Ultrasound of peripheral nerves in acromegaly: changes at 1-year follow-up

Neuromuscular Ultrasound in Polyneuropathies

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.

Changes in Cross-Sectional Area of the Median Nerve and Body Composition Parameters after Treatment of Acromegaly: 1 year Follow-Up

OBJECTIVE

Median neuropathy is a common manifestation of acromegaly, although its pathology is uncertain. Changes in levels of growth hormone (GH) and insulin-like growth factor I (IGF-I) and body composition are potential parameters in pathology of median neuropathy in acromegaly. We aimed to assess changes in the cross-sectional area (CSA) of the median nerve and body composition in newly diagnosed acromegalic patients 1 year after treatment and to determine their mutual relationships.

DESIGN

This prospective study included 30 patients with newly diagnosed acromegaly and 30 healthy controls matched for age, gender, and body mass index. Physical and laboratory examinations, dual-energy X-ray absorptiometry (DXA), and ultrasound evaluations were performed at baseline and 1 year after initial treatment.

RESULTS

The CSA of the median nerve was increased in acromegalic patients compared with controls (13.1 mm² [12.2-14.9] vs 7.5 mm² [6.4-8.4], P < 0.001). One year after treatment of acromegaly, GH and IGF-I levels decreased significantly. The median nerve CSA was significantly reduced after treatment (11.6 mm² [10.2-13.1], P < 0.001). Reduction of IGF-I levels correlated with a decrease in lean mass and increase in fat mass. The median nerve CSA positively correlated with IGF-I levels (R = 0.492, P=0.006) and lean mass (R = 0.419, P=0.021) in acromegalic patients before treatment.

CONCLUSION

This study demonstrates a reduction in the median nerve CSA 1 year after treatment of acromegaly. These changes are closely associated with a reduction in IGF- I levels and in lean body mass. The enlargement of the median nerve in acromegaly can be reversed with adequate treatment.

Circulating insulin-like growth factor-I and risk of 25 common conditions: outcome-wide analyses in the UK Biobank study

While there is strong epidemiological evidence that circulating insulin-like growth factor-I (IGF-I) is associated with a higher risk of several cancers, little is known about its association with non-cancer outcomes. We investigated associations of circulating IGF-I with risk of 25 common conditions, other than cancer, in a large British cohort. Study participants were 318,749 middle-aged adults enrolled in the UK Biobank Study. Serum IGF-I concentration was measured in samples collected at baseline (2006-2010), and re-measured in 12,334 participants after an average of 4.3 years. We followed-up participants over an average of 11.5 years by linking to hospital admissions and mortality registries. Multivariable-adjusted Cox regressions estimated hazard ratios (HRs) and 95% confidence intervals (CIs) for associations between circulating IGF-I and 25 common conditions, using the repeated IGF-I measurements to correct for regression dilution bias. After correction for multiple testing (P < 0.002), IGF-I was positively associated with carpal tunnel syndrome (HR per 5 nmol/l higher concentration = 1.12, 95% CI 1.08-1.16), and inversely associated with varicose veins (0.90, 0.85-0.95), cataracts (0.97, 0.95-0.99), diabetes (0.92, 0.90-0.95), and iron deficiency anaemia (0.90, 0.86-0.93). The associations for cataracts and diabetes attenuated when restricted to cases diagnosed after five or more years of follow-up, suggesting that these associations were likely affected by reverse causality. Higher IGF-I concentration might be associated with the risk for several conditions, but genetic studies are needed to clarify which associations may be causal.

Influence of Disease Activity and Body Composition Parameters on Cross-Sectional Area of the Median Nerve in Acromegalic Patients

