Fig 2 - uploaded by Univ. Prof. Dr. Hannes Gruber
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a, b Transverse a and longitudinal b section through a peripheral nerve. The typical honeycomb echotexture which is caused by the hypoechoic fascicles embedded in the hyperechoic epineurium and endoneurium (arrows) is visible in the transverse section (sciatic nerve in this example).The peripheral nerve (median nerve in this example) is typically seen in the longitudinal section as a hypoechoic longitudinal structure (between the arrows) with slightly wavy internal echoes.
Similar publications
Abdominal wall pain can be challenging to diagnose and treat, as many etiologies can have similar presentations. Anterior cutaneous nerve entrapment syndrome has been reported to be a significant cause of AWP. Here, we report the case of a patient who was initially diagnosed with anterior cutaneous nerve entrapment syndrome and ultimately found to...
Citations
... The cross sectional area (CSA) of the tibial nerve was measured at its transverse view at about 3 cm above the medial malleolus bone avoiding tibial nerve branches, by using a free hand tracing technique. The measurement involves the nerve fibers just inside the epineurium border The transducer was placed perpendicular to the nerve fibers to acquire accurate measurement with no additional pressure force to avoid any nerve deformity leads to false measurement [11,24]. Normal tibial nerve cross sectional area is 12.7 mm 2 ± 2.5 at the level of the medial malleolus; in reference to previous literature [24,25]. ...
... The measurement involves the nerve fibers just inside the epineurium border The transducer was placed perpendicular to the nerve fibers to acquire accurate measurement with no additional pressure force to avoid any nerve deformity leads to false measurement [11,24]. Normal tibial nerve cross sectional area is 12.7 mm 2 ± 2.5 at the level of the medial malleolus; in reference to previous literature [24,25]. ...
... In our study, the healthy controls showed comparable values of tibial nerve CSA to those reported in previous literature [24,25], no statistically significant difference between diabetic patients without DPN and healthy controls in regards to tibial nerve CSA. Meanwhile, the tibial nerve CSA was found to be larger in patients with DPN compared to other groups (DM and controls). ...
Background
Diabetic peripheral neuropathy (DPN) is a major complication of Diabetes mellitus. So this study aimed at investigation of the value of tibial nerve stiffness measured by shear wave ultrasound elastography (SWE) for detection of DPN. This case–control study involved 50 patients with DPN, 50 patients with diabetes mellitus but without DPN, and 50 healthy controls. Clinical examination, nerve conduction study of both tibial nerves, high resolution ultrasound and SWE to assess cross sectional area "CSA" of tibial nerves, and tibial nerves mean stiffness, respectively. ROC curve analysis was also performed.
Results
Mean tibial nerve stiffness by SWE was higher in patients with DPN compared to other groups ( P value < 0.001). The CSA of the tibial nerve in the DPN group was significantly larger than that in the other groups ( P value = 0.01). The cutoff value by ROC curve analysis for tibial nerve stiffness to differentiate patients with DPN and control group was 70.6 kPa ( P value < 0.001, 95.4% sensitivity, 94.7% specificity, AUC = 0.963), while 86.5 kPa was the optimal cutoff point to differentiate patients with DPN and other groups with a 94.6% sensitivity, 93.8% specificity, AUC of 0.975 and P value < 0.001. Higher diagnostic accuracy was found when combination of SWE and high resolution US (high resolution US + shear wave; 0.987, P value < 0.001).
Conclusions
Tibial nerve stiffness was increased in patients with DPN. SWE can be used as an effective complementary method in diagnosis of DPN with high sensitivity and accuracy.
... For Peer Review Only Diabetes So far, ultrasonography provides additional information including nervous lesion morphology, anatomic location, relationship of lesions to surrounding soft tissues for diagnosis and surgical planning for peripheral nerve lesions (22,23). But it is still unable to evaluate neuromuscular function. ...
