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Nasr-Eldin YK, Cartwright MS, Hamed A, Ali LH, Abdel-Nasser AM. Neuromuscular Ultrasound in Polyneuropathies. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024; 43:1181-1198. [PMID: 38504399 DOI: 10.1002/jum.16447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 02/20/2024] [Accepted: 02/25/2024] [Indexed: 03/21/2024]
Abstract
Neuromuscular ultrasound is a painless, radiation-free, high-resolution imaging technique for assessing the peripheral nervous system. It can accurately depict changes in the nerves and muscles of individuals with neuromuscular conditions, and it is therefore a robust diagnostic tool for the assessment of individuals with polyneuropathies. This review will outline the typical ultrasonographic changes found in a wide variety of polyneuropathies. In general, demyelinating conditions result in greater nerve enlargement than axonal conditions, and acquired conditions result in more patchy nerve enlargement compared to diffuse nerve enlargement in hereditary conditions. This review is data-driven, but more nuanced anecdotal findings are also described. The overall goal of this paper is to provide clinicians with an accessible review of the ultrasonographic approaches and findings in a wide variety of polyneuropathies.
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Affiliation(s)
| | - Michael S Cartwright
- Neurology Department, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Ahmed Hamed
- Rheumatology and Rehabilitation Department, Minia University, Minia, Egypt
| | - Lamia Hamdy Ali
- Clinical Pathology Department, Minia University, Minia, Egypt
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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] [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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Bae DW, An JY. Cross-sectional area reference values for high-resolution ultrasonography of the lower extremity nerves in healthy Korean adults. Medicine (Baltimore) 2022; 101:e29842. [PMID: 35777005 PMCID: PMC9239665 DOI: 10.1097/md.0000000000029842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
The cross-sectional area (CSA) reference values of the lower extremity nerves in Asians have been rarely reported. For this study, 107 sex- and age-matched, healthy subjects with a mean age of 46 years (range, 24-75 years) were recruited. All subjects underwent standardized nerve conduction studies of the upper and lower extremities. The CSA was measured unilaterally at 12 sites in the lower extremity nerves, including the femoral, lateral femoral cutaneous, sciatic, common peroneal, superficial peroneal, deep peroneal, tibial, and sural nerves. The CSA significantly correlated with height, weight, and body mass index. The CSA was significantly larger in males than females at most nerves except for the lateral femoral cutaneous, common peroneal (fibular head), and superficial peroneal nerves (distal calf). There was no statistically significant difference between the age groups except for the tibial nerve (ankle). The results of this study provide CSA reference values for the lower extremity nerves including small branches and the values can be useful in the ultrasonographic investigation of various peripheral neuropathies in East Asian populations.
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Affiliation(s)
- Dae Woong Bae
- Department of Neurology, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jae Young An
- Department of Neurology, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- *Correspondence: Jae Young An, Department of Neurology, St. Vincent’s Hospital, The Catholic University of Korea, 93-6, Ji-dong, Paldal-gu, Suwon, Gyeonggi-do 442-723, Korea (e-mail: )
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Ma X, Du L, Yuan W, Han T. Application and Research Progress of High Frequency Ultrasound in the Diagnosis of Chronic Inflammatory Neuropathies. Front Neurol 2022; 13:860144. [PMID: 35812115 PMCID: PMC9263972 DOI: 10.3389/fneur.2022.860144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 04/25/2022] [Indexed: 11/24/2022] Open
Abstract
In recent years, clinicians have gradually improved their understanding of multiple neuropathy and have done some studies about chronic inflammatory neuropathies, for example, chronic inflammatory demyelinating polyneuropathy, multifocal motor neuropathy, and Lewis-Sumne syndrome. The early diagnosis is very important for the next step treatment and long-term prognosis. At present, the disease mainly depends on clinical and neural electrophysiological examination, but imaging studies are few. In recent years, with the rapid development of high frequency ultrasound, it could clearly show the morphology of the nerve, and it has been an emerging diagnosis tool of polyneuropathies. This article mainly reviews the application and the latest research progress of high frequency ultrasound in these diseases.
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Affiliation(s)
- Xishun Ma
- Department of Ultrasound, Qingdao Municipal Hospital, Qingdao, China
| | - Lizhen Du
- Department of Ultrasound, Qingdao Municipal Hospital, Qingdao, China
| | - Wenqing Yuan
- Department of Primary Medical Management, Qingdao Municipal Hospital, Qingdao, China
- Wenqing Yuan
| | - Tongliang Han
- Department of Ultrasound, Qingdao Municipal Hospital, Qingdao, China
- *Correspondence: Tongliang Han
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Chen Z, Saini M, Neo SXM, Ng PS, Koh JS, Prasad K, Verma K, Davila S, Lim WK, Phua Z, Li MM, Kang C, Tay KSS, Chai JYH. Acute to Subacute Atraumatic Entrapment Neuropathies in Patients With CMT1A: A Report of a Distinct Phenotypic Variant of CMT1A. Front Neurol 2022; 13:826634. [PMID: 35280294 PMCID: PMC8914073 DOI: 10.3389/fneur.2022.826634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 01/31/2022] [Indexed: 11/13/2022] Open
Abstract
Charcot-Marie-Tooth type 1A (CMT1A) is typically characterised as a childhood-onset, symmetrical, length-dependent polyneuropathy with a gradual progressive clinical course. Acute to subacute neurological deterioration in CMT1A is rare, and has been reported secondary to overlap pathologies including inflammatory neuropathy. We identified two patients with CMT1A who presented with acute to subacute, atraumatic, entrapment neuropathies as an initial symptom. A superimposed inflammatory neuropathy was excluded. Both patients had a diffuse demyelinating polyneuropathy, with markedly low motor nerve conduction velocities (<20 m/s). In both patients, we demonstrated symptomatic and asymptomatic partial conduction blocks at multiple entrapment sites. Nerve ultrasound findings in our patients demonstrated marked diffuse nerve enlargement, more pronounced at non-entrapment sites compared to entrapment sites. We discuss ways to distinguish this condition from its other differentials. We propose pathophysiological mechanisms underlying this condition. We propose that CMT1A with acute to subacute, atraumatic, entrapment neuropathies to be a distinct phenotypic variant of CMT1A.
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Affiliation(s)
- Zhiyong Chen
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
- *Correspondence: Zhiyong Chen
| | - Monica Saini
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
| | - Shermyn X. M. Neo
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
| | - Peng-Soon Ng
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
| | - Jasmine S. Koh
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
| | - Kalpana Prasad
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
| | - Kamal Verma
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
| | - Sonia Davila
- Singhealth Duke-National University of Singapore (NUS) Institute of Precision Medicine, Singapore, Singapore
- Cardiovascular and Metabolic Disorders, Duke-National University of Singapore (NUS) Medical School, Singapore, Singapore
- SingHealth Duke-National University of Singapore (NUS) Genomic Medicine Centre, Singapore, Singapore
| | - Weng Khong Lim
- Singhealth Duke-National University of Singapore (NUS) Institute of Precision Medicine, Singapore, Singapore
- SingHealth Duke-National University of Singapore (NUS) Genomic Medicine Centre, Singapore, Singapore
- Cancer and Stem Cell Biology Program, Duke-National University of Singapore (NUS) Medical School, Singapore, Singapore
| | - Ziqun Phua
- Neurodiagnostic Laboratory, National Neuroscience Institute, Singapore, Singapore
| | - Michelle M. Li
- Neurodiagnostic Laboratory, National Neuroscience Institute, Singapore, Singapore
| | - Corrine Kang
- Clinical Measurement Unit, Changi General Hospital, Singapore, Singapore
| | - Karine S. S. Tay
- Neuromuscular Laboratory, National Neuroscience Institute, Singapore, Singapore
| | - Josiah Y. H. Chai
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
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Zwicker JC, Breiner A, Warman-Chardon JP, Bourque PR. Multifocal acquired demyelinating sensory and motor neuropathy presenting with a unilateral radial neuropathy. Muscle Nerve 2022; 65:E21-E23. [PMID: 35146762 DOI: 10.1002/mus.27516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 01/31/2022] [Accepted: 02/06/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Jocelyn Christine Zwicker
- The Division of Neurology The Ottawa Hospital/The University of Ottawa 1053 Carling Avenue Ottawa, Ontario, Canada
| | - Ari Breiner
- The Division of Neurology The Ottawa Hospital/The University of Ottawa 1053 Carling Avenue Ottawa, Ontario, Canada
| | - Jodi Paulla Warman-Chardon
- The Division of Neurology The Ottawa Hospital/The University of Ottawa 1053 Carling Avenue Ottawa, Ontario, Canada
| | - Pierre Raymond Bourque
- The Division of Neurology The Ottawa Hospital/The University of Ottawa 1053 Carling Avenue Ottawa, Ontario, Canada
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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] [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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Oka Y, Tsukita K, Tsuzaki K, Takamatsu N, Hamano T. Sonographic Multifocal Cranial Nerve Enlargement in Multifocal Acquired Demyelinating Sensory and Motor Neuropathy. Intern Med 2021; 60:2867-2871. [PMID: 33746164 PMCID: PMC8479218 DOI: 10.2169/internalmedicine.6782-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Multifocal enlargements with the alteration of a normal fascicular pattern are considered to be sonographic peripheral nerve features in multifocal acquired demyelinating sensory and motor neuropathy (MADSAM), a subtype of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). We herein present the case of an 18-year-old patient with MADSAM in whom intensive sonological assessments revealed multifocal nerve enlargement within clinically affected cranial nerves. Our case demonstrated that, if systematically investigated with ultrasound, morphological changes similar to those in the peripheral nerves may be detected in a large proportion of clinically affected cranial nerves in MADSAM, boosting the future applications of cranial nerve ultrasound in CIDP.
