI-Research Center, Maastricht University, Maastricht, The Netherlands
| | - Kimberly Vervaart
- Department of Neurology, Catharina Hospital, Eindhoven, The Netherlands
| | - Joep Teijink
- Department of Vascular surgery, Catharina Hospital, Eindhoven, The Netherlands.,CAPHRI-Research Center, Maastricht University, Maastricht, The Netherlands
| | - Bart van Nuenen
- Department of Neurology, Catharina Hospital, Eindhoven, The Netherlands
| | - Nens van Alfen
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
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17
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Nagappa M, Pujar GS, Keshavan AH, Bathala L, Jain RD, Das A, Mehndiratta MM, Visser LH, Kumar HM. Sonographic pattern of median nerve enlargement in Hansen's neuropathy. Acta Neurol Scand 2021; 144:155-160. [PMID: 33899225 DOI: 10.1111/ane.13432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 03/10/2021] [Accepted: 03/30/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Median nerve enlargement in leprosy seems to be more proximal than in carpal tunnel syndrome (CTS), but this feature has not been studied systematically. The aim of the study was to compare the sites of median nerve enlargement in patients with leprosy with that of patients with CTS. MATERIALS AND METHODS Transverse sections of the median nerve were recorded from wrist to the mid-forearm (at distal wrist crease and at 2-cm: M1, 4-cm: M2, 6-cm: M3, 8-cm: M4 and 10-cm: M5, proximal to the distal wrist crease in the forearm) in patients with leprosy, CTS and healthy subjects using high-resolution ultrasound. RESULTS Twenty-six patients each with leprosy and CTS were compared with healthy controls. Patients with leprosy included 6 (23.1%), 7 (26.9%), 7 (26.9%) and 6 (23.1%) patients with borderline tuberculoid, borderline-borderline, borderline lepromatous and lepromatous leprosy, respectively. Cross-sectional area (CSA) of median nerve was increased in all patients with leprosy as compared to healthy controls at all points of measurement. CSA was higher among patients with leprosy as compared to CTS at all points except at the wrist. In patients with leprosy, the maximal enlargement was noted 2-cm (M1) proximal to the wrist crease with gradual tapering of the CSA proximally (p < .05). In contrast, in patients with CTS the median nerve was maximally enlarged at the distal wrist crease (p<.05). CONCLUSIONS Median nerve enlargement 2-cm proximal to the distal wrist crease distinguishes leprosy from CTS. This important discriminating sign can be used at point-of-care to identify patients with leprosy.
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Affiliation(s)
- Madhu Nagappa
- Department of Neurology National Institute of Mental Health and Neurosciences (NIMHANS) Bangalore India
| | | | | | - Lokesh Bathala
- Department of Neurology Aster CMI Hospital Bangalore India
| | - Richa D. Jain
- Department of Radiology Aster CMI Hospital Bangalore India
| | - Abhijit Das
- Department of Pathology Janakpuri Super Speciality Hospital New Delhi India
| | | | - Leo H. Visser
- Departments of Neurology and Clinical Neurophysiology ETZ, St. Elisabeth Hospital Tilburg Netherlands
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Seeliger T, Bönig L, Gingele S, Prenzler NK, Thiele T, Ernst D, Witte T, Stangel M, Skripuletz T, Körner S. Nerve ultrasound findings in Sjögren's syndrome-associated neuropathy. J Neuroimaging 2021; 31:1156-1165. [PMID: 34270142 DOI: 10.1111/jon.12907] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 06/30/2021] [Accepted: 06/30/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND PURPOSE The phenotype of Sjögren's syndrome-associated neuropathy has been better characterized in recent years. However, Sjögren's syndrome-associated neuropathy remains an underdiagnosed entity with only few insights considering the pathomechanisms of nerve damage. Nerve ultrasound has proven to be a useful and efficient tool in detecting nerve damage of autoimmune origin. We, therefore, aimed to evaluate this method for Sjögren's syndrome-associated neuropathy. METHODS Patients with Sjögren's syndrome and clinical signs of neuropathy underwent sonographic examination of both median and ulnar nerves. Nerve thickening was classified for cross-sectional areas of >12 mm² at the median nerve and for >10 mm² at the ulnar nerve. Fascicle thickening was documented for cross-sectional areas ≥5 mm² at the median and ≥3 mm² at the ulnar nerve. RESULTS Forty-three patients were included in the analysis (median age 60 years [interquartile range 53-73 years], female rate 60%). 31/43 patients (72%) showed abnormalities on nerve ultrasound, while nerve thickening was found more frequently than fascicle thickening (90% vs. 52% of patients with sonographic abnormalities, respectively). Abnormal findings were observed more frequently at the median nerve and in proximal localization. Abnormal findings on nerve conduction studies were evident in 36/43 patients (84%). Nerve conduction studies revealed a tendency of demyelinating nerve damage patterns being associated with abnormal findings on nerve ultrasound. CONCLUSIONS In addition to nerve conduction studies, nerve ultrasound may have a supporting role in the diagnosis of Sjögren's syndrome-associated neuropathy. Also, our data support an immune-mediated inflammatory demyelinating pathogenesis of Sjögren's syndrome-associated neuropathy.
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Affiliation(s)
- Tabea Seeliger
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Lena Bönig
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Stefan Gingele
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Nils K Prenzler
- Department of Otolaryngology, Hannover Medical School, Hannover, Germany
| | - Thea Thiele
- Department of Rheumatology & Immunology, Hannover Medical School, Hannover, Germany
| | - Diana Ernst
- Department of Rheumatology & Immunology, Hannover Medical School, Hannover, Germany
| | - Torsten Witte
- Department of Rheumatology & Immunology, Hannover Medical School, Hannover, Germany
| | - Martin Stangel
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | | | - Sonja Körner
- Department of Neurology, Hannover Medical School, Hannover, Germany
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19
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Fisse AL, Katsanos AH, Gold R, Krogias C, Pitarokoili K. Cross-sectional area reference values for peripheral nerve ultrasound in adults: A systematic review and meta-analysis-Part II: Lower extremity nerves. Eur J Neurol 2021; 28:2313-2318. [PMID: 33794049 DOI: 10.1111/ene.14850] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 03/25/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Measurement of the cross-sectional area (CSA) of peripheral nerves using ultrasound is useful in the evaluation of focal lesions such as entrapment syndromes and inflammatory polyneuropathies. We performed a systematic review and meta-analysis of published CSA reference values for lower extremity nerves. METHODS We included available-to-date nerve ultrasound studies on healthy adults and provide meta-analysis for CSA of the following nerves: fibular nerve at fibular head, popliteal fossa; tibial nerve at popliteal fossa, malleolus; and sural nerve at the level of the two heads of gastrocnemius muscle. We report regression and correlation analyses for age, gender distribution, height, weight, and geographic continent. RESULTS We included 16 studies with 1001 healthy volunteers (mean age = 47.9 years) and 4023 examined nerve sites. Calculated mean pooled CSA of fibular nerve at fibular head was 8.4 mm2 (95% confidence interval [CI] = 6.8-9.9 mm2 , n = 1166), at popliteal fossa was 7.9 mm2 (95% CI = 6.6-9.2 mm2 , n = 995), of tibial nerve at popliteal fossa was 25.9 mm2 (95% CI = 17.5-34.4 mm2 , n = 771), at malleolus was 10.0 mm2 (95% CI = 7.7-12.4 mm2 , n = 779), and of sural nerve was 2.4 mm2 (95% CI = 1.7-3.1 mm2 , n = 312). Substantial heterogeneity across studies (I2 > 50%) was found only for tibial nerve at popliteal fossa. Subgroup analysis revealed a lower CSA of tibial nerve at popliteal fossa and sural nerve in studies conducted in Europe than in North America and New Zealand. CONCLUSIONS We provide the first meta-analysis on CSA reference values for the lower extremities with no or low heterogeneity of reported CSA values in all nerve sites except tibial nerve at popliteal fossa. Our data facilitate the goal of an international standardized evaluation protocol.
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Affiliation(s)
- Anna Lena Fisse
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr University Bochum, Bochum, Germany
| | - Aristeidis H Katsanos
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada
| | - Ralf Gold
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr University Bochum, Bochum, Germany
| | - Christos Krogias
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Kalliopi Pitarokoili
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr University Bochum, Bochum, Germany
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20
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Fisse AL, Katsanos AH, Gold R, Pitarokoili K, Krogias C. Cross-sectional area reference values for peripheral nerve ultrasound in adults: A systematic review and meta-analysis-Part III: Cervical nerve roots and vagal nerve. Eur J Neurol 2021; 28:2319-2326. [PMID: 33838065 DOI: 10.1111/ene.14862] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 03/28/2021] [Accepted: 04/07/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND PURPOSE Measurement of the cross-sectional area (CSA) of cervical nerve roots using ultrasound is useful in the evaluation of inflammatory polyneuropathies, and measurement of CSA of the vagal nerve might give information about involvement of the autonomic nervous system. We performed a systematic review and meta-analysis of published CSA reference values for cervical nerve roots and vagal nerve. METHODS We included available-to-date nerve ultrasound studies on healthy adults and provide meta-analysis for CSA of the following nerves: cervical nerve roots C5, C6, and C7 as well as vagal nerve in the carotid sheath at the carotid bifurcation level. We report regression and correlation analyses for age, gender, height, weight, and geographic continent. RESULTS We included 11 studies with 885 healthy volunteers (mean age = 42.7 years) and 3149 examined nerve sites. Calculated mean pooled CSA of C5 root was 5.6 mm2 (95% confidence interval [CI] = 4.6-6.7 mm2 , n = 911), of C6 root was 8.8 mm2 (95% CI = 7.4-10.3 mm2 , n = 909), of C7 root was 9.5 mm2 (95% CI = 8.0-10.9 mm2 , n = 909), and of vagal nerve was 2.2 mm2 (95% CI = 1.5-2.9 mm2 , n = 420). No heterogeneity was found across studies for any site. Subgroup analysis revealed no significant effects of age, gender, height, weight, and geographic continent on CSA for any of these nerve sites. CONCLUSIONS We provide the first meta-analysis on CSA reference values for the cervical nerve roots and the vagal nerve, with no heterogeneity of reported CSA values at all nerve sites. Our data facilitate the goal of an international standardized evaluation protocol.