The aim of this study was to explore changes in morphological and mechanical properties of lower limb skeletal muscles in diabetic patients with and without diabetic peripheral neuropathy (DPN) and seek to find a potential image indicator for monitoring the progress of DPN in patients with type 2 diabetes mellitus (T2DM). A total of 203 patients with type 2 diabetes mellitus (T2DM), with and without DPN, were included in this study. Ultrasonography and ultrasound shear wave imaging (USWI) of the abductor hallux (AbH), tibialis anterior (TA), and peroneal longus (PER) muscles were performed for each subject, and the shear wave velocity (SWV) and cross-sectional area (CSA) of each AbH, TA, and PER were measured. The clinical factors influencing AbH_CSA and AbH_SWV were analyzed, and the risk factors for DPN complications were investigated. AbH_CSA and AbH_SWV in the T2DM group with DPN decreased significantly (p < 0.05), but no significant differences were found in the SWV and CSA of the TA and PER between the two groups. TCSS score and glycosylated haemoglobin were independent predictors of AbH_CSA and AbH_SWV. As AbH_SWV and AbH_CSA decreased, the TCSS score and glycosylated haemoglobin increased, and the incidence of DPN increased significantly. In conclusion, the AbH muscle of T2DM patients with DPN became smaller and softer, while its morphological and mechanical properties were associated with the clinical indicators related to the progression of DPN. Thus, they could be potential imaging indicators for monitoring the progress of DPN in T2DM patients.
... Carpal tunnel syndrome (CTS) is the most frequent compressive neuropathy, caused by compression of the median nerve at the level of the transverse carpal ligament (TCL) [1][2][3]. Diagnosis of CTS is mainly based on typical clinical symptoms, electrodiagnostic testing and high-resolution ultrasound (HRUS) [4]. ...
Purpose
To present a safety-optimized ultrasound-guided minimal invasive carpal tunnel release (CTR) procedure.
Materials and Methods
104 patients (67 female, 37 male; mean age 60.6 ± 14.3 years, 95% CI 57.9 to 63.4 years) with clinical and electrophysiological verified typical carpal tunnel syndrome were referred for a high-resolution ultrasound of the median nerve and were then consecutively assigned for an ultrasound-guided CTR after exclusion of possible secondary causes of carpal tunnel syndrome such as tumors, tendovaginitis, ganglia and possible contraindications (e.g., crossing collateral vessels, nerve variations). Applying a newly adapted and optimized algorithm, basing on the work proposed by Petrover et al. CTR was performed using a button tip cannula which has several safety advantages: On the one hand, the button tip cannula acts as a blunt and atraumatic guiding splint for the subsequent insertion of the hook-knife, and on the other hands, it serves as a “hydro-inflation”-tool, i.e., a fluid-based expansion of the working-space is warranted during the whole procedure whenever needed.
Results
In all patients, successful releases were confirmed by the depiction of a completely transected transverse carpal ligament during and in the postoperative ultrasound-controls two weeks after intervention. All patients reported markedly reduction of symptoms promptly after this safety-optimized ultrasound-guided minimal invasive CTR and at the follow-up examination. No complications were evident.
Conclusion
The here proposed optimized algorithm assures a reliable and safe ultrasound-guided CTR and thus should be taken into account for this minimal invasive interventional procedure.
... Neuroma-in-continuity is seen as fusiform hypoechoic thickened nerve with extincted nerve echotexture Thus, US can facilitate the therapeutic decisions with proper method (neurorrhaphy, nerve grafting or neurolysis). Postoperative complications such as abnormal scarring and dehiscence of the nerve sutures can be diagnosed too [12]. Other advantages of US are it is portable ,able of continuous scanning without skipped sections, gives a more dynamic study and real time imaging, furthermore it can be used on claustrophobic patients and it facilitated the surgical planning in cases with neuroma, foreign bodies and post fracture complication. ...
... patients were males(60%), 6 patients were female(40%). Twelve (12) nerves have been injured in the RT side (60%) and the Lt side was involved in (8) nerves (40%). The mean age was 30.20± 14.67 years (minimum age was 12 years and maximum was 56 years).The most affected age group was between 15-30 years (40% of the cases).Isolated nerve injury has been reported in 66.7% of cases and two nerve injuries was noticed in 5 patients (33,3%).the ...
... Bij de besproken patiënte was er, zoals hogerop beschreven, een afplatting van de zenuw ter hoogte van zijn compressieplaats door de MAE met proximaal hiervan een duidelijke opzetting van de zenuw. Deze vormafwijkingen zijn een gevolg van abnormale druk op de zenuw met lokale disruptie van de microcirculatie en veneuze congestie, met op zijn beurt oedeem van het epi-/endoneurium (17). Een MRI kan, maar is niet noodzakelijk om de diagnose te stellen (5,9). ...