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Affiliation(s)
- Yuwa Oka
- Department of Neurology, Kansai Electric Power Hospital, Japan
- Division of Clinical Neurology, Kansai Electric Power Medical Research Institute, Japan
- Department of Neurology, Kitano Hospital, Tazuke Kofukai Medical Research Institute, Japan
| | - Kazuto Tsukita
- Department of Neurology, Kansai Electric Power Hospital, Japan
- Department of Neurology, Graduate School of Medicine, Kyoto University, Japan
- Laboratory of Barriology and Cell Biology, Graduate School of Frontier Biosciences, Osaka University, Japan
| | - Koji Tsuzaki
- Department of Neurology, Kansai Electric Power Hospital, Japan
- Division of Clinical Neurology, Kansai Electric Power Medical Research Institute, Japan
| | - Naoko Takamatsu
- Department of Neurology, Kansai Electric Power Hospital, Japan
- Department of Neurology, Tokushima University, 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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Hannaford A, Vucic S, Kiernan MC, Simon NG. Review Article "Spotlight on Ultrasonography in the Diagnosis of Peripheral Nerve Disease: The Evidence to Date". Int J Gen Med 2021; 14:4579-4604. [PMID: 34429642 PMCID: PMC8378935 DOI: 10.2147/ijgm.s295851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 07/27/2021] [Indexed: 11/23/2022] Open
Abstract
Neuromuscular ultrasound is rapidly becoming incorporated into clinical practice as a standard tool in the assessment of peripheral nerve diseases. Ultrasound complements clinical phenotyping and electrodiagnostic evaluation, providing critical structural anatomical information to enhance diagnosis and identify structural pathology. This review article examines the evidence supporting neuromuscular ultrasound in the diagnosis of compressive mononeuropathies, traumatic nerve injury, generalised peripheral neuropathy and motor neuron disease. Extending the sonographic evaluation of nerves beyond simple morphological measurements has the potential to improve diagnostics in peripheral neuropathy, as well as advancing the understanding of pathological mechanisms, which in turn will promote precise therapies and improve therapeutic outcomes.
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Affiliation(s)
- Andrew Hannaford
- Westmead Clinical School, Westmead Hospital, University of Sydney, Sydney, Australia
| | - Steve Vucic
- Westmead Clinical School, Westmead Hospital, University of Sydney, Sydney, Australia
| | - Matthew C Kiernan
- Brain and Mind Centre, University of Sydney, University of Sydney and Department of Neurology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Neil G Simon
- Northern Beaches Clinical School, Macquarie University, Sydney, Australia
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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] [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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Vizcarra JA, Harrison TB, Garcia-Santibanez R. Update on Nodopathies of the Peripheral Nerve. Curr Treat Options Neurol 2021. [DOI: 10.1007/s11940-021-00683-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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12
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Kwak S, Boudier-Revéret M, Cho HK, Chang MC. Multifocal acquired demyelinating sensory and motor neuropathy misdiagnosed as carpal tunnel syndrome: a case report. J Int Med Res 2021; 49:300060521998896. [PMID: 33706556 PMCID: PMC8165854 DOI: 10.1177/0300060521998896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Multifocal acquired demyelinating sensory and motor neuropathy (MADSAM), a
subtype of chronic inflammatory demyelinating polyneuropathy, is a
non-compressive peripheral nerve disorder. Symptoms of MADSAM include
asymmetrical weakness and sensory deficits in the distribution of individual
peripheral nerves, which are frequently noted in the distal portion of
peripheral nerves. MADSAM can be easily misdiagnosed as any of the various
compressive peripheral neuropathies. Here, we present a case of MADSAM
misdiagnosed as carpal tunnel syndrome (CTS). A 53-year-old woman had bilateral
asymmetrical hand weakness (left hand: significant weakness, right hand: slight
motor weakness) and a slight weakness of her bilateral lower extremities.
Sensory deficit was found on the volar side of her left hand. She had visited
many clinics previously and was diagnosed with CTS. However, an
electrodiagnostic study performed in our hospital did not identify CTS but
indicated a demyelinating peripheral neuropathy in all limbs. On the basis of
the patient’s clinical symptoms and laboratory findings, she was diagnosed with
MADSAM. When patients exhibit progressive aggravating motor weakness and sensory
deficits in more than one distal limb without a specific finding of compressive
neuropathy in electrodiagnostic studies, clinicians should consider the
possibility of MADSAM.
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Affiliation(s)
- Soyoung Kwak
- Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University, Daegu, Republic of Korea
| | - Mathieu Boudier-Revéret
- Department of Physical Medicine and Rehabilitation, Centre Hospitalier de l'Université de Montréal, Montreal, Canada
| | - Hee Kyung Cho
- Department of Rehabilitation Medicine, Catholic University of Daegu School of Medicine, Daegu, Republic of Korea
| | - Min Cheol Chang
- Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University, Daegu, Republic of Korea
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Bae DW, An JY. Cross-sectional area reference values for high-resolution ultrasonography of the upper extremity nerves in healthy Asian adults. Medicine (Baltimore) 2021; 100:e25812. [PMID: 33950986 PMCID: PMC8104199 DOI: 10.1097/md.0000000000025812] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 04/14/2021] [Indexed: 01/04/2023] Open
Abstract
In this study, multiple-site, cross-sectional area (CSA) reference values were established for major peripheral nerves, including small branches, in the upper extremity of a healthy Asian population.This study included 107 prospectively recruited age-matched, healthy subjects with a mean age of 46 years (range, 24-75 years). All subjects underwent standardized nerve conduction studies for the median, ulnar, peroneal, posterior tibial, and sural nerves. CSA was measured unilaterally at 21 sites of the median, ulnar, radial, posterior interosseous, superficial radial sensory, musculocutaneous, lateral antebrachial cutaneous, and medial antebrachial cutaneous nerves.According to their age, the subjects were assigned to the younger group (20-40 years, n = 40), the middle group (40-59 years, n = 40), and the older group (60-80 years, n = 27). The significant differences of CSA values between age groups were found only at certain sites, such as the median (wrist, P = .003), ulnar (medial epicondyle, P = .031; forearm, P = .022), radial (antecubital fossa, P = .037), and superficial radial sensory nerve (P = .028). The CSA significantly correlated with gender, height, weight, and body mass index.This study provides CSA reference values for nerves, including small sensory nerves in the upper extremity, which can be useful in the ultrasonographic investigation of various peripheral neuropathies in the upper extremity.
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Abstract
We herein report a 73-year-old woman case with sarcoid neuropathy showing nerve enlargement assessed by nerve ultrasound both before and after treatment. The site of conduction block in the left tibial nerve corresponded to the site of nerve enlargement with a hypo-echoic pattern. After treatment with prednisolone, nerve ultrasound detected the remission of the nerve enlargement, and the conduction block and clinical symptoms also improved. Nerve enlargement may reflect inflammation of the peripheral nerve. A follow-up study of sonographic nerve enlargement may be of clinical significance for assessing the effectiveness of treatment for sarcoid neuropathy.