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Affiliation(s)
- Anna Lena Fisse
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr University Bochum, Bochum, Germany
| | - Aristeidis H Katsanos
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, ON, Canada
| | - Ralf Gold
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr University Bochum, Bochum, Germany
| | - Kalliopi Pitarokoili
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr University Bochum, Bochum, Germany
| | - Christos Krogias
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
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21
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Ripellino P, Ventura E, Querol L, Gobbi C. Chronic inflammatory demyelinating polyneuropathy with hypertrophic nerves. J Peripher Nerv Syst 2021; 26:227-230. [PMID: 33881184 DOI: 10.1111/jns.12445] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 04/12/2021] [Accepted: 04/18/2021] [Indexed: 12/21/2022]
Abstract
We describe the distinctive features (with images and video) of a case of chronic inflammatory demyelinating polyneuropathy (CIDP) with giant nerves. The main clinical findings were insidious onset, gait ataxia and sensory symptoms. Electrodiagnostic studies showed very slow nerve conduction velocities, multiple conduction blocks, distal CMAP duration increase and absence of F-waves. The protein level in the cerebrospinal fluid was very high. Nerve ultrasound showed swelling of all peripheral nerves outside entrapment sites, with significant variability within different segments of the same nerve; nerves were massively enlarged (up to 10-fold normal values). Brain MRI showed hypertrophic cranial nerves, with gadolinium-enhancement. Spinal MRI showed hypertrophy of spinal roots and cauda equine, with gadolinium enhancement. Genetic test (PMP22 duplication/deletion, Whole Exome Sequencing panel for neuropathies) resulted negative. The patient had a relapsing-remitting course and responded to immunoglobulin treatment. In CIDP with hypertrophic nerves, there is discrepancy between severe nerve hypertrophy and mild clinical symptoms. Nerve enlargement seems inversely related to nerve conduction velocity and directly correlated with disease duration, but not associated with disease severity.
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Affiliation(s)
- Paolo Ripellino
- Department of Neurology, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - Elisa Ventura
- Department of Neuroradiology, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - Luis Querol
- Neurology Department, Hospital de la Santa Creu i Sant Pau, Institut de Recerca Biomèdica Sant Pau, Barcelona, Spain
| | - Claudio Gobbi
- Department of Neurology, Neurocenter of Southern Switzerland, Lugano, Switzerland.,Faculty of Biomedical Sciences, Università della Svizzera Italiana (USI), Lugano, Switzerland
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22
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Issar T, Tummanapalli SS, Borire AA, Kwai NCG, Poynten AM, Arnold R, Markoulli M, Krishnan AV. Impact of the metabolic syndrome on peripheral nerve structure and function in type 2 diabetes. Eur J Neurol 2021; 28:2074-2082. [PMID: 33682297 DOI: 10.1111/ene.14805] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 02/25/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND PURPOSE There is a strong association between the metabolic syndrome in diabetes and the development of peripheral neuropathy; however, the pathophysiological mechanisms remain unknown. METHODS Participants with type 2 diabetes and metabolic syndrome (T2DM/MetS, n = 89) and type 2 diabetes alone (T2DM; n = 59) underwent median nerve ultrasound and excitability studies to assess peripheral nerve structure and function. A subset of T2DM/MetS (n = 24) and T2DM (n = 22) participants underwent confocal microscopy to assess central and inferior whorl corneal nerve structure. Neuropathy severity was assessed using the modified Toronto Clinical Neuropathy Score (mTCNS). Diabetes groups were similar for age, sex distribution, diabetes duration, hemoglobin A1c , insulin treatment, and renal function. Sixty healthy controls similar for age and sex distribution were recruited for comparison. RESULTS Participants with T2DM/MetS manifested with a greater mTCNS compared to T2DM (p < 0.05). Median nerve cross-sectional area was larger in the T2DM/MetS group compared to the T2DM cohort (p < 0.05). Participants with T2DM/MetS had reductions in central (all p < 0.01) and inferior whorl (all p < 0.05) nerve measures. Compared to T2DM, the T2DM/MetS group demonstrated more severe changes in nerve excitability measures, which was due to reduced sodium channel permeability and sodium-potassium pump function. In comparison, only sodium channel permeability was reduced in the T2DM group. CONCLUSIONS Compared to participants with type 2 diabetes alone, those with diabetes and metabolic syndrome manifested greater alterations in peripheral nerve structure and function, which may be due to reduced function of the sodium-potassium pump.
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Affiliation(s)
- Tushar Issar
- Prince of Wales Clinical School, UNSW Sydney, Sydney, NSW, Australia
| | | | - Adeniyi A Borire
- Prince of Wales Clinical School, UNSW Sydney, Sydney, NSW, Australia
| | - Natalie C G Kwai
- Prince of Wales Clinical School, UNSW Sydney, Sydney, NSW, Australia.,Department of Exercise Physiology, UNSW Sydney, Sydney, NSW, Australia
| | - Ann M Poynten
- Department of Endocrinology, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Ria Arnold
- Department of Exercise Physiology, UNSW Sydney, Sydney, NSW, Australia
| | - Maria Markoulli
- School of Optometry & Vision Science, UNSW Sydney, Sydney, NSW, Australia
| | - Arun V Krishnan
- Prince of Wales Clinical School, UNSW Sydney, Sydney, NSW, Australia
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23
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Fisse AL, Katsanos AH, Gold R, Pitarokoili K, Krogias C. Cross-sectional area reference values for peripheral nerve ultrasound in adults: a systematic review and meta-analysis-Part I: Upper extremity nerves. Eur J Neurol 2021; 28:1684-1691. [PMID: 33527596 DOI: 10.1111/ene.14759] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 10/22/2020] [Accepted: 01/27/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE Measurement of the cross-sectional area (CSA) of peripheral nerves using ultrasound is useful in the evaluation of focal lesions like entrapment syndromes and inflammatory polyneuropathies. Here, a systematic review and meta-analysis of published CSA reference values for upper extremity nerves was performed. METHODS Available to date nerve ultrasound studies on healthy adults were included and a meta-analysis for CSA was provided of the following nerves: median nerve at the wrist, forearm, upper arm; ulnar nerve at the Guyon's canal, forearm, elbow, upper arm; radial nerve at the upper arm. Regression and correlation analyses for age, gender, height, weight, geographic continents and publication year are reported. RESULTS Seventy-four studies with 4186 healthy volunteers (mean age 42.7 years) and 18,226 examined nerve sites were included. The calculated mean pooled CSA of the median nerve at the wrist was 8.3 mm2 (95% confidence interval [95% CI] 7.9-8.7, n = 4071), at the forearm 6.4 mm2 (95% CI 5.9-6.9, n = 3021), at the upper arm 8.3 mm2 (95% CI 7.5-9.0, n = 1388), of the ulnar nerve at the Guyon's canal 4.1 mm2 (95% CI 3.6-4.6, n = 1688), at the forearm 5.2 mm2 (95% CI 4.8-5.7, n = 1983), at the elbow 5.9 mm2 (95% CI 5.4-6.5, n = 2551), at the upper arm 6.6 mm2 (95% CI 5.1-6.1, n = 1737) and of the radial nerve 5.1 mm2 (95% CI 4.0-6.2, n = 1787). Substantial heterogeneity across studies (I2 > 50%) was found only for the radial nerve. Subgroup analysis revealed a positive effect of age for the median nerve at the wrist and for height and weight for different sites of the ulnar nerve. CONCLUSION The first meta-analysis on CSA reference values for the upper extremities with no or only low heterogeneity of reported CSA values in most nerve sites is provided. Our data facilitate the goal of an international standardized evaluation protocol.