... The examination of the MN is usually started with transverse sections. Once found, the MN can be simply traced upwards and downwards in crosssections (5). The site of underlying pathology of the NM should be examined on longitudinal scans as well. ...
Introduction: High resolution ultrasound (US) is one of the most commonly used method for visualing the median nerve. One
of the most important US features of the MN pathology is change of nerve size. Therefore it is crucial to have normal values of the MN routinelly assessed. The purpose of this study was to determinate the reference values for the cross sectional area (CSA) of the MN in a healthy Bosnian population.
Participants and methods: One hundred healthy individuals were investigated with high reso lution US at the Department of Neurology
University Clinical Centre in Tuzla from January 2016 to June 2019. Participants were recruited from the hospital staff and medical students. Demographic data such as age, gender, height and body weight were recorde
Results: Average age of participants was 41.4 6.1 years; weight
66.0 3.1 kg and height 168 3 cm. The 3 CSA measurements of the MN were carried out: MN at the mid upper arm; MN at the distal third of the forearm and MN at the proximal entrance of the carpal tunnel. Mean CSA measures of MN ranged from to 5.6 to 8.9 mm 2
Discussion: CSA measurements of the MN were dependent of age but independent of weight and height. Regarding gender, males had thicker nerves in the arm and carpal area. Several reports have been published on reference values for the CSA of the MN. The US is important as a diagnostic tool in pathology of NM due to dynamic
examination, assesment of long median nerve segments in a short time, bed side availibility, non invasive and low cost.
Keywords
nervus medianus, cross sectional area, ultrasound
... High resolution ultrasound is a cheap, noninvasive examination method (21,22). It has unique advantages to the morphological description of neuropathy, which makes it possible to visualize the location and range of the lesion (23). It is widely used in the detection of neuropathy. ...
Background:
To evaluate the value of shear wave elastography (SWE) in the detection of diabetic peripheral neuropathy (DPN) of the median and tibial nerves.
Methods:
The study included 40 DPN patients, 40 diabetic mellitus (DM) patients without DPN, and 40 healthy subjects. High-resolution ultrasonography (US) and SWE were performed on the median nerve (MN) and tibial nerve (TN), and cross-sectional area (CSA) and nerve stiffness were measured. ROC analysis was also performed.
Results:
The patients with DPN demonstrated higher stiffness of the median and tibial nerve compared with that of healthy volunteers and DM patients (P<0.001). Bilateral analysis showed that there was no significant difference in nerve stiffness between the left and right median nerves and tibial nerves in DPN patients (P>0.05). The stiffness of median nerve and tibial nerve in each one side also had no significant difference in patients with DPN (P>0.05). The CSA of the tibial nerve in the DPN group was significantly larger than that in the other groups (P<0.001), while there was no significant difference of median nerve CSA among the three groups (P>0.05). The area under curve (AUC) of SWE (MN: 0.899, TN: 0.927) to diagnose DPN was significantly greater than that of CSA (TN: 0.798). The optimal cut-off value in SWE of the tibial nerve and median nerve for diagnosis of DPN was 4.11 and 4.06 m/s, respectively, with a good sensitivity and specificity.
Conclusions:
Median and tibial nerve stiffness was significantly higher in patients with DPN. These findings suggest that SWE-based stiffness measurement of the nerve was a better method than CSA, and it can be used as another effective assistant method in the diagnosis of DPN.
... Limitations are the costs and as-yet unproven diagnostic sensitivity. Peripheral nerve ultrasound is becoming more common for the diagnosis of peripheral neuropathies [46,47] . Sural nerve ultrasound has been shown to visualize the inner portions of the sural nerve allowing for morphological changes of diabetic neuropathy to be seen [48] . ...