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Affiliation(s)
- Takamasa Kitaoji
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Japan
| | - Yukiko Tsuji
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Japan
| | - Yu-Ichi Noto
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Japan
| | - Shinji Ashida
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Japan
| | - Akihiro Tanaka
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Japan
| | - Toshiki Mizuno
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Japan
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Nerve Ultrasound as Helpful Tool in Polyneuropathies. Diagnostics (Basel) 2021; 11:diagnostics11020211. [PMID: 33572591 PMCID: PMC7910962 DOI: 10.3390/diagnostics11020211] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 01/26/2021] [Accepted: 01/27/2021] [Indexed: 02/06/2023] Open
Abstract
Background: Polyneuropathies (PNP) are a broad field of diseases affecting millions of people. While the symptoms presented are mostly similar, underlying causes are abundant. Thus, early identification of treatable causes is often difficult. Besides clinical data and basic laboratory findings, nerve conduction studies are crucial for etiological classification, yet limited. Besides Magnetic Resonance Imaging (MRI), high-resolution nerve ultrasound (HRUS) has become a noninvasive, fast, economic and available tool to help distinguish different types of nerve alterations in neuropathies. Methods: We aim to describe typical ultrasound findings in PNP and patterns of morphological changes in hereditary, immune-mediated, diabetic, metabolic and neurodegenerative PNP. Literature research was performed in PubMed using the terms ‘nerve ultrasound’, neuromuscular ultrasound, high-resolution nerve ultrasound, peripheral nerves, nerve enlargement, demyelinating, hereditary, polyneuropathies, hypertrophy’. Results: Plenty of studies over the past 20 years investigated the value of nerve ultrasound in different neuropathies. Next to nerve enlargement, patterns of nerve enlargement, echointensity, vascularization and elastography have been evaluated for diagnostic terms. Furthermore, different scores have been developed to distinguish different etiologies of PNP. Conclusions: Where morphological alterations of the nerves reflect underlying pathologies, early nerve ultrasound might enable a timely start of available treatment and also facilitate follow up of therapy success.
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Fisse AL, Motte J, Grüter T, Sgodzai M, Pitarokoili K, Gold R. Comprehensive approaches for diagnosis, monitoring and treatment of chronic inflammatory demyelinating polyneuropathy. Neurol Res Pract 2020; 2:42. [PMID: 33324942 PMCID: PMC7722337 DOI: 10.1186/s42466-020-00088-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 09/04/2020] [Indexed: 02/08/2023] Open
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is the most common chronic inflammatory neuropathy. CIDP is diagnosed according to the European Federation of Neurological Societies/Peripheral Nerve Society (EFNS/PNS) criteria, which combine clinical features with the electrophysiological evidence of demyelination. However, firstly, diagnosis is challenging, as some patients e.g. with severe early axonal damage do not fulfil the criteria. Secondly, objective and reliable tools to monitor the disease course are lacking. Thirdly, about 25% of CIDP patients do not respond to evidence-based first-line therapy. Recognition of these patients is difficult and treatment beyond first-line therapy is based on observational studies and case series only. Individualized immunomodulatory treatment does not exist due to the lack of understanding of essential aspects of the underlying pathophysiology. Novel diagnostic imaging techniques and molecular approaches can help to solve these problems but do not find enough implementation. This review gives a comprehensive overview of novel diagnostic techniques and monitoring approaches for CIDP and how these can lead to individualized treatment and better understanding of pathophysiology.
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Affiliation(s)
- Anna Lena Fisse
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr-University Bochum, Bochum, Germany
| | - Jeremias Motte
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr-University Bochum, Bochum, Germany
| | - Thomas Grüter
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr-University Bochum, Bochum, Germany
| | - Melissa Sgodzai
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr-University Bochum, Bochum, Germany
| | - Kalliopi Pitarokoili
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr-University Bochum, Bochum, Germany
| | - Ralf Gold
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr-University Bochum, Bochum, Germany
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Su X, Kong X, Lu Z, Zhou M, Wang J, Liu X, Kong X, Zhang H, Zheng C. Use of Magnetic Resonance Neurography for Evaluating the Distribution and Patterns of Chronic Inflammatory Demyelinating Polyneuropathy. Korean J Radiol 2020; 21:483-493. [PMID: 32193896 PMCID: PMC7082655 DOI: 10.3348/kjr.2019.0739] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Accepted: 12/19/2019] [Indexed: 02/07/2023] Open
Abstract
Objective To evaluate the distribution and characteristics of peripheral nerve abnormalities in chronic inflammatory demyelinating polyneuropathy (CIDP) using magnetic resonance neurography (MRN) and to examine the diagnostic efficiency. Materials and Methods Thirty-one CIDP patients and 21 controls underwent MR scans. Three-dimensional sampling perfections with application-optimized contrasts using different flip-angle evolutions and T1-/T2- weighted turbo spin-echo sequences were performed for neurography of the brachial and lumbosacral (LS) plexus and cauda equina, respectively. Clinical data and scores of the inflammatory Rasch-built overall disability scale (I-RODS) in CIDP were obtained. Results The bilateral extracranial vagus (n = 11), trigeminal (n = 12), and intercostal nerves (n = 10) were hypertrophic. Plexus hypertrophies were observed in the brachial plexus of 19 patients (61.3%) and in the LS plexus of 25 patients (80.6%). Patterns of hypertrophy included uniform hypertrophy (17 [54.8%] brachial plexuses and 21 [67.7%] LS plexuses), and multifocal fusiform hypertrophy (2 [6.5%] brachial plexuses and 4 [12.9%] LS plexuses) was present. Enlarged and/or contrast-enhanced cauda equina was found in 3 (9.7%) and 13 (41.9%) patients, respectively. Diameters of the brachial and LS nerve roots were significantly larger in CIDP than in controls (p < 0.001). The largest AUC was obtained for the L5 nerve. There were no significant differences in the course duration, I-RODS score, or diameter between patients with and without hypertrophy. Conclusion MRN is useful for the assessment of distribution and characteristics of the peripheral nerves in CIDP. Compared to other regions, LS plexus neurography is more sensitive for CIDP.
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Affiliation(s)
- Xiaoyun Su
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Xiangquan Kong
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Zuneng Lu
- Department of Neurology, Renming Hospital of Wuhan University, Wuhan, China
| | - Min Zhou
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Jing Wang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Xiaoming Liu
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Xiangchuang Kong
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Huiting Zhang
- MR Scientific Marketing, Siemens Healthineers, Shanghai, China
| | - Chuansheng Zheng
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China.
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Carroll AS, Simon NG. Current and future applications of ultrasound imaging in peripheral nerve disorders. World J Radiol 2020; 12:101-129. [PMID: 32742576 PMCID: PMC7364285 DOI: 10.4329/wjr.v12.i6.101] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/10/2020] [Accepted: 05/28/2020] [Indexed: 02/06/2023] Open
Abstract
Neuromuscular ultrasound (NMUS) is a rapidly evolving technique used in neuromuscular medicine to provide complimentary information to standard electrodiagnostic studies. NMUS provides a dynamic, real time assessment of anatomy which can alter both diagnostic and management pathways in peripheral nerve disorders. This review describes the current and future techniques used in NMUS and details the applications and developments in the diagnosis and monitoring of compressive, hereditary, immune-mediated and axonal peripheral nerve disorders, and motor neuron diseases. Technological advances have allowed the increased utilisation of ultrasound for management of peripheral nerve disorders; however, several practical considerations need to be taken into account to facilitate the widespread uptake of this technique.
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Affiliation(s)
- Antonia S Carroll
- Brain and Mind Research Centre, University of Sydney, Camperdown 2050, NSW, Australia
- Department of Neurology, Westmead Hospital, University of Sydney, Westmead 2145, NSW, Australia
- Department of Neurology, St Vincent’s Hospital, Sydney, Darlinghurst 2010, NSW, Australia
| | - Neil G Simon
- Northern Clinical School, University of Sydney, Frenchs Forest 2086, NSW, Australia
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19
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Gonzalez NL, Hobson-Webb LD. Neuromuscular ultrasound in clinical practice: A review. Clin Neurophysiol Pract 2019; 4:148-163. [PMID: 31886438 PMCID: PMC6921231 DOI: 10.1016/j.cnp.2019.04.006] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 04/18/2019] [Accepted: 04/29/2019] [Indexed: 12/11/2022] Open
Abstract
Neuromuscular ultrasound (NMUS) is becoming a standard element in the evaluation of peripheral nerve and muscle disease. When obtained simultaneously to electrodiagnostic studies, it provides dynamic, structural information that can refine a diagnosis or identify a structural etiology. NMUS can improve patient care for those with mononeuropathies, polyneuropathy, motor neuron disease and muscle disorders. In this article, we present a practical guide to the basics of NMUS and its clinical application. Basic ultrasound physics, scanning techniques and clinical applications are reviewed, along with current challenges.
