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Introduction: We describe a unique method that combines ultrasound and electromyography to guide intramuscular diaphragm injections in anesthetized large animals., Methods: Ultrasound was used to visualize the diaphragm on each side of spontaneously breathing, anesthetized beagle dogs and cynomolgus macaques. An electromyography (EMG) needle was introduced and directed by ultrasound to confirm that the needle entered the muscular portion of the diaphragm, and methylene blue was injected. Injection accuracy was confirmed upon necropsy by tracking the spread of methylene blue., Results: All methylene blue injections were confirmed to have been placed appropriately into the diaphragm., Conclusions: This study demonstrates the feasibility and accuracy of using ultrasound and EMG to guide injections and to reduce complications associated with conventional blind techniques. Ultrasound guidance can be used for clinical EMG of the diaphragm. Future applications may include targeted diaphragm injections with gene replacement therapy in neuromuscular diseases., (© 2014 Wiley Periodicals, Inc.)

Disulfiram toxicity can cause multiple neurologic problems, including a reversible distal sensorimotor axonal polyneuropathy. Although electrodiagnosis and biopsy results have been described in the diagnosis and management of patients with disulfiram associated polyneuropathy, neuromuscular ultrasound findings have not been reported. The authors present a case of electrodiagnostically confirmed axonal polyneuropathy with relative sural sparing secondary to disulfiram and describe the neuromuscular ultrasound findings in this individual. Ultrasound demonstrated distal enlargement with slight side-to-side asymmetry and normal proximal cross-sectional area in the lower extremity nerves. Neuromuscular ultrasound is another diagnostic modality that may be used to assist in the diagnosis of patients with polyneuropathy secondary to disulfiram.

Introduction: The aim of this study was to determine whether there is an association between flexor digitorum and lumbrical muscle intrusion into the carpal tunnel and carpal tunnel syndrome (CTS)., Methods: Five hundred thirteen manual laborers (1026 wrists) were evaluated with ultrasound to determine whether those with CTS had more muscle intrusion into the carpal tunnel than those without CTS. One hundred ninety of the participants without CTS at baseline (363 wrists) were followed over 1 year to determine whether muscle intrusion at baseline predicted the development of CTS., Results: Participants with CTS had more muscle within the carpal tunnel with the wrist in the neutral (P=0.026) and flexed (P=0.018) positions than those without CTS. Baseline muscle intrusion did not predict development of CTS at 1 year., Conclusions: Muscle intrusion into the carpal tunnel is associated with CTS, but muscle intrusion alone does not predict the development of CTS over the course of a year., (© 2014 Wiley Periodicals, Inc.)

Introduction: We tested the feasibility of using neuromuscular ultrasound for non-invasive real-time assessment of diaphragmatic structure and function in a canine model of X-linked myotubular myopathy (XLMTM)., Methods: Ultrasound images in 3 dogs [wild-type (WT), n=1; XLMTM untreated, n=1; XLMTM post-AAV8-mediated MTM1 gene replacement, n=1] were analyzed for diaphragm thickness, change in thickness with respiration, muscle echogenicity, and diaphragm excursion amplitude during spontaneous breathing., Results: Quantitative parameters of diaphragm structure were different among the animals. WT diaphragm was thicker and less echogenic than the XLMTM control, whereas the diaphragm measurements of the MTM1-treated XLMTM dog were comparable to those of the WT dog., Conclusions: This pilot study demonstrates the feasibility of using ultrasound for quantitative assessment of the diaphragm in a canine model. In the future, ultrasonography may replace invasive measures of diaphragm function in canine models and in humans for non-invasive respiratory monitoring and evaluation of neuromuscular disease., (Copyright © 2014 Wiley Periodicals, Inc.)

Observations: This case report describes a 75 year-old Caucasian male who initially presented with persistent daily headaches. Physical exam elicited multiple cranial nerve palsies. Gadolinium-enhanced brain MRI demonstrated pachymeningitis. Labs revealed elevated proteinase-3 antineutrophil cytoplasmic antibodies (PR3-ANCA) and cytoplasmic antineutrophil cytoplasmic antibodies (c-ANCA), confirming a diagnosis of GPA., Conclusion: GPA should be considered in older patients presenting with persistent daily headaches and pachymeningitis. Contrast-enhanced brain MRI is an important diagnostic tool., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Background: This analysis examines the associations of work organization attributes among Latino women in manual occupations with musculoskeletal and neurological injuries., Methods: Participants included 234 women in western North Carolina. Outcome measures included epicondylitis, rotator cuff syndrome, back pain, and carpal tunnel syndrome. Independent measures included indicators of job demand, job control, and job support, as well as personal characteristics., Results: Latina workers commonly experienced epicondylitis, rotator cuff syndrome, back pain, and CTS. Awkward posture and decision latitude were associated with epicondylitis. Rotator cuff syndrome was associated with awkward posture and psychological demand. Awkward posture and psychological demand, and decreased skill variety and job control were related to CTS., Conclusions: Work organization factors are potentially important for musculoskeletal and neurological injury among vulnerable workers. Research is required to understand the associations of work and health outcomes of these women. Policy initiatives need to consider how work organization affects health., (© 2014 Wiley Periodicals, Inc.)