Objective: To review the current diagnostic modalities for diabetic neuropathy, common long-term complications of diabetes mellitus. Methods: We performed a MEDLINE using a combination of words (diabetic neuropathy, diagnosis, and treatment) to identify original studies, consensus statements, and reviews published in the last thirty years. Emphasis was on the diagnosis of diabetic distal symmetrical polyneuropathy (the most common form), especially newer modalities. Results: A plethora of tests are available for the diagnosis of diabetic neuropathy. Some of these are simple and easy to perform in clinical settings while others require sophisticated equipment and expertise to be carried out. Conclusion: Early screening and diagnosis of diabetic neuropathy, preventive modalities, patient, and physician education remain cardinal factors in reducing this complication and mortality.
... In most cases, CTS is qualified as idiopathic [4]. Well-known etiologies for secondary CTS include tenosynovitis of the flexor tendons, joint ganglions, accessory muscle bellies, tendon sheath fibromas, amyloid deposits, and thrombosis of a persistent median artery [5]. However, the indication for surgery is still based on clinical presentation [6]. ...
Purpose
High-resolution ultrasound is increasingly used in the diagnosis of carpal tunnel syndrome; yet little is known about gender differences in clinical presentation and ultrasound findings.
Materials and methods
In this high-resolution ultrasound-based retrospective study in 170 cases, we assessed gender influence in CTS in terms of the severity of neural alterations by wrist-to-forearm ratio (WFR), epineural thickening, loss of fascicular anatomy, as well as classical signs and symptoms. The control group consisted of 42 wrists.
Results
Women present with a greater WFR at first admission are affected more often bilaterally, and report less subjective pain intensity, while men report fewer nightly pain episodes at higher WFR. Loss of fascicular anatomy is three times more frequent in women. An increase in epineural thickness, loss of fascicular anatomy, and involvement of more than 1.5 fingers correlate significantly with WFR regardless of sex.
Conclusion
Women differ significantly from men in terms of clinical presentation and ultrasound findings upon first diagnosis of CTS, which should be included in further diagnostic considerations.
... It is also noteworthy that high-resolution nerve ultrasound may visualize nerve compromise related to motion with less effort than MRN. The basic requirement for this method, that is already frequently used for the examination of the PNS, is a high-end sonography unit provided with a highresolution broadband linear probe (> 12 MHz, ideally 18-22 MHz) and corresponding soft tissue contrast enhancing software [23]. With a 15 MHz transmission frequency, an axial resolution of up to 250 µm can be achieved [23]. ...
... The basic requirement for this method, that is already frequently used for the examination of the PNS, is a high-end sonography unit provided with a highresolution broadband linear probe (> 12 MHz, ideally 18-22 MHz) and corresponding soft tissue contrast enhancing software [23]. With a 15 MHz transmission frequency, an axial resolution of up to 250 µm can be achieved [23]. The axial in-plane resolution of MRN at distal extremity level is at a similar order at 100-200 µm and depends on several factors such as acquisition time. ...
... Besides cost-and time-effectiveness, the major advantage of high-resolution sonography is that it allows direct and dynamic imaging of peripheral nerves under physiological movement. It might be helpful for example in secondary or atypical cubital tunnel syndrome, where it can help to establish the diagnosis of ulnar nerve dislocation over the medial epicondyle, which typically occurs during elbow flexion and is reduced with elbow extension, and at the same time to clarify whether additional snapping triceps syndrome accompanies this pathological situation [23,24]. ...
The diagnostic work-up of peripheral neuropathies is often challenging and is mainly based on a combination of clinical and electrophysiological examinations. One of the most important difficulties is the accurate determination of the lesion site (lesion localization), lesion extension, and spatial lesion dispersion, which all represent essential diagnostic information crucial for finding the correct diagnosis and hence an adequate therapeutic approach. A typical pitfall in the conventional diagnostic reasoning is the differentiation between a distal, complete cross-sectional nerve lesion and a more proximally located, fascicular nerve lesion. Magnetic resonance neurography (MRN) has been proven to be capable of improving the diagnostic accuracy by providing direct, noninvasive visualization of nerve injury with high structural resolution even reaching the anatomical level of single nerve fascicles (fascicular imaging) and at the same time with large anatomical coverage. It is also feasible to detect structural nerve damage earlier and with higher sensitivity than gold-standard nerve conduction studies. The purpose of this study is to review the literature for current developments and advances in MRN for the precise spatial detection of nerve lesions in focal and non-focal disorders of the peripheral nervous system.