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Affiliation(s)
- Natalia L. Gonzalez
- Department of Neurology/Neuromuscular Division, Duke University Hospital, DUMC 3403, Durham, NC 27710, USA
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Multimodal magnetic resonance imaging of peripheral nerves: Establishment and validation of brachial and lumbosacral plexi measurements in 163 healthy subjects. Eur J Radiol 2019; 117:41-48. [PMID: 31307651 DOI: 10.1016/j.ejrad.2019.05.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 05/19/2019] [Accepted: 05/23/2019] [Indexed: 01/06/2023]
Abstract
PURPOSE This study aims to provide normal reference values for quantitative parameters for brachial and lumbosacral plexi on multimodal MRI. In addition, the parameter variations between the left and right sides, the individual nerve groups, genders and age groups were also evaluated. MATERIALS AND METHODS Multimodal MRI was evaluated in 163 healthy subjects, who were randomly divided into three groups: brachial plexus, lumbosacral plexus and diffusion tensor imaging groups. Nerve diameters, contrast ratios, T2 nerve-muscle signal ratios (nT2), fractional anisotropy (FA) values and apparent diffusion coefficients (ADC) were measured in both plexi. Parametric tests and Pearson correlation for normally distributed data, and non-parametric tests and Spearman correlation for non-normally distributed data were used. RESULTS There were no significant differences in parameters between the left and right sides. The diameters of the C7, L4-S1, sciatic, and femoral nerve roots were larger in men than in women (P < 0.05). The nT2 in the brachial and lumbosacral plexi and the contrast ratio in the lumbosacral plexus were significantly higher in the elderly. The diameter of the S1 nerve root was smaller in the elderly. There were no significant differences between the individual nerve groups in contrast ratios and in brachial plexus nT2. A gradual increase in the nT2 from the top to the bottom was observed in the L4-S1 nerve roots (P < 0.05). CONCLUSION This study provides multi-parameter normative data for the brachial and lumbosacral plexi while considering differences between the two sides, the individual nerves, genders, and the ages.
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Telleman JA, Grimm A, Goedee S, Visser LH, Zaidman CM. Nerve ultrasound in polyneuropathies. Muscle Nerve 2018; 57:716-728. [PMID: 29205398 DOI: 10.1002/mus.26029] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 11/30/2017] [Accepted: 11/30/2017] [Indexed: 12/13/2022]
Abstract
Ultrasound can be used to visualize pathology in the peripheral nerves of patients with polyneuropathy. Nerve enlargement is the most frequent pathology, but other abnormalities, including abnormal nerve echogenicity and vascularity, are also encountered. This monograph presents an overview of the role of nerve ultrasound in the evaluation and management of both inherited and acquired polyneuropathies. A description of the sonographic techniques and common abnormalities is provided, followed by a presentation of typical findings in different neuropathies. Scoring systems for characterizing the presence and pattern of nerve abnormalities as they relate to different polyneuropathies are presented. Muscle Nerve 57: 716-728, 2018.
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Affiliation(s)
- Johan A Telleman
- Department of Neurology and Clinical Neurophysiology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands.,Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, UMC Utrecht, Utrecht, The Netherlands
| | - Alexander Grimm
- Department Neurology, University Hospital Tuebingen, Germany
| | - Stephan Goedee
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, UMC Utrecht, Utrecht, The Netherlands
| | - Leo H Visser
- Department of Neurology and Clinical Neurophysiology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Craig M Zaidman
- Departments of Neurology and Pediatrics, Washington University St. Louis, Missouri, 660 South Euclid, Box 8111, St. Louis, Missouri, 63110-1093, USA
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22
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Décard BF, Pham M, Grimm A. Ultrasound and MRI of nerves for monitoring disease activity and treatment effects in chronic dysimmune neuropathies – Current concepts and future directions. Clin Neurophysiol 2018; 129:155-167. [DOI: 10.1016/j.clinph.2017.10.028] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Revised: 10/03/2017] [Accepted: 10/07/2017] [Indexed: 02/07/2023]
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Grimm A, Winter N, Rattay TW, Härtig F, Dammeier NM, Auffenberg E, Koch M, Axer H. A look inside the nerve - Morphology of nerve fascicles in healthy controls and patients with polyneuropathy. Clin Neurophysiol 2017; 128:2521-2526. [PMID: 28958781 DOI: 10.1016/j.clinph.2017.08.022] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 07/31/2017] [Accepted: 08/20/2017] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Polyneuropathies are increasingly analyzed by ultrasound. Summarizing, diffuse enlargement is typical in Charcot-Marie Tooth type 1 (CMT1a), regional enlargement occurs in inflammatory neuropathies. However, a distinction of subtypes is still challenging. Therefore, this study focused on fascicle size and pattern in controls and distinct neuropathies. METHODS Cross-sectional area (CSA) of the median, ulnar and peroneal nerve (MN, UN, PN) was measured at predefined landmarks in 50 healthy controls, 15 CMT1a and 13 MMN patients. Additionally, largest fascicle size and number of visible fascicles was obtained at the mid-upper arm cross-section of the MN and UN and in the popliteal fossa cross-section of the PN. RESULTS Cut-off normal values for fascicle size in the MN, UN and PN were defined (<4.8mm2, <2.8mm2 and <3.5mm2). In CMT1a CSA and fascicle values are significantly enlarged in all nerves, while in MMN CSA and fascicles are regionally enlarged with predominance in the upper arm nerves. The ratio of enlarged fascicles and all fascicles was significantly increased in CMT1a (>50%) in all nerves (p<0.0001), representing diffuse fascicle enlargement, and moderately increased in MMN (>20%), representing differential fascicle enlargement (enlarged and normal fascicles at the same location) sparing the peroneal nerve (regional fascicle enlargement). Based on these findings distinct fascicle patterns were defined. CONCLUSION Normal values for fascicle size could be evaluated; while CMT1a features diffuse fascicle enlargement, MMN shows regional and differential predominance with enlarged fascicles as single pathology. SIGNIFICANCE Pattern analysis of fascicles might facilitate distinction of several otherwise similar neuropathies.
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Affiliation(s)
- Alexander Grimm
- Center for Neurology, Tübingen University Hospital and Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, Tübingen, Germany.
| | - Natalie Winter
- Center for Neurology, Tübingen University Hospital and Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, Tübingen, Germany.
| | - Tim W Rattay
- Center for Neurology, Tübingen University Hospital and Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, Tübingen, Germany; German Center for Neurodegenerative Diseases (DZNE), Tübingen, Germany.
| | - Florian Härtig
- Center for Neurology, Tübingen University Hospital and Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, Tübingen, Germany.
| | - Nele M Dammeier
- Center for Neurology, Tübingen University Hospital and Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, Tübingen, Germany.
| | - Eva Auffenberg
- Center for Neurology, Tübingen University Hospital and Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, Tübingen, Germany.
| | - Marilin Koch
- Center for Neurology, Tübingen University Hospital and Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, Tübingen, Germany.
| | - Hubertus Axer
- Hans Berger Department of Neurology, Jena University Hospital, Friedrich-Schiller University Jena, Jena, Germany.
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Podnar S, Omejec G, Bodor M. Nerve conduction velocity and cross-sectional area in ulnar neuropathy at the elbow. Muscle Nerve 2017; 56:E65-E72. [DOI: 10.1002/mus.25655] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2017] [Indexed: 11/05/2022]
Affiliation(s)
- Simon Podnar
- Institute of Clinical Neurophysiology; University Medical Center Ljubljana; SI-1525 Ljubljana Slovenia
| | - Gregor Omejec
- Institute of Clinical Neurophysiology; University Medical Center Ljubljana; SI-1525 Ljubljana Slovenia
| | - Marko Bodor
- Department of Physical Medicine and Rehabilitation; University of California Davis; Sacramento California USA
- Department of Neurological Surgery; University of California San Francisco; San Francisco California USA
- Interventional Spine and Sports Medicine; Napa California USA
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Hsu PC, Chiu JW, Chou CL, Wang JC. Acute Radial Neuropathy at the Spiral Groove Following Massage: A Case Presentation. PM R 2017; 9:1042-1046. [DOI: 10.1016/j.pmrj.2017.03.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 03/14/2017] [Accepted: 03/23/2017] [Indexed: 11/28/2022]
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Grimm A, Schubert V, Axer H, Ziemann U. Giant nerves in chronic inflammatory polyradiculoneuropathy. Muscle Nerve 2016; 55:285-289. [PMID: 27463360 DOI: 10.1002/mus.25272] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 07/19/2016] [Accepted: 07/21/2016] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Nerve enlargement (NE) is described in inflammatory and inherited neuropathies. It is commonly multifocal and moderate in the former and homogeneous and generalized in the latter. We describe 4 cases of massive NE in inflammatory neuropathies. METHODS Patients presented with symptoms of polyneuropathy that progressed over months to years. Nerve conduction studies (NCS), laboratory analysis, nerve MRI, and nerve ultrasound were performed. RESULTS NCS revealed demyelinating neuropathy in all with multifocal conduction blocks or increased terminal latency indices. MRI/ultrasound revealed extensive NE in the roots and nerves. Detailed diagnostics including biopsies, positron emission tomography-computed tomography, and genetic testing revealed no other pathology. Chronic inflammatory demyelinating polyneuropathy variants were diagnosed in all, and immunotherapies were successfully initiated. CONCLUSIONS MRI and ultrasound contributed to diagnosis and therapy. All patients had giant NE in common, which strongly suggested inherited neuropathy. However, the final diagnosis was inflammatory neuropathy. Impressive NE can occur in immune-mediated neuropathies and should be carefully differentiated from inherited neuropathies. Muscle Nerve 55: 285-289, 2017.