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Affiliation(s)
- Anna Lena Fisse
- Department of Neurology, St Josef Hospital, Ruhr-University Bochum, Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr University Bochum, Bochum, Germany
| | - Aristeidis H Katsanos
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, ON, Canada
| | - Ralf Gold
- Department of Neurology, St Josef Hospital, Ruhr-University Bochum, Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr University Bochum, Bochum, Germany
| | - Kalliopi Pitarokoili
- Department of Neurology, St Josef Hospital, Ruhr-University Bochum, Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr University Bochum, Bochum, Germany
| | - Christos Krogias
- Department of Neurology, St Josef Hospital, Ruhr-University Bochum, Bochum, Germany
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24
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Besmens IS, Guidi M, Schiller A, Jann D, Giovanoli P, Calcagni M. Management of posterior interosseous nerve (PIN) palsies after distal biceps tendon repair using a single incision technique- a conclusive approach to diagnostics and therapy. J Plast Surg Hand Surg 2021; 55:226-231. [PMID: 33586601 DOI: 10.1080/2000656x.2020.1858841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Complete distal ruptures of the biceps brachii tendon are rather rare and surgical reinsertion is the gold standard. Recently, one incision approaches for the refixation of the distal biceps tendon have been popularized with the introduction of a single-incision approach employing a trans-radial cortical button fixation. Since the introduction of this fixation technique we have seen more iatrogenic lesions to the posterior interosseous nerve (PIN) after not having seen any PIN lesions with 2 incision biceps refixation techniques over the last 5 years. Several patients with iatrogenic PIN affections after one incision refixation techniques of the distal biceps tendon were referred to our level 1 department of Plastic surgery and hand surgery from different orthopedic surgeons. Over the course of 6 months we saw 5 patients with a similar history. We decided to analyze this problem and propose a course of action to regain function of the PIN innervated muscles as good and fast as possible. If there is a loss of function in the PIN innervated muscles after distal biceps refixation a neurological evaluation including electrophysiology needs to be conducted. An ultrasound assessment of the nerve itself should guide the clinician in the decision between a conservative and a surgical treatment in the early postoperative phase. If surgical exploration is warranted intraoperative neurography should be the basis on which ground (partial) grafting or solely neurolysis is performed. Postoperatively all patients need to follow a rehabilitation protocol to help with nerve regeneration and regaining of motor function.
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Affiliation(s)
- Inga S Besmens
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Marco Guidi
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Andreas Schiller
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - David Jann
- Department of Orthopedic Surgers, Traumatology and Sport Medicine, Spital STS AG, Thun, Switzerland
| | - Pietro Giovanoli
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Maurizio Calcagni
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
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25
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Wijntjes J, Borchert A, van Alfen N. Nerve Ultrasound in Traumatic and Iatrogenic Peripheral Nerve Injury. Diagnostics (Basel) 2020; 11:E30. [PMID: 33375348 DOI: 10.3390/diagnostics11010030] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 12/22/2020] [Accepted: 12/23/2020] [Indexed: 01/04/2023] Open
Abstract
Peripheral nerve injury is a potentially debilitating disorder that occurs in an estimated 2–3% of all patients with major trauma, in a similar percentage of medical procedures. The workup of these injuries has traditionally been clinical, combined with electrodiagnostic testing. However, this has limitations, especially in the acute phase of the trauma or lack of any recovery, when it is very important to determine nerve continuity and perform surgical exploration and repair in the case of the complete transection or intraneural fibrosis. Ultrasound can help in those situations. It is a versatile imaging technique with a high sensitivity of 93% for detecting focal nerve lesions. Ultrasound can assess the structural integrity of the nerve, neuroma formation and other surrounding abnormalities of bone or foreign bodies impeding the nerve. In addition, this can help to prevent iatrogenic nerve injury by marking the nerve before the procedure. This narrative review gives an overview of why and how nerve ultrasound can play a role in the detection, management and prevention of peripheral nerve injury.
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26
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Walker FO, Cartwright MS, Hunt CH. Managing uncommon and unexpected findings during neuromuscular ultrasound. Muscle Nerve 2020; 63:793-806. [PMID: 33325071 DOI: 10.1002/mus.27128] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 11/20/2020] [Accepted: 11/23/2020] [Indexed: 12/18/2022]
Abstract
One barrier to widespread adoption of neuromuscular ultrasound by clinical neurophysiologists is concern over how to identify and manage non-neuromuscular findings. This review addresses this concern by describing the sonographic appearance of a variety of commonly observed pathologies and anatomic variants in dermal, subcutaneous, bony, glandular, lymphatic, vascular, and other superficial tissues. Additionally, it outlines techniques to ensure proper clinical and ultrasound evaluation of unexpected or uncommon findings. Finally, it highlights strategies to manage unexpected findings, including how to best communicate findings to patients and referring clinicians to avoid unnecessary testing and ensure appropriate follow-up. Ultrasound extends the ability of the neuromuscular sonographer-clinician to contribute to patient care.
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Affiliation(s)
- Francis O Walker
- Division of Neuromuscular Disorders, Department of Neurology, Wake Forest Medical School, Medical Center Blvd, Winston-Salem, NC, 27157-1078, USA
| | - Michael S Cartwright
- Division of Neuromuscular Disorders, Department of Neurology, Wake Forest Medical School, Medical Center Blvd, Winston-Salem, NC, 27157-1078, USA
| | - Christopher H Hunt
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
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27
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Tian X, Lam WL, Guo W, Chen T, Chen S. Congenital peripheral nerve hypoplasia: a report of seven cases. J Hand Surg Eur Vol 2020; 45:1028-1033. [PMID: 32903127 DOI: 10.1177/1753193420951341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We report the clinical findings of congenital peripheral nerve hypoplasia in seven patients. All seven children presented with unilateral ulnar or median nerve palsy or both. They were assessed clinically, and nerve diameters were assessed with ultrasonography and compared with the contralateral limb. Nerve conduction studies were performed in five children, and the nerves were explored in the four children who presented with accompanying constriction bands. By ultrasonography, the mean diameter of the ulnar nerve was 63% and 29% when compared with the normal arm and forearm, respectively, and the mean diameter of the median nerve was 63% and 46%. Hypoplasia in the nerve was not confined to constriction points but occurred in the entire upper limb in all seven cases. These patients were followed for an average of 12 months (range 6 to 30). Despite neurolysis and surgical decompression in four patients, none of the nerve palsies had recovered. The clinical findings suggest that this condition cannot be explained by simple mechanical compression, and more extensive pathological changes in the involved upper limb are evident in this rare disease.Level of evidence: IV.
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Affiliation(s)
- Xiaofei Tian
- Department of Burns and Plastic, Children's Hospital of Chongqing Medical University, Chongqing, China
| | | | - Wen Guo
- Department of Ultrasonography, Beijing Ji Shui Tan Hospital, Xicheng, China
| | - Tao Chen
- Department of Ultrasonography, Beijing Ji Shui Tan Hospital, Xicheng, China
| | - Shanlin Chen
- Department of Hand Surgery, Beijing Ji Shui Tan Hospital, Xicheng, China
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28
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VanHorn TA, Cartwright MS. Neuromuscular Ultrasound in the Pediatric Population. Diagnostics (Basel) 2020; 10:E1012. [PMID: 33255940 DOI: 10.3390/diagnostics10121012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 11/19/2020] [Accepted: 11/24/2020] [Indexed: 12/15/2022] Open
Abstract
The diagnosis and evaluation of neuromuscular disorders traditionally involves electrodiagnostic (EDx) testing, including nerve conduction studies (NCSs) and electromyography (EMG). These tools can cause pain and discomfort, an important consideration when performed on children. Neuromuscular ultrasound is noninvasive, cost-effective, and increasingly utilized for the detection of neuromuscular pathology. Studies investigating the performance and clinical implementation of ultrasound have primarily been performed in adult populations. Ultrasound in children has the potential to guide EDx testing and ultimately improve diagnostic efficiency and accuracy. This review aims to describe key features of neuromuscular ultrasound in the pediatric population based on the available studies, including our own institutional experience.
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29
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Boso F, Zanette G, Baldinotti F, Bertelloni S, Taioli F, Monaco S, Fabrizi GM, Cavallaro T. Convergent pathological and ultrasound features in hereditary syndromic and non-syndromic minifascicular neuropathy related to DHH. J Peripher Nerv Syst 2020; 25:423-428. [PMID: 33107133 DOI: 10.1111/jns.12417] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 10/15/2020] [Accepted: 10/20/2020] [Indexed: 11/29/2022]
Abstract
Minifascicular neuropathy (MN) is a rare, autosomal recessive disease with prominent structural changes of peripheral nerves. So far, it has been observed in females with a 46,XY karyotype and mutations of the Desert Hedgehog (DHH) gene, thus linking MN to gonadal dysgenesis (GD) and disorders of sex development (DSD). However, a 46,XX proband with normal female sex and gender development underwent clinical evaluations, nerve conduction studies and genetic screening for a severe motor-sensory neuropathy with a pathological phenotype that hinted at MN. Indeed, sural nerve biopsy revealed a profound disturbance of perineurium development with a thin and loose structure. High-resolution ultrasound (HRUS) also disclosed diffuse changes of nerve echotexture that visibly correlated with the pathological features. After extensive genetic testing, a novel homozygous DHH null mutation (p.Ser185*) was identified in the proband and in her sister, who was affected by a similar motor-sensory neuropathy, but was eventually found to be a 46,XY patient according to a late diagnosis of DSD with complete GD. DHH should therefore be considered as a possible cause of rare non-syndromic hereditary motor-sensory neuropathies, regardless of DSD. Furthermore, HRUS could effectively smooth the complex diagnostic workup as it demonstrated a high predictive power to detect MN, providing the same detailed correlations to the pathologic features of the nerve biopsy and Dhh-/- mice in both sisters. Hence, HRUS may assume a pivotal role in guiding molecular analysis in individuals with or without DSD.