Carpal tunnel syndrome (CTS) is neuropathy that occurs due to compression of the median nerve in the carpal tunnel. Acromegaly is one of the important causes of CTS. The aim of this study was to examine median nerve with ultrasound in acromegalic patients and to assess the relationship with activity, duration of disease and body composition parameters. We prospectively examined the cross-sectional area (CSA) of the median nerve with high-resolution ultrasound in 107 acromegalic patients – control group (70 females and 37 males) and 107 healthy controls (70 females and 37 males) matched for age, gender, and BMI. Body composition parameters were assessed by dual-energy X-ray absorptiometry (DXA). The Student t-tests and Pearson correlation were used for data analysis. The cross sectional area of the median nerve was increased in acromegalic patients compared to controls (11.9±4.8 mm2 vs. 7.7±2.4 mm2, P<0.001). Positive correlation was found between IGF-1 levels and CSA in the acromegalic group (R = 0.400, P<0.001). Relationship between CSA and duration of acromegaly was not confirmed. In acromegalic patients, BMI correlated with the CSA (R=0.294, P=0.002). There was no significant difference in BMI, fat mass between the acromegalic and control group, but lean mass was higher in acromegalic patients compared with controls (54.8±13.3 vs. 51±11.6, P=0.047). Lean mass and LMI (total body lean mass/height) positively correlated with CSA in acromegalic patients (R=0.340, P<0.001; R=0.424, P<0.001). No correlation was observed between fat mass and CSA of median nerve in all groups. We confirmed the enlargement of the median nerve in acromegalic patients. This enlargement is proportional to the degree of IGF-1 levels and is not dependent on the duration of the disease. The enlargement of the median nerve in acromegalic patients also depends on lean body mass and is not dependent on fat body mass.

Influence of Disease Activity and Body Composition Parameters on Cross-Sectional Area of the Median Nerve in Acromegalic Patients

Carpal tunnel syndrome (CTS) is neuropathy that occurs due to compression of the median nerve in the carpal tunnel. Acromegaly is one of the important causes of CTS. The aim of this study was to examine median nerve with ultrasound in acromegalic patients and to assess the relationship with activity, duration of disease and body composition parameters. We prospectively examined the cross-sectional area (CSA) of the median nerve with high-resolution ultrasound in 107 acromegalic patients (70 females and 37 males) and 107 healthy controls (70 females and 37 males) matched for age, gender, and BMI. Body composition parameters were assessed by dual-energy X-ray absorptiometry (DXA). The Student t-tests and Pearson correlation were used for data analysis. The cross sectional area of the median nerve was increased in acromegalic patients compared to controls (11.9 ± 4.8 mm2 vs. 7.7 ± 2.4 mm2, P < 0.001). Positive correlation was found between IGF-1 levels and CSA in the acromegalic group (R = 0.400, P < 0.001). Relationship between CSA and duration of acromegaly was not confirmed. In acromegalic patients, BMI correlated with the CSA (R = 0.294, P = 0.002). There was no significant difference in BMI, fat mass between the acromegalic and control group, but lean mass was higher in acromegalic patients compared with controls (54.8 ± 13.3 vs. 51 ± 11.6, P = 0.047). Lean mass and LMI (total body lean mass/height) positively correlated with CSA in acromegalic patients (R = 0.340, P < 0.001; R = 0.424, P < 0.001). No correlation was observed between fat mass and CSA of median nerve in either group. We confirmed the enlargement of the median nerve in acromegalic patients. This enlargement is proportional to the degree of IGF-1 levels and is not dependent on the duration of the disease. The enlargement of the median nerve in acromegalic patients also depends on lean body mass and is not dependent on fat body mass.

A Consensus on the Diagnosis and Treatment of Acromegaly Comorbidities: An Update

OBJECTIVE

The aim of the Acromegaly Consensus Group was to revise and update the consensus on diagnosis and treatment of acromegaly comorbidities last published in 2013.

PARTICIPANTS

The Consensus Group, convened by 11 Steering Committee members, consisted of 45 experts in the medical and surgical management of acromegaly. The authors received no corporate funding or remuneration.

EVIDENCE

This evidence-based consensus was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe both the strength of recommendations and the quality of evidence following critical discussion of the current literature on the diagnosis and treatment of acromegaly comorbidities.

CONSENSUS PROCESS

Acromegaly Consensus Group participants conducted comprehensive literature searches for English-language papers on selected topics, reviewed brief presentations on each topic, and discussed current practice and recommendations in breakout groups. Consensus recommendations were developed based on all presentations and discussions. Members of the Scientific Committee graded the quality of the supporting evidence and the consensus recommendations using the GRADE system.

CONCLUSIONS

Evidence-based approach consensus recommendations address important clinical issues regarding multidisciplinary management of acromegaly-related cardiovascular, endocrine, metabolic, and oncologic comorbidities, sleep apnea, and bone and joint disorders and their sequelae, as well as their effects on quality of life and mortality.

Acromegaly and ultrasound: how, when and why?

BACKGROUND

Acromegaly is a rare disease caused by an excess of growth hormone and insulin-like growth factor 1. It is usually diagnosed because of typical signs such as macroglossia, acral enlargement, jaw prognathism and malocclusion. Systemic complications are a major cause of morbidity and mortality in acromegaly, and many patients remain undiagnosed for several years. Increased ultrasound (US) application in the general population, and including among acromegaly patients, has revealed many suggestive features which, taken together with clinical suspicion, could induce suspicion of this disease.