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Affiliation(s)
- Alexander Grimm
- Center of Neurology, Tübingen University Hospital, and Hertie Institute for Clinical Brain Research, Eberhard-Karls University Tübingen, Hoppe-Seyler Str. 3, D-72076, Tübingen, Germany
| | - Victoria Schubert
- Center of Neurology, Tübingen University Hospital, and Hertie Institute for Clinical Brain Research, Eberhard-Karls University Tübingen, Hoppe-Seyler Str. 3, D-72076, Tübingen, Germany
| | - Hubertus Axer
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Ulf Ziemann
- Center of Neurology, Tübingen University Hospital, and Hertie Institute for Clinical Brain Research, Eberhard-Karls University Tübingen, Hoppe-Seyler Str. 3, D-72076, Tübingen, Germany
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Tanaka K, Ota N, Harada Y, Wada I, Suenaga T. Normalization of sonographical multifocal nerve enlargements in a MADSAM patient following a good clinical response to intravenous immunoglobulin. Neuromuscul Disord 2016; 26:619-23. [PMID: 27460345 DOI: 10.1016/j.nmd.2016.06.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Revised: 05/23/2016] [Accepted: 06/10/2016] [Indexed: 12/20/2022]
Abstract
Focal nerve enlargements at sites of conduction blocks can be visualized sonographically in patients with multifocal acquired demyelinating sensory and motor neuropathy (MADSAM). However, little is known about association between nerve morphological changes and treatment responses. Here we present a 73-year-old female MADSAM patient whose sonographical multifocal nerve enlargements normalized following a good treatment response. She was admitted to our department with progressive asymmetrical muscle weakness and sensory disturbances for 6 months. Ultrasonography revealed multifocal nerve enlargements at sites of electrophysiological demyelination. Intravenous immunoglobulin improved her symptoms and electrophysiological abnormalities. Six months later, ultrasonography revealed normalization of multifocal nerve enlargements. Contrary to our observations, one previous report described a MADSAM patient with persistent nerve enlargements at the sites of resolved conduction blocks. In this earlier patient, however, the time from onset to remission was approximately 30 months. Morphological changes of nerve enlargements in MADSAM may vary with treatment response.
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Affiliation(s)
- Kanta Tanaka
- Department of Neurology, Tenri Hospital, Tenri, Japan.
| | - Natsuko Ota
- Department of Clinical Pathology, Tenri Hospital, Tenri, Japan
| | - Yuzuru Harada
- Department of Clinical Pathology, Tenri Hospital, Tenri, Japan
| | - Ikko Wada
- Department of Neurology, Tenri Hospital, Tenri, Japan
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Pedro MT, Antoniadis G, Scheuerle A, Pham M, Wirtz CR, Koenig RW. Intraoperative high-resolution ultrasound and contrast-enhanced ultrasound of peripheral nerve tumors and tumorlike lesions. Neurosurg Focus 2016; 39:E5. [PMID: 26323823 DOI: 10.3171/2015.6.focus15218] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The diagnostic workup and surgical therapy for peripheral nerve tumors and tumorlike lesions are challenging. Magnetic resonance imaging is the standard diagnostic tool in the preoperative workup. However, even with advanced pulse sequences such as diffusion tensor imaging for MR neurography, the ability to differentiate tumor entities based on histological features remains limited. In particular, rare tumor entities different from schwannomas and neurofibromas are difficult to anticipate before surgical exploration and histological confirmation. High-resolution ultrasound (HRU) has become another important tool in the preoperative evaluation of peripheral nerves. Ongoing software and technical developments with transducers of up to 17-18 MHz enable high spatial resolution with tissue-differentiating properties. Unfortunately, high-frequency ultrasound provides low tissue penetration. The authors developed a setting in which intraoperative HRU was used and in which the direct sterile contact between the ultrasound transducer and the surgically exposed nerve pathology was enabled to increase structural resolution and contrast. In a case-guided fashion, the authors report the sonographic characteristics of rare tumor entities shown by intraoperative HRU and contrast-enhanced ultrasound.
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Affiliation(s)
| | | | | | - Mirko Pham
- Department of Neuroradiology, University of Heidelberg, Germany
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Grimm A, Vittore D, Schubert V, Lipski C, Heiling B, Décard BF, Axer H. Ultrasound pattern sum score, homogeneity score and regional nerve enlargement index for differentiation of demyelinating inflammatory and hereditary neuropathies. Clin Neurophysiol 2016; 127:2618-24. [PMID: 27291881 DOI: 10.1016/j.clinph.2016.04.009] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Revised: 03/22/2016] [Accepted: 04/05/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To investigate the use of nerve ultrasound in the differentiation between Charcot-Marie Tooth hereditary neuropathy (CMT1) and chronic inflammatory demyelinating polyradiculoneuropathies (CIDP), multifocal motor neuropathy (MMN) and multifocal acquired demyelinating sensory and motor neuropathies (MADSAM). METHODS Ultrasound/electrophysiology of predefined nerves was performed in CMT1a/b, immunoneuropathies, and healthy controls. Ultrasound pattern sum score (UPSS, sum of the amount of 12 predefined measurement points), homogeneity score (HS) and regional nerve enlargement index (RNEI) in ulnar, median, and tibial nerve were used for evaluation of morphology. RESULTS 13 CMT1, 27 CIDP, 10 MADSAM, 12 MMN, and 23 controls were included. Significant enlargement was shown in all neuropathies compared to the controls, (p<0.001), however the amount of enlargement as evaluated by the UPSS was most prominent in CMT compared to the others (median UPSS 18 vs. 11/8.5/5 in CIDP/MADSAM/MMN, p<0.001). Homogeneous enlargement was significantly more often seen in CMT (67%, HS 6 vs. 2-3 in immune-mediated PNP, p<0.001), while in CIDP the enlargement was regional, homogeneous or inhomogeneous with equal contribution. In MMN and MADSAM regional enlargement (48%/40%) next to normal segments (∼20%) predominated (RNEI in MMN=2, in MADSAM=1 vs. 0 in the others). CSAs were inversely correlated with motor conduction velocity. CONCLUSION Ultrasound, quantified by UPSS, HS, and RNEI facilitates a reliable and reproducible differentiation of immunoneuropathies and hereditary neuropathies by the use of boundary values. SIGNIFICANCE By the use of quantitative scores, ultrasound differentiation of demyelinating neuropathies is operationalized and ameliorated compared to CSA measurements only.
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Affiliation(s)
- Alexander Grimm
- Department of Neurology, Tübingen University Hospital, Tübingen, Germany.
| | - Debora Vittore
- Department of Neurology, Tübingen University Hospital, Tübingen, Germany
| | - Victoria Schubert
- Department of Neurology, Tübingen University Hospital, Tübingen, Germany
| | - Christina Lipski
- Department of Neurology, Tübingen University Hospital, Tübingen, Germany
| | - Bianka Heiling
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Bernhard F Décard
- Department of Neurology, Basel University Hospital, Basel, Switzerland
| | - Hubertus Axer
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
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Ultrasound aspects in therapy-naive CIDP compared to long-term treated CIDP. J Neurol 2016; 263:1074-82. [PMID: 27017343 DOI: 10.1007/s00415-016-8100-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 03/13/2016] [Accepted: 03/14/2016] [Indexed: 12/11/2022]
Abstract
To investigate the use of nerve ultrasound (NUS) along with the European Federation of Neurological Societies (EFNS) guidelines and clinical scores in untreated, recently diagnosed chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) vs. long-lasting treated CIDP. NUS and nerve conduction studies (NCS) of predefined nerves/cervical roots were performed in CIDP on diagnostic onset and "chronic-CIDP" (diagnosis and therapy >6 months), compared to controls. Nerve morphology was quantified using the modified ultrasound pattern sum score mUPSS, which is the sum of 3 ultrasound scores derived at 12 predefined measurement points and the homogeneity score (HS) in ulnar, median, and tibial nerve. 21 onset-CIDP, 21 "chronic-CIDP", and 21 age-matched controls were included. No differences in clinical scores or in the number of electrophysiologically affected nerves existed between the groups. Significantly enlarged cross-sectional areas of the nerves and diameters of the roots ensued already in onset-CIDP; however, with proximal predominance, whilst in chronic-CIDP, nerve enlargement was more prominent and ubiquitous. Increased UPS scores were shown in both patient groups compared to the controls. Significant differences between the patient groups were found particularly in the peripheral nerve score UPSA. Evaluation by means of HS revealed that the nerves in onset-CIDP were mostly regionally enlarged (often sparing distal segments) whereas in chronic-CIDP, nerves were more generalized enlarged. Onset- and chronic-CIDP show enlarged nerves and therefore increased mUPSS, however, nerve enlargement shows a more generalized pattern in chronic-CIDP compared to disease onset and correlates with disease duration and delayed therapy start, but not with disability.