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Affiliation(s)
- Federica Boso
- Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy.,Neurology Division, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | | | - Fulvia Baldinotti
- Laboratory of Molecular Genetics, Department of Laboratory Medicine, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
| | - Silvano Bertelloni
- Pediatric and Adolescent Endocrinology, Pediatrics Division, Department of Obstetrics, Gynecology and Pediatrics, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
| | - Federica Taioli
- Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy.,Neurology Division, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Salvatore Monaco
- Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy.,Neurology Division, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Gian Maria Fabrizi
- Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy.,Neurology Division, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Tiziana Cavallaro
- Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy.,Neurology Division, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
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30
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Kojima Y, Noto YI, Tsuji Y, Kitani-Morii F, Shiga K, Mizuno T, Nakagawa M. Charcot-Marie-Tooth disease type 1A: Longitudinal change in nerve ultrasound parameters. Muscle Nerve 2020; 62:722-727. [PMID: 32959396 DOI: 10.1002/mus.27068] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 09/03/2020] [Accepted: 09/11/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND This study aimed to elucidate the longitudinal changes in nerve ultrasound parameters of adult Charcot-Marie-Tooth disease type 1A (CMT1A) patients. METHODS Fifteen adult patients with CMT1A prospectively underwent nerve ultrasound and clinical assessment (CMT neuropathy score [CMTNS]) at baseline and 5 y later. Nerve cross-sectional area (CSA) and echogenicity were measured in the median and sural nerves. Changes in ultrasound parameters and CMTNS and correlation between changes of ultrasound parameters and CMTNS were analyzed. RESULTS Median and sural nerve CSAs did not change over 5 y, although CMTNS increased (P < .01). Nerve echogenicity in the sural nerve decreased over 5 y (P = .045). No correlations between changes in nerve ultrasound parameters and CMTNS were identified. CONCLUSIONS No longitudinal changes in nerve size was detected in adult CMT1A. Exploring the factors that determine nerve size in childhood CMT1A may lead to the development of treatments.
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Affiliation(s)
- Yuta Kojima
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yu-Ichi Noto
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yukiko Tsuji
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Fukiko Kitani-Morii
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kensuke Shiga
- Department of Neurology, Matsushita Memorial Hospital, Osaka, Japan
| | - Toshiki Mizuno
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masanori Nakagawa
- North Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
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31
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Dörner M, Schreiber F, Stephanik H, Tempelmann C, Winter N, Stahl JH, Wittlinger J, Willikens S, Kramer M, Heinze HJ, Vielhaber S, Schelle T, Grimm A, Schreiber S. Peripheral Nerve Imaging Aids in the Diagnosis of Immune-Mediated Neuropathies-A Case Series. Diagnostics (Basel) 2020; 10:diagnostics10080535. [PMID: 32751486 PMCID: PMC7459443 DOI: 10.3390/diagnostics10080535] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 07/28/2020] [Accepted: 07/29/2020] [Indexed: 02/06/2023] Open
Abstract
Background: Diagnosis of immune-mediated neuropathies and their differentiation from amyotrophic lateral sclerosis (ALS) can be challenging, especially at early disease stages. Accurate diagnosis is, however, important due to the different prognosis and available treatment options. We present one patient with a left-sided dorsal flexor paresis and initial suspicion of ALS and another with multifocal sensory deficits. In both, peripheral nerve imaging was the key for diagnosis. Methods: We performed high-resolution nerve ultrasound (HRUS) and 7T or 3T magnetic resonance neurography (MRN). Results: In both patients, HRUS revealed mild to severe, segmental or inhomogeneous, nerve enlargement at multiple sites, as well as an area increase of isolated fascicles. MRN depicted T2 hyperintense nerves with additional contrast-enhancement. Discussion: Peripheral nerve imaging was compatible with the respective diagnosis of an immune-mediated neuropathy, i.e., multifocal motor neuropathy (MMN) in patient 1 and multifocal acquired demyelinating sensory and motor neuropathy (MADSAM) in patient 2. Peripheral nerve imaging, especially HRUS, should play an important role in the diagnostic work-up for immune-mediated neuropathies and their differentiation from ALS.
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Affiliation(s)
- Marc Dörner
- Center for Neurology, Tuebingen University Hospital and Hertie-Institute for Clinical Brain Research, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany; (N.W.); (J.-H.S.); (J.W.); (S.W.); (M.K.); (A.G.)
- Correspondence: ; Tel.: +49-0707-1298-2141
| | - Frank Schreiber
- Department of Neurology, Otto-von-Guericke University, 39120 Magdeburg, Germany; (F.S.); (H.S.); (C.T.); (H.-J.H.); (S.V.); (S.S.)
- German Center for Neurodegenerative Diseases (DZNE) within the Helmholtz Association, 39120 Magdeburg, Germany
| | - Heike Stephanik
- Department of Neurology, Otto-von-Guericke University, 39120 Magdeburg, Germany; (F.S.); (H.S.); (C.T.); (H.-J.H.); (S.V.); (S.S.)
| | - Claus Tempelmann
- Department of Neurology, Otto-von-Guericke University, 39120 Magdeburg, Germany; (F.S.); (H.S.); (C.T.); (H.-J.H.); (S.V.); (S.S.)
| | - Natalie Winter
- Center for Neurology, Tuebingen University Hospital and Hertie-Institute for Clinical Brain Research, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany; (N.W.); (J.-H.S.); (J.W.); (S.W.); (M.K.); (A.G.)
| | - Jan-Hendrik Stahl
- Center for Neurology, Tuebingen University Hospital and Hertie-Institute for Clinical Brain Research, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany; (N.W.); (J.-H.S.); (J.W.); (S.W.); (M.K.); (A.G.)
| | - Julia Wittlinger
- Center for Neurology, Tuebingen University Hospital and Hertie-Institute for Clinical Brain Research, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany; (N.W.); (J.-H.S.); (J.W.); (S.W.); (M.K.); (A.G.)
| | - Sophia Willikens
- Center for Neurology, Tuebingen University Hospital and Hertie-Institute for Clinical Brain Research, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany; (N.W.); (J.-H.S.); (J.W.); (S.W.); (M.K.); (A.G.)
| | - Magdalena Kramer
- Center for Neurology, Tuebingen University Hospital and Hertie-Institute for Clinical Brain Research, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany; (N.W.); (J.-H.S.); (J.W.); (S.W.); (M.K.); (A.G.)
| | - Hans-Jochen Heinze
- Department of Neurology, Otto-von-Guericke University, 39120 Magdeburg, Germany; (F.S.); (H.S.); (C.T.); (H.-J.H.); (S.V.); (S.S.)
- German Center for Neurodegenerative Diseases (DZNE) within the Helmholtz Association, 39120 Magdeburg, Germany
- Center for Behavioural Brain Sciences (CBBS), 39120 Magdeburg, Germany
- Leibniz Institue for Neurobiology (LIN), 39120 Magdeburg, Germany
| | - Stefan Vielhaber
- Department of Neurology, Otto-von-Guericke University, 39120 Magdeburg, Germany; (F.S.); (H.S.); (C.T.); (H.-J.H.); (S.V.); (S.S.)
- German Center for Neurodegenerative Diseases (DZNE) within the Helmholtz Association, 39120 Magdeburg, Germany
- Center for Behavioural Brain Sciences (CBBS), 39120 Magdeburg, Germany
| | - Thomas Schelle
- Department of Neurology, Städtisches Klinikum Dessau, 06847 Dessau, Germany;
| | - Alexander Grimm
- Center for Neurology, Tuebingen University Hospital and Hertie-Institute for Clinical Brain Research, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany; (N.W.); (J.-H.S.); (J.W.); (S.W.); (M.K.); (A.G.)
| | - Stefanie Schreiber
- Department of Neurology, Otto-von-Guericke University, 39120 Magdeburg, Germany; (F.S.); (H.S.); (C.T.); (H.-J.H.); (S.V.); (S.S.)
- German Center for Neurodegenerative Diseases (DZNE) within the Helmholtz Association, 39120 Magdeburg, Germany
- Center for Behavioural Brain Sciences (CBBS), 39120 Magdeburg, Germany
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Abstract
Distal acquired demyelinating symmetric neuropathy (DADS) is a variant of chronic inflammatory demyelinating polyneuropathy (CIDP) characterized by symmetrical, distal, sensory or sensorimotor involvement. DADS with M-protein (DADS-M) is less responsive to immunotherapy compared to those without M-protein (DADS-I). We report a case of DADS-I with severe clinical presentation viz. early hand involvement with marked wasting, inexcitable peripheral nerves on neurophysiology and poor response to immunotherapy. Despite the unusual presentation, ancillary tests including cerebrospinal fluid analysis, nerve biopsy and nerve ultrasound were supportive of an inflammatory demyelinating polyneuropathy. This case demonstrated the heterogeneity of the disorder and expands the clinical spectrum of DADS neuropathy.
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Affiliation(s)
- Tien Lee Ong
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya; Department of Neurology, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Khean-Jin Goh
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Nortina Shahrizaila
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Kum-Thong Wong
- Department of Pathology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Cheng-Yin Tan
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Preisner F, Bendszus M, Schwarz D. Visualization of Direct Median Nerve Damage Following Transbrachial Arterial Access. JACC Cardiovasc Interv 2020; 13:1265-1266. [PMID: 32360262 DOI: 10.1016/j.jcin.2020.02.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 02/25/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Fabian Preisner
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Daniel Schwarz
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany.