PURPOSE

This review describes main US features in acromegaly. Echocardiography shows a typical cardiomyopathy, characterized by left ventricular hypertrophy, diastolic and systolic dysfunction, aortic and mitral regurgitation, and increased aortic root diameters. US preclinical markers of atherosclerosis, such as intima media thickness (IMT), seem also to be impaired. Visceromegaly and increased organ stiffness are other features of acromegaly, including enlarged prostate, kidneys, liver, and thyroid. In addition, other US findings are: renal cysts, micronephrolithiasis, impairment of renal haemodynamic parameters, gallstones and gallbladder polyps, hepatic steatosis, thyroid nodules, multinodular goiter, and polycystic ovaries. Musculoskeletal US findings are increased cartilage thickness, impaired density and elasticity of bones, nerve enlargement, carpal and cubital tunnel syndrome, and trigger finger.

CONCLUSIONS

Acromegaly patients frequently present systemic complications and a diagnostic delay. US features of acromegaly are not specific, but could potentially have a key role in early detection of the disease in the presence of typical clinical features.

Current perspectives on the impact of clinical disease and biochemical control on comorbidities and quality of life in acromegaly

Acromegaly is a rare chronic, systemic disorder caused by excessive growth hormone (GH) secretion from a somatotroph pituitary adenoma. GH hypersecretion leads to overproduction of insulin-like growth factor-1 (IGF-1), which contributes to the somatic overgrowth, physical disfigurement, onset of multiple systemic comorbidities, reduced quality of life (QoL) and premature mortality of uncontrolled patients. Somatostatin receptor ligands, dopamine agonists and a GH receptor antagonist are currently available for medical therapy of acromegaly. The main aim of treatment is biochemical normalisation, defined as age-normalised serum IGF-1 values and random GH levels <1.0 μg/L. However, there is an increasing evidence suggesting that achieving biochemical control does not always decrease the burden of disease-related comorbidities and/or improve patients' QoL. This lack of correlation between biochemical and clinical control can be due to both disease duration (late diagnosis) or to the peculiarity of a given comorbidity. Herein we conducted ad hoc literature searches in order to find the most recent and relevant reports on biochemical and clinical disease control during medical treatment of acromegaly. Particularly, we analyse and describe the relationship between biochemical, as well as clinical disease control in patients with acromegaly receiving medical therapy, with a focus on comorbidities and QoL. In conclusion, we found that current literature data seem to indicate that clinical disease control (besides biochemical control), encompassing clinical signs and symptoms, comorbidities and QoL, emerge as a primary focus of acromegaly patient management.

Effects of anodyne treatment on local blood flow and cutaneous sensation of the foot in a patient with peripheral neuropathy secondary to acromegaly

Acromegaly is an excessive amount of serum growth hormone, which may present with sensorimotor polyneuropathy, affecting sensation and/or blood flow in the limbs. Symptoms include numbness, tingling or pain with impaired sensation including kinesthesia and proprioception. We report here of a 48-year-old male with a defined diagnosis of acromegaly and surgical excision of a pituitary adenoma 20 years ago. Recently he reports feet stepping on, and not feeling, objects under foot and balance problems starting 10 years ago. This study used a single-subject A-B-A design to show that behavioral changes are evident only in the presence of an intervention. Intervention consisted of Monochromatic Infrared Light Energy (MIRE), delivered by the Anodyne Therapy System (ATS). The DRT-4 laser Doppler measured red blood cell flux (flow), concentration and velocity. Levels of significance utilized the two standard deviation band method. Peripheral sensation of eight sites on each foot assessed using Semmes-Weinstein monofilaments (SWM) revealed a lack of sensation in the feet. A treatment effect as exhibited by blood flow velocity and red blood cell concentration was detected after the third week of treatment indicating peripheral dilation of the microvasculature. MIRE was an effective intervention for the treatment of acromegaly - induced polyneuropathy in this patient.

Ultrasound versus MRI in common fibular neuropathy

INTRODUCTION

We prospectively compared ultrasound (US) and MRI in patients with common fibular neuropathy.

METHODS

Forty adult patients with clinical suspicion of common fibular neuropathy and 40 healthy controls underwent both US and MRI. US and MRI datasets were randomized for prospective reading.