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Rasenack M, Proebstel AK, Athanasopoulou IM, Décard BF, Grimm A. Nerve Hypertrophy in Primary Amyloidosis. Muscle Nerve 2016; 54:510-2. [PMID: 26999802 DOI: 10.1002/mus.25113] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 03/18/2016] [Accepted: 03/18/2016] [Indexed: 12/12/2022]
Affiliation(s)
- Maria Rasenack
- Department of Neurology, Basel University Hospital, Basel, Switzerland
| | | | | | - Bernhard F Décard
- Department of Neurology, Basel University Hospital, Basel, Switzerland
| | - Alexander Grimm
- Department of Neurology, Basel University Hospital, Basel, Switzerland.,Department of Neurology, Tübingen University Hospital, Tübingen, Germany
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Grimm A, Décard BF, Axer H. Ultrasonography of the peripheral nervous system in the early stage of Guillain-Barré syndrome. J Peripher Nerv Syst 2015; 19:234-41. [PMID: 25418824 DOI: 10.1111/jns.12091] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Revised: 06/22/2014] [Accepted: 07/31/2014] [Indexed: 12/18/2022]
Abstract
Ultrasonography can be used to visualize peripheral nerve abnormalities in immune-mediated neuropathies. The objective of this study was to prove the role of ultrasonography (US) in acute phase of Guillain-Barré syndrome (GBS). Systematic ultrasonic measurements of several peripheral nerves including the vagal nerve as well as the sixth cervical nerve root were performed in 18 patients with GBS at days 1-3 after symptom onset and compared to 21 healthy controls. Nerve conduction studies (NCS) of corresponding nerves were undertaken. Consequently, significant differences between the groups were found in compound muscle action potential amplitudes, F-wave latency, and persistency. Ultrasonic cross-sectional areas (CSAs) showed significant enlargement in all nerves except of the ulnar nerve (upper arm) and the sural nerve compared to healthy controls, most prominent in proximal and middle median nerve (p < 0.01). The vagal nerve also showed enlargement compared to controls (p < 0.05), which was most pronounced in patients with autonomic dysfunction compared to patients without (p < 0.05). C6 root diameter showed a significant correlation to the amount of cerebrospinal fluid (CSF)-protein (Pearson correlation, p < 0.05). US shows nerve enlargement in several peripheral nerves including vagal nerve and C6 root in acute phase of GBS and could be an additional diagnostic tool for example, in GBS of atypical onset and autonomic dysfunction.
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Affiliation(s)
- Alexander Grimm
- Department of Neurology, Basel University Hospital, Basel, Switzerland
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Reckelhoff KE, Li J, Kaeser MA, Haun DW, Kettner NW. Ultrasound Evaluation of the Normal Ulnar Nerve in Guyon's Tunnel: Cross-sectional Area and Anthropometric Measurements. J Med Ultrasound 2015. [DOI: 10.1016/j.jmu.2015.09.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Grimm A, Thomaser AL, Peters N, Fuhr P. Neurological picture. Vagal hypertrophy in immune-mediated neuropathy visualised with high-resolution ultrasound (HR-US). J Neurol Neurosurg Psychiatry 2015; 86:1277-8. [PMID: 25209417 DOI: 10.1136/jnnp-2014-308271] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 08/19/2014] [Indexed: 01/03/2023]
Affiliation(s)
- Alexander Grimm
- Department of Neurology, Basel University Hospital, University Basel, Basel, Switzerland
| | - Anna-Lena Thomaser
- Department of Neurology, Basel University Hospital, University Basel, Basel, Switzerland
| | - Nils Peters
- Department of Neurology, Basel University Hospital, University Basel, Basel, Switzerland
| | - Peter Fuhr
- Department of Neurology, Basel University Hospital, University Basel, Basel, Switzerland
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Gallardo E, Noto YI, Simon NG. Ultrasound in the diagnosis of peripheral neuropathy: structure meets function in the neuromuscular clinic. J Neurol Neurosurg Psychiatry 2015; 86:1066-74. [PMID: 25653385 DOI: 10.1136/jnnp-2014-309599] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 01/08/2015] [Indexed: 02/06/2023]
Abstract
Peripheral nerve ultrasound (US) has emerged as a promising technique for the diagnosis of peripheral nerve disorders. While most experience with US has been reported in the context of nerve entrapment syndromes, the role of US in the diagnosis of peripheral neuropathy (PN) has recently been explored. Distinctive US findings have been reported in patients with hereditary, immune-mediated, infectious and axonal PN; US may add complementary information to neurophysiological studies in the diagnostic work-up of PN. This review describes the characteristic US findings in PN reported to date and a classification of abnormal nerve US patterns in PN is proposed. Closer scrutiny of nerve abnormalities beyond assessment of nerve calibre may allow for more accurate diagnostic classification of PN, as well as contribute to the understanding of the intersection of structure and function in PN.
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Affiliation(s)
- Elena Gallardo
- Service of Radiology, University Hospital Marqués de Valdecilla; Instituto de Investigación Marqués de Valdecilla (IDIVAL), Santander, Spain University of Cantabria (UC); and Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED), Santander, Spain
| | - Yu-Ichi Noto
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Japan
| | - Neil G Simon
- Prince of Wales Clinical School, University of New South Wales, Australia Central Clinical School, The University of Sydney, Australia
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Arányi Z, Csillik A, Dévay K, Rosero M, Barsi P, Böhm J, Schelle T. Ultrasonographic identification of nerve pathology in neuralgic amyotrophy: Enlargement, constriction, fascicular entwinement, and torsion. Muscle Nerve 2015; 52:503-11. [PMID: 25703205 DOI: 10.1002/mus.24615] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2015] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The aim of this study was to characterize the ultrasonographic findings on nerves in neuralgic amyotrophy. METHODS Fourteen patients with neuralgic amyotrophy were examined using high-resolution ultrasound. RESULTS Four types of abnormalities were found: (1) focal or diffuse nerve/fascicle enlargement (57%); (2) incomplete nerve constriction (36%); (3) complete nerve constriction with torsion (50%; hourglass-like appearance); and (4) fascicular entwinement (28%). Torsions were confirmed intraoperatively and were seen on the radial nerve in 85% of patients. A significant correlation was found between no spontaneous recovery of nerve function and constriction/torsion/fascicular entwinement (P = 0.007). CONCLUSION Ultrasonographic nerve pathology in neuralgic amyotrophy varies in order of severity from nerve enlargement to constriction to nerve torsion, with treatment ranging from conservative to surgical. We postulate that the constriction caused by inflammation is the precursor of torsion and that development of nerve torsion is facilitated by the rotational movements of limbs.
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Affiliation(s)
- Zsuzsanna Arányi
- Department of Neurology, MTA-SE NAP B Peripheral Nervous System Research Group, Semmelweis University, Balassa u. 6, Budapest, 1083, Hungary
| | - Anita Csillik
- Department of Neurology, MTA-SE NAP B Peripheral Nervous System Research Group, Semmelweis University, Balassa u. 6, Budapest, 1083, Hungary
| | - Katalin Dévay
- Department of Traumatology, Szt. István and László Hospital, Budapest, Hungary
| | - Maja Rosero
- Department of Traumatology, Szt. István and László Hospital, Budapest, Hungary
| | - Péter Barsi
- MRI Research Center, Semmelweis University, Budapest, Hungary
| | - Josef Böhm
- Department of Neurology, Kreiskrankenhaus Freiberg, Freiberg, Germany
| | - Thomas Schelle
- Department of Neurology, Städtisches Klinikum Dessau, Dessau, Germany
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Simon NG, Kiernan MC. Precise correlation between structural and electrophysiological disturbances in MADSAM neuropathy. Neuromuscul Disord 2015; 25:904-7. [PMID: 26314279 DOI: 10.1016/j.nmd.2015.07.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 07/14/2015] [Accepted: 07/16/2015] [Indexed: 12/17/2022]
Abstract
Multifocal acquired demyelinating sensory and motor neuropathy is characterised by multifocal clinical deficits. Imaging studies have identified multifocal enlargements of nerve trunks, but a precise correlation between structural abnormalities and electrophysiological dysfunction has not been elucidated. Two patients diagnosed with multifocal acquired demyelinating sensory and motor neuropathy were evaluated with nerve conduction studies, including short segment nerve conduction studies to precisely localise motor conduction block, and ultrasound studies of corresponding nerve trunks. Motor conduction block was identified in each patient (upper limb nerves in two patients), superimposed on additional demyelinating neurophysiological features. Upper limb ultrasound studies demonstrated focal nerve enlargement that precisely correlated with neurophysiological conduction block. The results of this study suggest that factors contributing to focal structural abnormalities in multifocal acquired demyelinating sensory and motor neuropathy are also those that produce conduction block.