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Grimm AS, Schubert C, Grimm A, Stahl JH, Küpper H, Horber V, Kegele J, Willikens S, Wittlinger J, Serna-Higuita L, Winter N, Groeschel S. Normative Observational Nerve Ultrasound Values in School-Age Children and Adolescents and Their Application to Hereditary Neuropathies. Front Neurol 2020; 11:303. [PMID: 32411079 PMCID: PMC7198742 DOI: 10.3389/fneur.2020.00303] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 03/30/2020] [Indexed: 12/31/2022] Open
Abstract
Backgrounds: We have aimed to establish nerve ultrasound reference data in 8 to 17-year-old children and adolescents and to compare those data to younger children, adults, and age-matched children with polyneuropathies. Methods: High-resolution ultrasounds of the nerves were performed in 117 healthy children and adolescents at 20 predefined landmarks in the neck and the extremities of both sides. Mean values, side-to-side differences and intraneural ratios, as well as upper limits have been calculated. In a second step, a comparison between 25 children and adolescents of the same age range with proven hereditary and acquired neuropathies and lysosomal storage diseases has been carried out. Results: Nerve growth correlates significantly with age and reaches adult values at the age of around 15 years. The influence of body mass index and gender is negligible at most segments. By the use of age-specific upper limits, nerve enlargement could be seen in distinct types of neuropathies, particularly in demyelinating hereditary and inflammatory types, which is comparable to findings in adults, but also in rare lysosomal storage diseases. Conclusion: Nerve size correlates with age during childhood and reaches a climax in younger adults. Age-matched reference data are inevitable to differ between hypertrophic and non-hypertrophic nerve damage, e.g., in neuropathies.
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Affiliation(s)
- Anna-Sophie Grimm
- Department of Pediatric Neurology, University Children's Hospital Tübingen, Tübingen, Germany
| | - Charlotte Schubert
- Department of Neurology and Hertie Institute for Clinical Brain Research (HIH), University of Tübingen, Tübingen, Germany
| | - Alexander Grimm
- Department of Neurology and Hertie Institute for Clinical Brain Research (HIH), University of Tübingen, Tübingen, Germany
| | - Jan-Hendrik Stahl
- Department of Neurology and Hertie Institute for Clinical Brain Research (HIH), University of Tübingen, Tübingen, Germany.,Center of Neurology and Hertie Institute for Clinical Brain Research (HIH), University of Tübingen, Tübingen, Germany
| | - Hanna Küpper
- Department of Pediatric Neurology, University Children's Hospital Tübingen, Tübingen, Germany
| | - Veronka Horber
- Department of Pediatric Neurology, University Children's Hospital Tübingen, Tübingen, Germany
| | - Josua Kegele
- Department of Neurology and Hertie Institute for Clinical Brain Research (HIH), University of Tübingen, Tübingen, Germany.,Center of Neurology and Hertie Institute for Clinical Brain Research (HIH), University of Tübingen, Tübingen, Germany.,University Hospital Tübingen, Neurology, Tübingen, Germany
| | - Sophia Willikens
- Department of Neurology and Hertie Institute for Clinical Brain Research (HIH), University of Tübingen, Tübingen, Germany.,University Hospital Tübingen, Neurology, Tübingen, Germany
| | | | - Lina Serna-Higuita
- Department of Clinical Epidemiology and Applied Biostatistics, Tübingen University, Tübingen, Germany
| | - Natalie Winter
- Department of Neurology and Hertie Institute for Clinical Brain Research (HIH), University of Tübingen, Tübingen, Germany.,Center of Neurology and Hertie Institute for Clinical Brain Research (HIH), University of Tübingen, Tübingen, Germany
| | - Samuel Groeschel
- Department of Pediatric Neurology, University Children's Hospital Tübingen, Tübingen, Germany
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de Leeuw C, Wijntjes J, Lassche S, van Alfen N. Nerve ultrasound for distinguishing inflammatory neuropathy from amyotrophic lateral sclerosis: Not black and white. Muscle Nerve 2020; 61:E33-E37. [PMID: 32129899 DOI: 10.1002/mus.26853] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 02/28/2020] [Accepted: 03/01/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Carola de Leeuw
- Department of Neurology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Juerd Wijntjes
- Department of Neurology and Clinical Neurophysiology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Saskia Lassche
- Department of Neurology and Clinical Neurophysiology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nens van Alfen
- Department of Neurology and Clinical Neurophysiology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
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36
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Issar T, Yan A, Kwai NCG, Poynten AM, Borire AA, Arnold R, Krishnan AV. Altered peripheral nerve structure and function in latent autoimmune diabetes in adults. Diabetes Metab Res Rev 2020; 36:e3260. [PMID: 31833206 DOI: 10.1002/dmrr.3260] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 11/14/2019] [Accepted: 11/27/2019] [Indexed: 11/07/2022]
Abstract
AIM The present study was undertaken to investigate mechanisms of peripheral nerve dysfunction in latent autoimmune diabetes in adults (LADA). MATERIALS AND METHODS Participants with LADA (n = 15) underwent median nerve ultrasonography and nerve excitability to examine axonal structure and function, in comparison to cohorts of type 1 diabetes (n = 15), type 2 diabetes (n = 23) and healthy controls (n = 26). The LADA group was matched for diabetes duration, glycaemic control, and neuropathy severity with the type 1 and type 2 diabetes groups. A validated mathematical model of the human axon was utilized to investigate the pathophysiological basis of nerve dysfunction. RESULTS The most severe changes in nerve structure and function were noted in the LADA group. The LADA cohort demonstrated a significant increase in nerve cross-sectional area compared to type 1 participants and controls. Compared to type 1 and 2 diabetes, measures of threshold electrotonus, which assesses nodal and internodal conductances, were significantly worse in LADA in response to both depolarising currents and hyperpolarising currents. In the recovery cycle, participants with LADA had a significant increase in the relative refractory period. Mathematical modelling of excitability recordings indicated the basis of nerve dysfunction in LADA was different to type 1 and 2 diabetes. CONCLUSIONS Participants with LADA exhibited more severe changes in nerve function and different underlying pathophysiological mechanisms compared to participants with type 1 or 2 diabetes. Intensive management of risk factors to delay the progression of neuropathy in LADA may be required.
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Affiliation(s)
- Tushar Issar
- Prince of Wales Clinical School, UNSW Sydney, Sydney, New South Wales, Australia
| | - Aimy Yan
- Prince of Wales Clinical School, UNSW Sydney, Sydney, New South Wales, Australia
| | - Natalie C G Kwai
- Prince of Wales Clinical School, UNSW Sydney, Sydney, New South Wales, Australia
- Department of Exercise Physiology, UNSW Sydney, Sydney, New South Wales, Australia
| | - Ann M Poynten
- Department of Endocrinology, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Adeniyi A Borire
- Prince of Wales Clinical School, UNSW Sydney, Sydney, New South Wales, Australia
| | - Ria Arnold
- Department of Exercise Physiology, UNSW Sydney, Sydney, New South Wales, Australia
| | - Arun V Krishnan
- Prince of Wales Clinical School, UNSW Sydney, Sydney, New South Wales, Australia
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Goedee HS, Herraets IJT, Visser LH, Franssen H, van Asseldonk JTH, van der Pol WL, van den Berg LH. Nerve ultrasound can identify treatment-responsive chronic neuropathies without electrodiagnostic features of demyelination. Muscle Nerve 2019; 60:415-419. [PMID: 31294858 PMCID: PMC6771613 DOI: 10.1002/mus.26629] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 07/01/2019] [Accepted: 07/05/2019] [Indexed: 02/06/2023]
Abstract
Introduction We present a case series of six treatment‐naive patients with clinical phenotypes compatible with chronic inflammatory demyelinating polyneuropathy and multifocal motor neuropathy without electrodiagnostic features of demyelination but with abnormal peripheral ultrasound findings who responded to treatment. Methods All six patients underwent a complete set of ancillary investigations, including extensive nerve conduction studies. We also performed standardized nerve ultrasound of median nerves and brachial plexus as part of a larger effort to evaluate diagnostic value of sonography. Results Nerve conduction studies did not show conduction block or other signs of demyelination in any of the six patients. Sonographic nerve enlargement was present in all patients and was most prominent in proximal segments of the median nerve and brachial plexus. Treatment with intravenous immunoglobulin resulted in objective clinical improvement. Discussion Our study provides evidence that nerve ultrasound represents a useful complementary diagnostic tool for the identification of treatment‐responsive inflammatory neuropathies.