RESULTS

The overall sensitivity of US and MRI for diagnosing fibular neuropathy was 90% (95% confidence interval [CI], 79.7%-97.3%) and 87.5% (95% CI, 71.55%-93.1%), respectively. The overall specificity of US and MRI was 92% (95% CI, 77.45%-96.1%) and 85% (95% CI, 73.3%-94.4%), respectively. The overall sensitivity and specificity of US combined with MRI were 94% (95% CI, 0.80%-0.99%) and 84% (95% CI, 0.70%-0.91%), respectively. Overall intra- and inter-observer agreements among 3 readers were 0.76% (95% CI, 0.62%-0.85%) and 0.74% (95% CI, 0.65%-0.81%).

CONCLUSIONS

US diagnostic accuracy for common fibular neuropathy was slightly higher than that of MRI. Muscle Nerve 55: 849-857, 2017.

Neurological Complications of Endocrine Disease

The endocrine system is a complex group of organs and glands that relates to multiple other organs and systems in the body with the ultimate goal of maintaining homeostasis. This complex network functions through hormones excreted by several glands and released in the blood, targeting different body tissues and modulating their function. Any primary disorders affecting the endocrine glands and altering the amount of hormones synthesized and released will lead to disruption in the functions of multiple organs. The central nervous system of a developing child is particularly sensitive to endocrine disorders. A variety of neurological manifestations have been described as features of several endocrine diseases in childhood. Their knowledge may contribute to an early diagnosis of a particular endocrine condition, especially when more typical features are not present yet. In this article, we discuss specific neurological manifestations found in various endocrine disorders in children.

Neuromuscular Ultrasound in the Assessment of Polyneuropathies and Motor Neuron Disease

Neuromuscular ultrasound is an emerging technology for the evaluation of conditions affecting nerve and muscle, with most of the research focusing on focal neuropathies. Despite this focus, researchers have also investigated the ultrasonographic changes that occur in the nerves and muscles of those with more diffuse polyneuropathies and motor neuron diseases, and this review will detail the findings in these conditions. Specific findings are discussed in this article, but general themes will also be presented and include the following: hereditary polyneuropathies show diffuse nerve enlargement, whereas immune-mediated polyneuropathies show more patchy involvement; nerve enlargement is more profound in demyelinating than axonal polyneuropathies; and muscle changes in motor neuron diseases include heterogeneous increases in echogenicity, atrophy, readily detectable fasciculations, and increased subcutaneous tissue thickness.

Peripheral nervous system assessment in acromegaly patients under somatostatin analogue therapy

PURPOSE

Acromegaly is known to affect peripheral nervous system (PNS) causing carpal tunnel syndrome (CTS) and polyneuropathy. The frequency of these disorders and the evaluation methods vary among studies. In the present study, we aimed to examine PNS of acromegaly patients under somatostatin analogue (SSA) therapy.

METHODS

Forty-eight acromegaly patients (26 F/22 M, 45.58 ± 11.6 years) under SSA treatment and 44 healthy controls (25 F/19 M, 47.46 ± 8.7 years) were assessed by symptom questionnaires, neurologic examination and electrophysiological studies.

RESULTS

87.5 % of the acromegaly patients had at least one abnormal finding regarding PNS. With the incorporation of palm-wrist median nerve conduction velocity method, we detected CTS in 50 % of patients. Polyneuropathy was less frequent (29.2 %). Both conditions were independent from the coexisting diabetes mellitus (p = 0.22 for CTS, p = 0.71 for polyneuropathy). Polyneuropathy but not CTS was more common among biochemically uncontrolled acromegaly patients rather than those under control (p = 0.03; p = 0.68, respectively).

CONCLUSION

Our findings emphasize the high prevalence of peripheral nervous system involvement in acromegaly patients under SSA therapy and importance of neurological evaluation of these patients. Early diagnosis and treatment of the disease may reduce the PNS involvement.

Ultrasonography of peripheral nerves

Over the last decade, neuromuscular ultrasonography has emerged as a useful tool for the diagnosis of peripheral nerve disorders. This article reviews sonographic findings of normal nerves, including key quantitative ultrasound measurements that are helpful in the evaluation of focal and possibly generalized peripheral neuropathies. It also discusses several recent articles outlining the evidence base for the use of this technology, as well as new findings in compressive, traumatic, and generalized neuropathies. Ultrasonography is well suited for use in electrodiagnostic laboratories, where physicians, experienced in both the clinical evaluation of patients and the application of hands-on technology, can integrate findings from the patient's history, physical examination, electrophysiological studies, and imaging for diagnosis and management.