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Affiliation(s)
- Neil G Simon
- Brain and Mind Research Institute, Sydney Medical School, The University of Sydney, Australia; Prince of Wales Clinical School, University of New South Wales, Australia.
| | - Matthew C Kiernan
- Brain and Mind Research Institute, Sydney Medical School, The University of Sydney, Australia
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Ultrasound and electrophysiologic findings in patients with Guillain-Barré syndrome at disease onset and over a period of six months. Clin Neurophysiol 2015. [PMID: 26220732 DOI: 10.1016/j.clinph.2015.06.032] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To investigate cross-sectional areas (CSAs) of several peripheral nerves including the vagus nerve and the diameter of spinal nerves as measured by nerve ultrasound (NUS) and nerve conduction studies (NCS) in Guillain-Barré syndrome (GBS) patients over at least six months compared to healthy controls. METHODS NUS and/or NCS of several nerves, the vagus nerve, and the 5th/6th cervical spinal nerves were performed in patients with GBS at days 2-3 after symptom onset, at days 10-14 after immunoglobulin therapy and after six months compared to healthy controls. RESULTS 27 GBS-patients and 31 controls were included. Using NUS significant enlargement was found in all measured nerves (P<0.001), except the sural nerve (P=0.086) compared to the controls at onset. The vagus (median 3.0 mm(2) vs. 2.0 mm(2), P<0.0001) and the cervical spinal nerves were significantly enlarged (median 3.5/4.0 mm vs. 2.6/3.2 mm, p<0.0001), the vagus most obviously in patients with autonomic dysregulation (AD, 4.0 mm(2)). Six months later, NCS showed persisting pathology in CMAP-amplitudes with amelioration of F-wave pathology. NUS showed restitution in the spinal nerves (median 2.6/3.2 mm) and the vagus (median 2.0 mm(2)) in all patients excluding the vagus in those with persistent AD (median 4.0 mm(2)). The peripheral nerves did not change significantly (P>0.05). CONCLUSION Ultrasonographic detection of cervical spinal nerve enlargement supports the diagnosis of GBS in the early phase. Its regression may be a good parameter for the clinical restitution over time. Vagus enlargement may be a risk marker for development of AD. SIGNIFICANCE Ultrasound is a reliable diagnostic follow-up tool in early GBS.
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Pitarokoili K, Gold R, Yoon MS. Nerve ultrasound in a case of multifocal motor neuropathy without conduction block. Muscle Nerve 2015; 52:294-9. [DOI: 10.1002/mus.24583] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2015] [Indexed: 12/13/2022]
Affiliation(s)
- Kalliopi Pitarokoili
- Department of Neurology; St. Josef Hospital, Ruhr-University of Bochum; Gudrunstr. 56 44791 Bochum Germany
| | - Ralf Gold
- Department of Neurology; St. Josef Hospital, Ruhr-University of Bochum; Gudrunstr. 56 44791 Bochum Germany
| | - Min-Suk Yoon
- Department of Neurology; St. Josef Hospital, Ruhr-University of Bochum; Gudrunstr. 56 44791 Bochum Germany
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Grimm A, Rasenack M, Athanasopoulou I, Peters N, Fuhr P. Long-term observations in asymmetric immune-mediated neuropathy with vagus hypertrophy using ultrasound of the nerves. J Neurol Sci 2015; 356:205-8. [PMID: 26081119 DOI: 10.1016/j.jns.2015.06.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Revised: 06/03/2015] [Accepted: 06/09/2015] [Indexed: 11/26/2022]
Affiliation(s)
- Alexander Grimm
- Department of Neurology, Hospital of University of Basel, Switzerland.
| | - Maria Rasenack
- Department of Neurology, Hospital of University of Basel, Switzerland
| | | | - Nils Peters
- Department of Neurology, Hospital of University of Basel, Switzerland
| | - Peter Fuhr
- Department of Neurology, Hospital of University of Basel, Switzerland
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Kerasnoudis A, Pitarokoili K, Behrendt V, Gold R, Yoon MS. Multifocal motor neuropathy: correlation of nerve ultrasound, electrophysiological, and clinical findings. J Peripher Nerv Syst 2015; 19:165-74. [PMID: 24862982 DOI: 10.1111/jns5.12067] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Revised: 03/07/2014] [Accepted: 03/19/2014] [Indexed: 02/06/2023]
Abstract
We present nerve ultrasound findings in multifocal motor neuropathy (MMN) and examine their correlation with electrophysiology and functional disability. Eighty healthy controls and 12 MMN patients underwent clinical, sonographic, and electrophysiological evaluation a mean of 3.5 years (standard deviation [SD] ± 2.1) after disease onset. Nerve ultrasound revealed significantly higher cross-sectional area (CSA) values of the median (forearm, p < 0.001), ulnar (p < 0.001), and tibial nerve (ankle, p < 0.001) when compared with controls. Electroneurography documented signs of significantly lower values of the motor conduction velocity and compound muscle action potentials (cMAPs) in the upper arm nerves (median, ulnar, radial, p < 0.001). A significant correlation between sonographic and electrophysiological findings in the MMN group was found only between cMAP and CSA of the median nerve at the upper arm (r = 0.851, p < 0.001). Neither nerve sonography nor electrophysiology correlated with functional disability. MMN seems to show inhomogeneous CSA enlargement in various peripheral nerves, with weak correlation to electrophysiological findings. Neither nerve sonography nor electrophysiology correlated with functional disability. Multicentre, prospective studies are required to prove the applicability and diagnostic values of these findings.
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Kerasnoudis A, Tsivgoulis G. Nerve Ultrasound in Peripheral Neuropathies: A Review. J Neuroimaging 2015; 25:528-38. [PMID: 25996962 DOI: 10.1111/jon.12261] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 04/06/2015] [Indexed: 12/12/2022] Open
Abstract
Peripheral neuropathies are one of the most common reasons for seeking neurological care in everyday practice. Electrophysiological studies remain fundamental for the diagnosis and etiological classification of peripheral nerve impairment. The recent technological development though of high resolution ultrasound has allowed the clinician to obtain detailed structural images of peripheral nerves. Nerve ultrasound mainly focuses on the evaluation of the cross sectional area, cross sectional area variability along the anatomical course, echogenity, vascularity and mobility of the peripheral nerves. An increase of the cross sectional area, hypervascularity, disturbed fascicular echostructure and reduced nerve mobility are some of the most common findings of entrapments neuropathies, such as the carpal or cubital tunnel syndrome. Both the cross-sectional area increase and the hypervascularity detected with the Doppler technique seem to correlate significantly with the clinical and electrophysiological severity of the later mononeuropathies. Significantly greater cross sectional area values of the clinically affected cervical nerve root are often detected in cases of cervical radiculopathy. In such cases, the ultrasound findings seem also to correlate significantly with disease duration. On the other hand, multifocal cross sectional area enlargement of cervical roots and/or peripheral nerves is often documented in cases of immune-mediated neuropathies. None of the later pathological ultrasound findings seem to correlate significantly with the electrophysiological parameters or the functional disability. The aim of this review is to provide a timely update on the role of neuromuscular ultrasound in the diagnostic of the most common entrapment and immune-mediated peripheral neuropathies in clinical practice.
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Affiliation(s)
| | - Georgios Tsivgoulis
- Second Department of Neurology, University of Athens, School of Medicine, "Attikon" University Hospital, Athens, Greece.,International Clinical Research Center, St. Anne's University Hospital in Brno, Brno, Czech Republic
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Gasparotti R, Lucchetta M, Cacciavillani M, Neri W, Guidi C, Cavallaro T, Ferrari S, Padua L, Briani C. Neuroimaging in diagnosis of atypical polyradiculoneuropathies: report of three cases and review of the literature. J Neurol 2015; 262:1714-23. [PMID: 25957643 DOI: 10.1007/s00415-015-7770-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 04/28/2015] [Accepted: 04/29/2015] [Indexed: 01/20/2023]
Abstract
Neuroimaging is increasingly used in the study of peripheral nerve diseases, and sometimes may have a pivotal role in the diagnostic process. We report on three patients with atypical chronic inflammatory polyradiculoneuropathy (CIDP) in whom magnetic resonance imaging (MRI) and nerve Ultrasound (US) were crucial for a correct diagnostic work-out. A literature review on MRI and US in acquired demyelinating polyneuropathies is also provided. Awareness of the imaging features of CIDP will assist in confirmation of the diagnosis, institution of the appropriate therapy, and prevention of inadequate or delayed treatment in atypical CIDP.