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Affiliation(s)
- H Stephan Goedee
- Brain Centre Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ingrid J T Herraets
- Brain Centre Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Neurology and Clinical Neurophysiology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Leo H Visser
- Department of Neurology and Clinical Neurophysiology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Hessel Franssen
- Brain Centre Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jan-Thies H van Asseldonk
- Department of Neurology and Clinical Neurophysiology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - W Ludo van der Pol
- Brain Centre Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Leonard H van den Berg
- Brain Centre Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Goedee HS, Notermans NC, Visser LH, van Asseldonk JTH, Franssen H, Vrancken AFJE, Nikolakopoulos S, van den Berg LH, van der Pol WL. Neuropathy associated with immunoglobulin M monoclonal gammopathy: A combined sonographic and nerve conduction study. Muscle Nerve 2019; 60:263-270. [PMID: 31269243 PMCID: PMC6771847 DOI: 10.1002/mus.26626] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 06/27/2019] [Accepted: 06/29/2019] [Indexed: 12/13/2022]
Abstract
Introduction We assessed the specific sonographic pattern of structural nerve abnormalities in immunoglobulin M (IgM) neuropathy and disease controls. Methods We enrolled 106 incident patients—32 patients with IgM neuropathy, 42 treatment‐naive patients with chronic inflammatory demyelinating polyneuropathy, and 32 patients with axonal neuropathies. All patients underwent standardized ancillary testing in addition to standardized sonography of the brachial plexus and the large arm and leg nerves bilaterally. Results We found widespread nerve enlargement in IgM neuropathy and chronic inflammatory demyelinating polyneuropathy (CIDP), with specific enlargement of brachial plexus and proximal segments of median nerve but not in axonal disease controls (P < .001). Sonographic nerve hypertrophy in IgM neuropathy was not associated with nerve conduction, clinical, or laboratory characteristics. Discussion Immunoglobulin M neuropathy is characterized by widespread nerve enlargement indistinguishable from CIDP. Our data provide evidence to confirm that the disease process is not confined to the more distal parts of nerves in either classical demyelinating or axonal variants of neuropathy with associated IgM.
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Affiliation(s)
- H Stephan Goedee
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Nicolette C Notermans
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Leo H Visser
- Department of Neurology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | | | - Hessel Franssen
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Alexander F J E Vrancken
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Stavros Nikolakopoulos
- Department of Biostatistics, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Leonard H van den Berg
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - W Ludo van der Pol
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Pelosi L, Iodice R, Antenora A, Kilfoyle D, Mulroy E, Rodrigues M, Roxburgh R, Iovino A, Filla A, Manganelli F, Santoro L. Spinocerebellar ataxia type 2-neuronopathy or neuropathy? Muscle Nerve 2019; 60:271-278. [PMID: 31228263 DOI: 10.1002/mus.26613] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 06/13/2019] [Accepted: 06/16/2019] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Use of peripheral nerve ultrasound alongside standard electrodiagnostic tests may help to gain insight into the pathophysiology of peripheral nerve involvement in type 2 spinocerebellar ataxia (SCA2). METHODS Twenty-seven patients with SCA2 underwent ultrasound cross-sectional area (CSA) measurement of median, ulnar, sural and tibial nerves, and motor (median, ulnar, tibial) and sensory (median, ulnar, radial, sural) nerve conduction studies. RESULTS Twenty patients had pathologically small-nerve CSAs, suggestive of sensory neuronopathy. In these patients, electrophysiology showed non-length-dependent sensory neuropathy (14 of 20), "possible sensory neuropathy" (1 of 20), or normal findings (5 of 20). Four different patients had length-dependent sensory neuropathy on electrophysiology, and 1 had enlarged nerve CSAs. Regression analysis showed an inverse relationship between ataxia scores and upper limb nerve CSA (P < 0.03). DISCUSSION Our findings suggest that a majority of patients with SCA2 (74%) have a sensory neuronopathy and this correlates with disability. A minority of patients have findings consistent with axonal neuropathy (18%). Muscle Nerve, 2019.
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Affiliation(s)
- Luciana Pelosi
- Department of Neurology and Clinical Neurophysiology, Bay of Plenty District Health Board, Tauranga Hospital, Tauranga, New Zealand
| | - Rosa Iodice
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University Federico II, Naples, Italy
| | - Antonella Antenora
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University Federico II, Naples, Italy
| | - Dean Kilfoyle
- Department of Neurology, Auckland District Health Board, Auckland, New Zealand
| | - Eoin Mulroy
- Department of Neurology, Auckland District Health Board, Auckland, New Zealand
| | - Miriam Rodrigues
- Department of Neurology, Auckland District Health Board, Auckland, New Zealand
| | - Richard Roxburgh
- Department of Neurology, Auckland District Health Board, Auckland, New Zealand.,Centre of Brain Research Neurogenetics Research Clinic, University of Auckland, Auckland, New Zealand
| | - Aniello Iovino
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University Federico II, Naples, Italy
| | - Alessandro Filla
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University Federico II, Naples, Italy
| | - Fiore Manganelli
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University Federico II, Naples, Italy
| | - Lucio Santoro
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University Federico II, Naples, Italy
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40
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Knoll A, Pal'a A, Pedro MT, Bäzner U, Schneider M, König RW, Wirtz CR, Friedrich S, Pauly M, Antoniadis G. Clinical outcome after decompression of intraneural peroneal ganglion cyst and its morphologic correlation to postoperative nerve ultrasound. J Neurosurg 2019; 133:1-7. [PMID: 31252391 DOI: 10.3171/2019.3.jns182699] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 03/12/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Intraneural ganglion cysts are rare and benign mucinous lesions that affect peripheral nerves, most frequently the common peroneal nerve (CPN). The precise pathophysiological mechanisms of intraneural ganglion cyst development remain unclear. A well-established theory suggests the spread of mucinous fluid along the articular branch of the peroneal nerve as the underlying mechanism. Clinical outcome following decompression of intraneural ganglion cysts has been demonstrated to be excellent. The aim of this study was to evaluate the correlation between clinical outcome and ultrasound-detected morphological nerve features following decompression of intraneural ganglion cysts of the CPN. METHODS Data were retrospectively analyzed from 20 patients who underwent common peroneal nerve ganglion cyst decompression surgery at the Universität Ulm/Günzburg Neurosurgery Department between October 2003 and October 2017. Postoperative clinical outcome was evaluated by assessment of the muscular strength of the anterior tibial muscle, the extensor hallucis longus muscle, and the peroneus muscle according to the Medical Research Council grading system. Hypesthesia was measured by sensation testing. In all patients, postoperative morphological assessment of the peroneal nerve was conducted between October 2016 and October 2017 using the iU22 Philips Medical ultrasound system at the last routine follow-up appointment. Finally, the correlations between morphological changes in nerve ultrasound and postoperative clinical outcomes were evaluated. RESULTS During the postoperative ultrasound scan an intraneural hypoechogenic ring structure located at the medial side of the peroneal nerve was detected in 15 (75%) of 20 patients, 14 of whom demonstrated an improvement in motor function. A regular intraneural fasicular structure was identified in 3 patients (15%), who also reported recovery. In 1 patient, a recurrent cyst was detected, and 1 patient showed intraneural fibrosis for which recovery did not occur in the year following the procedure. Two patients (10%) developed neuropathic pain that could not be explained by nerve ultrasound findings. CONCLUSIONS The results of this study demonstrate significant recovery from preoperative weakness after decompression of intraneural ganglion cysts of the CPN. A favorable clinical outcome was highly correlated with an intraneural hypoechogenic ring-shaped structure on the medial side of the CPN identified during a follow-up postoperative ultrasound scan. These study results indicate the potential benefit of ultrasound scanning as a prognostic tool following decompression procedures for intraneural ganglion cysts of the CPN.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Gregor Antoniadis
- 3Department of Neurosurgery-Section of Peripheral Nerve Surgery, University of Ulm, Günzburg, Germany
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Pitarokoili K, Sturm D, Labedi A, Greiner T, Eitner L, Kumowski N, Enax-Krumova EK, Fisse AL, Maier C, Gold R, Tegenthoff M, Schmidt-Wilcke T, Yoon MS. Neuroimaging markers of clinical progression in chronic inflammatory demyelinating polyradiculoneuropathy. Ther Adv Neurol Disord 2019; 12:1756286419855485. [PMID: 31244899 PMCID: PMC6582292 DOI: 10.1177/1756286419855485] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 05/16/2019] [Indexed: 12/13/2022] Open
Abstract
Background: One of the main goals of novel, noninvasive imaging techniques like high-resolution nerve ultrasound (HRUS) and corneal confocal microscopy (CCM) is the prediction of treatment response for patients with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). Methods: A total of 17 patients with CIDP were examined prospectively at baseline and every 9 months over a period of 18 months using CCM to quantify corneal nerve degeneration markers and immune cell infiltration as well as HRUS to detect changes of the cross-sectional area (CSA) of the peripheral nerves. Additionally, skin biopsy of the distal and proximal leg as well as quantitative sensory testing were performed at the first follow-up visit. Results: A value of more than 30 total corneal cells/mm2 in CCM at baseline identified patients with clinical progression with a sensitivity/specificity of 100% in our cohort. Corneal nerve fiber density and length remained low and stable over the study period and intra-epidermal fiber density was markedly reduced in the majority of the patients. Furthermore, an increase in Bochum ultrasound score (BUS), which summarizes the CSA of the ulnar nerve in Guyons’ canal, the ulnar nerve in the upper arm, the radial nerve in the spiral groove and the sural nerve between the gastrocnemius muscle, and a maximum BUS of 4 at study initiation identified patients with disease progression (sensitivity 80%, specificity 88%). Conclusions: BUS and corneal total cell infiltration seem to represent early markers for clinical progression in CIDP, thus having the potential to identify at-risk patients and impact treatment decisions.
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Affiliation(s)
- Kalliopi Pitarokoili
- Department of Neurology, Ruhr University, St. Josef Hospital, Gudrunstr. 56, 44791 Bochum, Germany
| | - Dietrich Sturm
- Department of Neurology, Bergmannsheil University Hospital, Ruhr University Bochum, Germany
| | - Adnan Labedi
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Germany
| | - Tineke Greiner
- Department of Neurology, Bergmannsheil University Hospital, Ruhr University Bochum, Germany
| | - Lynn Eitner
- Department for Pain Medicine, Bergmannsheil University Hospital, Ruhr University Bochum, Germany
| | - Nina Kumowski
- Department for Pain Medicine, Bergmannsheil University Hospital, Ruhr University Bochum, Germany
| | - Elena K Enax-Krumova
- Department of Neurology, Bergmannsheil University Hospital, Ruhr University Bochum, Germany
| | - Anna Lena Fisse
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Germany
| | - Christoph Maier
- Department for Pain Medicine, Bergmannsheil University Hospital, Ruhr University Bochum, Germany
| | - Ralf Gold
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Germany
| | - Martin Tegenthoff
- Department of Neurology, Bergmannsheil University Hospital, Ruhr University Bochum, Germany
| | - Tobias Schmidt-Wilcke
- St Mauritius Therapie Clinic, Ruhr University Bochum, Meerbusch and Department of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich Heine University Düsseldorf, Germany
| | - Min-Suk Yoon
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Germany
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42
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Fisse AL, Pitarokoili K, Trampe N, Motte J, Kerasnoudis A, Gold R, Yoon MS. Clinical, Sonographic, and Electrophysiologic Longitudinal Features of Chronic Inflammatory Demyelinating Polyneuropathy. J Neuroimaging 2018; 29:223-232. [PMID: 30407676 DOI: 10.1111/jon.12579] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Revised: 10/30/2018] [Accepted: 10/30/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND PURPOSE Several studies have aimed to find potential biomarkers to simplify the diagnosis of chronic inflammatory demyelinating polyneuropathy (CIDP) and to monitor and predict the disease course. However, reliable markers are still lacking. We aimed to investigate whether high-resolution nerve ultrasound (HRUS) is suitable for monitoring the long-term clinical course of CIDP. METHODS Twenty patients fulfilling the definite diagnostic criteria of CIDP received clinical examination, evaluation of the INCAT (inflammatory neuropathy cause and treatment) overall disability sum score (ODSS) as well as nerve conduction studies, and HRUS every 6 months over a median follow-up time of 34 months. Patients were divided into clinically stable/regressive disease course or progressive disease course according to the development of the ODSS. RESULTS The intranerve cross-sectional-area (CSA) variability of the nerves of the lower extremity increased with disease progression, whereas it remained unchanged in patients with a stable or remitting disease course. CONCLUSION Nerve ultrasound can be used as a method to objectify the long-term disease course in CIDP patients. The intranerve CSA variability is suitable for monitoring the clinical course of patients with CIDP.
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Affiliation(s)
- Anna Lena Fisse
- Department of Neurology, Ruhr University Bochum, Bochum, Germany
| | | | - Nadine Trampe
- Department of Neurology, Ruhr University Bochum, Bochum, Germany
| | - Jeremias Motte
- Department of Neurology, Ruhr University Bochum, Bochum, Germany
| | | | - Ralf Gold
- Department of Neurology, Ruhr University Bochum, Bochum, Germany
| | - Min-Suk Yoon
- Department of Neurology, Ruhr University Bochum, Bochum, Germany
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43
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Pitarokoili K, Höffken N, Lönneker N, Fisse AL, Trampe N, Gold R, Reinacher-Schick A, Yoon MS. Prospective Study of the Clinical, Electrophysiologic, and Sonographic Characteristics of Oxaliplatin-Induced Neuropathy. J Neuroimaging 2018; 29:133-139. [PMID: 30198601 DOI: 10.1111/jon.12557] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 08/22/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND AND PURPOSE Oxaliplatin-induced neuropathy is a major dose limiting side effect of the highly effective combination chemotherapy with oxaliplatin, irinotecan, and 5-fluorouracil (FOLFIRINOX) in patients with metastastic pancreatic cancer. We present the first longitudinal sonographical-electrophysiological study on oxaliplatin-induced neuropathy. METHODS Thirteen patients with metastatic pancreatic cancer underwent clinical, sonographic, and electrophysiological evaluation before, 3 and 7 months after treatment with 12 two-week cycles of FOLFIRINOX. RESULTS The majority of patients (61%) developed symptoms and electrophysiological signs of a length-dependent sensorimotor axonal neuropathy 7 months after treatment initiation. Oxaliplatin-induced neuropathy presented with a cross-sectional area (CSA) increase of mostly the tibial and fibular nerve, which developed parallel or prior to clinical signs and electrophysiological changes. Furthermore, isolated CSA at entrapment sites of the upper and lower extremities was measured without relevant symptoms. No correlation between sonographic and electrophysiological findings or clinical severity was detected. CONCLUSIONS Oxaliplatin-induced neuropathy is characterized by an axonal length-dependent nerve affection presenting with a combination of sonographical and electrophysiological alterations.
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Affiliation(s)
| | - Nadine Höffken
- Department of Hematology, Oncology and Palliative Care, St. Josef Hospital, Ruhr-University Bochum, Germany
| | - Niko Lönneker
- Department of Neurology, St. Josef Hospital, Ruhr-University Bochum, Germany
| | - Anna Lena Fisse
- Department of Neurology, St. Josef Hospital, Ruhr-University Bochum, Germany
| | - Nadine Trampe
- Department of Neurology, St. Josef Hospital, Ruhr-University Bochum, Germany
| | - Ralf Gold
- Department of Neurology, St. Josef Hospital, Ruhr-University Bochum, Germany
| | - Anke Reinacher-Schick
- Department of Hematology, Oncology and Palliative Care, St. Josef Hospital, Ruhr-University Bochum, Germany
| | - Min-Suk Yoon
- Department of Neurology, St. Josef Hospital, Ruhr-University Bochum, Germany
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Pelosi L, Mulroy E, Leadbetter R, Kilfoyle D, Chancellor AM, Mossman S, Wing L, Wu TY, Roxburgh RH. Peripheral nerves are pathologically small in cerebellar ataxia neuropathy vestibular areflexia syndrome: a controlled ultrasound study. Eur J Neurol 2018; 25:659-665. [PMID: 29316033 DOI: 10.1111/ene.13563] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 12/27/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND PURPOSE Sensory neuronopathy is a cardinal feature of cerebellar ataxia neuropathy vestibular areflexia syndrome (CANVAS). Having observed that two patients with CANVAS had small median and ulnar nerves on ultrasound, we set out to examine this finding systematically in a cohort of patients with CANVAS, and compare them with both healthy controls and a cohort of patients with axonal neuropathy. We have previously reported preliminary findings in seven of these patients with CANVAS and seven healthy controls. METHODS We compared the ultrasound cross-sectional area of median, ulnar, sural and tibial nerves of 14 patients with CANVAS with 14 healthy controls and 14 age- and gender-matched patients with acquired primarily axonal neuropathy. We also compared the individual nerve cross-sectional areas of patients with CANVAS and neuropathy with the reference values of our laboratory control population. RESULTS The nerve cross-sectional area of patients with CANVAS was smaller than that of both the healthy controls and the neuropathy controls, with highly significant differences at most sites (P < 0.001). Conversely, the nerve cross-sectional areas in the upper limb were larger in neuropathy controls than healthy controls (P < 0.05). On individual analysis, the ultrasound abnormality was sufficiently characteristic to be detected in all but one patient with CANVAS. DISCUSSION Small nerves in CANVAS probably reflect nerve thinning from loss of axons due to ganglion cell loss. This is distinct from the ultrasound findings in axonal neuropathy, in which nerve size was either normal or enlarged. Our findings indicate a diagnostic role for ultrasound in CANVAS sensory neuronopathy and in differentiating neuronopathy from neuropathy.
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Affiliation(s)
- L Pelosi
- Department of Neurology and Clinical Neurophysiology, Bay of Plenty District Health Board, Tauranga
| | - E Mulroy
- Auckland District Health Board, Auckland
| | - R Leadbetter
- Capital and Coast District Health Board, Wellington
| | - D Kilfoyle
- Auckland District Health Board, Auckland
| | - A M Chancellor
- Department of Neurology and Clinical Neurophysiology, Bay of Plenty District Health Board, Tauranga
| | - S Mossman
- Capital and Coast District Health Board, Wellington
| | - L Wing
- Department of Endocrinology, Bay of Plenty District Health Board, Tauranga
| | - T Y Wu
- Christchurch Hospital, Christchurch
| | - R H Roxburgh
- Auckland District Health Board, Auckland.,Department of Medicine, University of Auckland, Auckland, New Zealand
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Mulroy E, Pelosi L, Leadbetter R, Joshi P, Rodrigues M, Mossman S, Kilfoyle D, Roxburgh R. Peripheral nerve ultrasound in Friedreich ataxia. Muscle Nerve 2017; 57:852-856. [PMID: 29130498 DOI: 10.1002/mus.26012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2017] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Sensory impairment in Friedreich ataxia (FRDA) is generally accepted as being due to a ganglionopathy. The degree of contribution from axonal pathology remains a matter of debate. Nerve ultrasound may be able to differentiate these processes. METHODS The ultrasound cross-sectional area of median, ulnar, tibial, and sural nerves of 8 patients with FRDA was compared with 8 age- and gender-matched healthy controls and with reference values in our population. RESULTS The nerves of the patients with FRDA were significantly larger than those of healthy controls at all upper limb sites (P < 0.05) but not significantly different in the lower limbs. DISCUSSION Our findings add additional weight to the theory that dorsal root ganglionopathy is not the sole cause of peripheral sensory loss in FRDA. Peripheral neuropathic processes are also likely to play a role. Muscle Nerve 57: 852-856, 2018.