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Affiliation(s)
- Roberto Gasparotti
- Section of Neuroradiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy,
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Noto YI, Shiga K, Tsuji Y, Mizuta I, Higuchi Y, Hashiguchi A, Takashima H, Nakagawa M, Mizuno T. Nerve ultrasound depicts peripheral nerve enlargement in patients with genetically distinct Charcot-Marie-Tooth disease. J Neurol Neurosurg Psychiatry 2015; 86:378-84. [PMID: 25091364 DOI: 10.1136/jnnp-2014-308211] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To elucidate the ultrasound (US) features of peripheral nerves including nerve roots in patients with different types of Charcot-Marie-Tooth disease (CMT), and the association between US findings, clinical features and parameters of nerve conduction studies (NCS) in CMT1A. METHODS US of median, sural and great auricular nerves and the C6 nerve root was performed in patients with CMT1A (n=20), MPZ-associated CMT (n=3), NEFL-associated CMT (n=4), EGR2-associated CMT (n=1), ARHGEF10-associated CMT (n=1) and in controls (n=30). In patients with CMT1A, we analysed the correlations between US findings and the following parameters: age, CMT Neuropathy Score (CMTNS) and NCS indices of the median nerve. RESULTS Cross-sectional areas (CSAs) of all the nerves were significantly increased in patients with CMT1A compared with that in controls. In MPZ-associated CMT, increased CSAs were found in the median nerve at wrist and in the great auricular nerve, whereas it was not increased in patients with NEFL-associated CMT. In patients with CMT1A, there was a positive correlation between CMTNS and the CSAs in the median nerves or great auricular nerves. In median nerves in patients with CMT1A, we found a negative correlation between the nerve conduction velocity and the CSA. CONCLUSIONS Nerve US may aid in differentiating among the subtypes of CMT in combination with NCS. In CMT1A, the median nerve CSA correlates with the disease severity and peripheral nerve function.
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Affiliation(s)
- Yu-ichi Noto
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kensuke Shiga
- Department of Medical Education and Primary Care, Graduate School of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yukiko Tsuji
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Ikuko Mizuta
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yujiro Higuchi
- Department of Neurology and Geriatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Akihiro Hashiguchi
- Department of Neurology and Geriatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Hiroshi Takashima
- Department of Neurology and Geriatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Masanori Nakagawa
- North Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Toshiki Mizuno
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Abstract
PURPOSE OF REVIEW The purpose of this study is to review advances in magnetic resonance (MR)-neurography and nerve-ultrasound for the precise visualization and localization of nerve lesions not only in nerve trauma or mass lesions, but also in entrapment-related and spontaneously occurring intrinsic neuropathies. These advances may improve the understanding and classification of peripheral neuropathies. RECENT FINDINGS Diagnostic studies of MR-neurography and high-resolution ultrasound in entrapment-neuropathies consistently report accurate determination and localization of symptomatic nerve entrapment. Additionally, the longitudinal sampling of nerve-T2-signal over larger areas of coverage has become technically feasible. With this approach, more complex patterns of spatial lesion dispersion in nonfocal neuropathies could be observed with reliable lesion image contrast at the level of individual nerve fascicles. Imaging detection of fascicular lesions allows for more accurate localization, because fascicular lesion types represent a specific pitfall for clinical-electrophysiological examinations. Fascicular hypoechogenicity of high-resolution ultrasound is the correlate of nerve-T2-signal lesions, but contrast is inferior and difficult to quantify. Therefore, nerve enlargement remains the main diagnostic criterion in high-resolution ultrasound. Diffusion-tensor-MR-neurography provides quantitative estimates of fiber structure, which were shown to correlate with aging and focal entrapment. SUMMARY High-resolution nerve imaging with extended anatomical coverage is feasible and improves the topographic description of spatial lesion dispersion which is particularly relevant for the discrimination between focal and nonfocal neuropathies.
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Grimm A, Décard BF, Athanasopoulou I, Schweikert K, Sinnreich M, Axer H. Nerve ultrasound for differentiation between amyotrophic lateral sclerosis and multifocal motor neuropathy. J Neurol 2015; 262:870-80. [PMID: 25626722 DOI: 10.1007/s00415-015-7648-0] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 01/12/2015] [Accepted: 01/13/2015] [Indexed: 12/15/2022]
Abstract
Ultrasound is useful for non-invasive visualization of focal nerve pathologies probably resulting from demyelination, remyelination, edema or inflammation. In patients with progressive muscle weakness, differentiation between multifocal motor neuropathy (MMN) and amyotrophic lateral sclerosis (ALS) is essential regarding therapy and prognosis. Therefore, the objective of this study was to investigate whether nerve ultrasound can differentiate between ALS and MMN. Systematic ultrasound measurements of peripheral nerves and the 6th cervical nerve root (C6) were performed in 17 patients with ALS, in 8 patients with MMN and in 28 healthy controls. Nerve conduction studies of corresponding nerves were undertaken in MMN and ALS patients. Electromyography was performed in ALS patients according to revised El-Escorial criteria. ANOVA and unpaired t test with Bonferroni correction revealed significant differences in cross-sectional areas (CSA) of different nerves and C6 diameter between the groups. Nerve enlargement was found significantly more frequently in MMN than in other groups (p < 0.001). Receiver operating characteristics analysis revealed detection of enlarged nerves/roots in at least four measurement points to serve as a good marker to differentiate MMN from ALS with a sensitivity of 87.5% and a specificity of 94.1%. Ultrasonic focal nerve enlargement in MMN was often not colocalized with areas of conduction blocks found in nerve conduction studies. Systematic ultrasound measurements in different nerves and nerve roots are valuable for detecting focal nerve enlargement in MMN, generally not found in ALS and thus could serve as a diagnostic marker to differentiate between both entities in addition to electrodiagnostic studies.
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Affiliation(s)
- Alexander Grimm
- Department of Neurology, Neuromuscular Center, Basel University Hospital, University Basel, Petersgraben 4, 4000, Basel, Switzerland,
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Ultrasonography of Multifocal Acquired Demyelinating Sensory and Motor Neuropathy (MADSAM). Clin Neuroradiol 2015; 25:423-5. [PMID: 25556187 DOI: 10.1007/s00062-014-0364-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 11/20/2014] [Indexed: 12/17/2022]
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Kerasnoudis A, Pitarokoili K, Gold R, Yoon MS. Bochum ultrasound score allows distinction of chronic inflammatory from multifocal acquired demyelinating polyneuropathies. J Neurol Sci 2015; 348:211-5. [DOI: 10.1016/j.jns.2014.12.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Revised: 11/09/2014] [Accepted: 12/08/2014] [Indexed: 01/23/2023]
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Grimm A, Heiling B, Schumacher U, Witte OW, Axer H. Ultrasound differentiation of axonal and demyelinating neuropathies. Muscle Nerve 2014; 50:976-83. [PMID: 24634226 DOI: 10.1002/mus.24238] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2014] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Ultrasound can be used to visualize peripheral nerve abnormality. Our objective in this study was to prove whether nerve ultrasound can differentiate between axonal and demyelinating polyneuropathies (PNPs). METHODS Systematic ultrasound measurements of peripheral nerves were performed in 53 patients (25 with demyelinating, 20 with axonal, 8 with mixed neuropathy) and 8 healthy controls. Nerve conduction studies of corresponding nerves were undertaken. RESULTS Analysis of variance revealed significant differences between the groups with regard to motor conduction velocity, compound muscle action potential amplitude, and cross-sectional area (CSA) of different nerves at different locations. Receiver operating characteristic curve analysis revealed CSA measurements to be well suited for detection of demyelinating neuropathies, and boundary values of peripheral nerve CSA could be defined. CONCLUSIONS Systematic ultrasound CSA measurement in different nerves helped detect demyelination, which is an additional cue in the etiological diagnosis of PNP, along with nerve conduction studies and nerve biopsy.
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Affiliation(s)
- Alexander Grimm
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany; Department of Neurology, Basel University Hospital, Petersgraben 4 CH-4000, Basel, Switzerland; Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
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