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Affiliation(s)
- Eoin Mulroy
- Department of Neurology, Auckland District Health Board, Auckland, New Zealand
- Department of Clinical Neurophysiology, Auckland District Health Board, Auckland, New Zealand
| | - Luciana Pelosi
- Bay of Plenty District Health Board, Tauranga, New Zealand
| | - Ruth Leadbetter
- Capital and Coast District Health Board, Wellington, New Zealand
| | - Purwa Joshi
- Capital and Coast District Health Board, Wellington, New Zealand
| | - Miriam Rodrigues
- Department of Neurology, Auckland District Health Board, Auckland, New Zealand
- Department of Clinical Neurophysiology, Auckland District Health Board, Auckland, New Zealand
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Stuart Mossman
- Bay of Plenty District Health Board, Tauranga, New Zealand
| | - Dean Kilfoyle
- Department of Neurology, Auckland District Health Board, Auckland, New Zealand
- Department of Clinical Neurophysiology, Auckland District Health Board, Auckland, New Zealand
| | - Richard Roxburgh
- Department of Neurology, Auckland District Health Board, Auckland, New Zealand
- Department of Clinical Neurophysiology, Auckland District Health Board, Auckland, New Zealand
- Department of Medicine, University of Auckland, Auckland, New Zealand
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Borire AA, Arnold R, Pussell BA, Kwai NC, Visser LH, Simon NG, Kiernan MC, Krishnan AV. Effects of hemodialysis on intraneural blood flow in end-stage kidney disease. Muscle Nerve 2017; 57:287-293. [PMID: 28556350 DOI: 10.1002/mus.25704] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 05/17/2017] [Accepted: 05/23/2017] [Indexed: 12/12/2022]
Abstract
INTRODUCTION We quantified intraneural blood flow (INBF) in 18 patients with end-stage kidney disease (ESKD) and examined its relationship with nerve size, neuropathy severity, and nerve excitability parameters. METHODS Sonographic measurements of the median nerve were performed at the same site before and after hemodialysis. INBF was quantified by analyzing power Doppler sonograms to obtain the vessel score (VSc) and maximum perfusion intensity (MPI). Corresponding median motor nerve excitability studies were performed. Neuropathy severity was assessed using Total Neuropathy Score. RESULTS A total of 39% of ESKD patients had detectable INBF compared with none in the control group (P < 0.0001). Patients with detectable INBF had larger nerves and more severe neuropathy (P < 0.01). INBF parameters were significantly reduced after a session of dialysis (VSc: P < 0.01; MPI: P < 0.01). A significant relationship was found between interdialytic change in INBF and changes in nerve excitability. CONCLUSIONS Increased INBF is a potential marker for neuropathy severity in ESKD patients. Muscle Nerve 57: 287-293, 2018.
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Affiliation(s)
- Adeniyi A Borire
- Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Ria Arnold
- School of Medical Sciences, University of New South Wales, Sydney, Australia
| | - Bruce A Pussell
- Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Natalie C Kwai
- Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Leo H Visser
- Elisabeth-Tweesteden Hospital, Department of Neurology, Tilburg, the Netherlands
| | - Neil G Simon
- St Vincent's Clinical School, University of New South Wales, Sydney, Australia.,Brain and Mind Centre, University of Sydney, Sydney, Australia
| | | | - Arun V Krishnan
- Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
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Pelz JO, Busch M, Weinreich A, Saur D, Weise D. Evaluation Of freehand high-resolution 3-dimensional ultrasound of the median nerve. Muscle Nerve 2016; 55:206-212. [PMID: 27387275 DOI: 10.1002/mus.25241] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 06/19/2016] [Accepted: 07/05/2016] [Indexed: 12/29/2022]
Abstract
INTRODUCTION In this study we evaluated freehand 3D ultrasound (3DUS) of the median nerve in comparison to 2D ultrasound (2DUS) and assessed the influence of tilting the transversal plane on cross-sectional area (CSA) measurement. METHODS Two examiners investigated the median nerves of 22 healthy subjects over a distance of 20 cm using 3DUS. Image quality and CSA were assessed at random points within the virtual 3D volume and compared with 2DUS. RESULTS Image quality within the virtual 3D volume was good/sufficient/poor in 53.0%/40.2%/6.8% (examiner 1) and 21.6%/69.6%/8.8% (examiner 2), respectively. CSA measurements with 3DUS were smaller than with 2DUS (-12% and -17%; Wilcoxon test, P < 0.001). Interrater agreement for 3DUS and intermethod agreement between 2DUS and 3DUS were moderate. Stepwise tilting of the transversal plane increased CSA significantly. CONCLUSION Freehand 3DUS of the median nerve over 20 cm is feasible and may help overcome some of the limitations and pitfalls of 2DUS. Muscle Nerve 55: 206-212, 2017.
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Affiliation(s)
- Johann Otto Pelz
- Department of Neurology, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Maria Busch
- Department of Neurology, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Anna Weinreich
- Department of Neurology, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Dorothee Saur
- Department of Neurology, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - David Weise
- Department of Neurology, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
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Samarawickrama D, Therimadasamy AK, Chan YC, Vijayan J, Wilder-Smith EP. Nerve ultrasound in electrophysiologically verified tarsal tunnel syndrome. Muscle Nerve 2016; 53:906-12. [PMID: 26562220 DOI: 10.1002/mus.24963] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 11/04/2015] [Accepted: 11/06/2015] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Tarsal tunnel syndrome (TTS) arises from tibial nerve damage under the flexor retinaculum of the fibro-osseus tunnel at the medial malleolus. It is notoriously difficult to diagnose, as many other foot pathologies result in a similar clinical picture. We examined the additional value of nerve ultrasound in patients with tarsal tunnel syndrome confirmed by nerve conduction. METHODS We performed a retrospective analysis of nerve ultrasound changes in electrophysiologically confirmed TTS spanning our records from 2007 to 2015. RESULTS Nine feet with TTS were identified, all of which showed abnormal nerve ultrasound findings, which in 6 feet, led to identification of the underlying cause. CONCLUSIONS This study shows that nerve ultrasound is abnormal in all cases of electrophysiologically verified TTS. The pattern of nerve abnormality is varied. This, and the fact that in the majority of patients causation was identified, suggests nerve ultrasound should form part of standard work-up for TTS. Muscle Nerve 53: 906-912, 2016.
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Affiliation(s)
| | | | - Yee Cheun Chan
- Neurology, National University Health Systems, Singapore
| | - Joy Vijayan
- Neurology, National University Health Systems, Singapore
| | - Einar P Wilder-Smith
- Neurology, Yong Loo Lin School of Medicine, National University of Singapore, 1 Kent Ridge Crescent, 119228, Singapore
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Pitarokoili K, Kerasnoudis A, Behrendt V, Labedi A, Ayzenberg I, Gold R, Yoon MS. Facing the diagnostic challenge: Nerve ultrasound in diabetic patients with neuropathic symptoms. Muscle Nerve 2016; 54:18-24. [DOI: 10.1002/mus.24981] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Revised: 11/10/2015] [Accepted: 11/16/2015] [Indexed: 12/12/2022]
Affiliation(s)
- Kalliopi Pitarokoili
- Department of Neurology; Ruhr University, St. Josef-Hospital; Gudrunstr. 56 44791 Bochum Germany
| | - Antonios Kerasnoudis
- Department of Neurology; Ruhr University, St. Josef-Hospital; Gudrunstr. 56 44791 Bochum Germany
| | - Volker Behrendt
- Department of Neurology; Ruhr University, St. Josef-Hospital; Gudrunstr. 56 44791 Bochum Germany
| | - Adnan Labedi
- Department of Neurology; Ruhr University, St. Josef-Hospital; Gudrunstr. 56 44791 Bochum Germany
| | - Ilya Ayzenberg
- Department of Neurology; Ruhr University, St. Josef-Hospital; Gudrunstr. 56 44791 Bochum Germany
| | - Ralf Gold
- Department of Neurology; Ruhr University, St. Josef-Hospital; Gudrunstr. 56 44791 Bochum Germany
| | - Min-Suk Yoon
- Department of Neurology; Ruhr University, St. Josef-Hospital; Gudrunstr. 56 44791 Bochum Germany
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Abstract
INTRODUCTION The aim of this case study is to describe the use of nerve ultrasound to visualize the morphological changes that occur during conduction velocity alterations after strenuous exercise. METHODS A 32-year-old, healthy runner underwent clinical, electrophysiological, and ultrasound evaluation 24 hours before, 30 minutes after, and 24 hours after a marathon. RESULTS An increase in motor conduction velocity of the median, ulnar, radial, and tibial nerves and sensory conduction velocity of the median and ulnar nerves was found between pre- and post-marathon studies. An increase in the cross-sectional area of the median (carpal tunnel), ulnar (Guyon canal and elbow), fibular (fibular head), and tibial (ankle) nerves was documented. No changes in the MRC sum scale score of the various peripheral nerves were detected. CONCLUSION The case described shows the morphological changes that occur in healthy peripheral nerves during conduction velocity alterations.
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