Introduction: Electrical impedance myography (EIM) can be used to assess amyotrophic lateral sclerosis (ALS) progression. The relationship between EIM values and standard assessment measures, however, is unknown., Methods: EIM 50 kHz phase data from 60 subjects who participated in a longitudinal natural history study of ALS were correlated with handheld dynamometry (HHD), the ALS Functional Rating Scale-Revised (ALSFRS-R) score, and motor unit number estimation (MUNE)., Results: Moderate strength correlations between EIM parameters and HHD were observed for both whole-body and individual upper and lower extremity values. Similarly, moderate strength correlations were observed between EIM and ALSFRS-R upper and lower extremity subscores, but not total ALSFRS-R scores. MUNE correlated significantly with single muscle EIM data but not with whole body or upper or lower extremity values., Conclusions: These results support the concept that EIM can serve as a meaningful measure of disease severity in ALS., (Copyright © 2013 Wiley Periodicals, Inc.)

Objective: To determine the incidence of carpal tunnel syndrome (CTS) over 1 year in Latino poultry processing workers., Methods: Symptoms and nerve conduction studies were used to identify Latino poultry processing workers (106 wrists) and Latinos in other manual labor occupations (257 wrists) that did not have CTS at baseline, and these individuals were then evaluated in the same manner 1 year later., Results: Based on wrists, the 1-year incidence of CTS was higher in poultry processing workers than non-poultry manual workers (19.8% vs. 11.7%, P = 0.022). Poultry workers had a higher odds (1.89; P = 0.089) of developing CTS over 1 year compared to non-poultry manual workers., Discussion: Latino poultry processing workers have an incidence of CTS that is possibly higher than Latinos in other manual labor positions. Latino poultry workers' high absolute and relative risk of CTS likely results from the repetitive and strenuous nature of poultry processing work., (© 2013 Wiley Periodicals, Inc.)

Neuromuscular ultrasound involves the use of high-resolution ultrasound to image the peripheral nervous system of patients with suspected neuromuscular diseases. It complements electrodiagnostic studies well by providing anatomic information regarding nerves, muscles, vessels, tendons, ligaments, bones, and other structures that cannot be obtained with nerve conduction studies and electromyography. Neuromuscular ultrasound has been studied extensively over the past 10 years and has been used most often in the assessment of entrapment neuropathies. This review focuses on the use of neuromuscular ultrasound in 4 of the most common entrapment neuropathies: carpal tunnel syndrome, ulnar neuropathy at the elbow and wrist, and fibular neuropathy at the knee., (Copyright © 2013 Wiley Periodicals, Inc.)

Introduction: The prevalence of bifid median nerves and persistent median arteries, their co-occurrence, and their relationship to carpal tunnel syndrome (CTS) are only understood partially., Methods: We screened 1026 wrists of 513 Latino manual laborers in North Carolina for bifid median nerves and persistent median arteries using electrodiagnosis and ultrasound., Results: A total of 8.6% of wrists had a bifid median nerve, and 3.7% of wrists had a persistent median artery independent of subgroup ethnicity, age, gender, or type of work. An association with definite carpal tunnel syndrome was not found. The presence of either anatomic variant was associated with a high likelihood of co-occurrence of another variant in the same or the contralateral wrist., Conclusions: The occurrence of median anatomic variants can be determined in field studies using ultrasound. Persistent median arteries and bifid median nerves tend to co-occur but do not put manual laborers at additional risk of developing CTS., (Copyright © 2013 Wiley Periodicals, Inc.)

Introduction: Manual laborers are at increased risk for carpal tunnel syndrome (CTS), and a combination of history, physical examination, and nerve conduction studies is often used to screen for CTS in this population. Neuromuscular ultrasound may be a better screening tool, because it is painless. In this study we compare the accuracy of nerve conduction studies and ultrasound for CTS screening., Methods: Five hundred thirteen manual laborers were screened prospectively for CTS using nerve conduction studies and neuromuscular ultrasound, and the accuracy of the 2 techniques was compared using the Katz hand diagram as the diagnostic standard., Results: The ROC curves for the 2 techniques were not significantly different (P = 0.542), indicating that the approaches had similar diagnostic accuracy., Conclusions: Neuromuscular ultrasound is a painless technique that has diagnostic accuracy similar to nerve conduction studies and can be used to screen large populations at risk for CTS., (Copyright © 2012 Wiley Periodicals, Inc.)

Introduction: Nerve cross-sectional area reference values have been reported for many nerves, but there have been few studies in pediatric and geriatric populations. This study was conducted to determine the influence of age on nerve cross-sectional area., Methods: Thirty-two children (3 months to 16 years) and 20 geriatric adults (67-92 years) without known neurologic conditions underwent bilateral ultrasound to measure the area of the following nerves: median at the wrist and forearm; ulnar at the wrist and elbow; radial in the spiral groove; sciatic in the distal thigh; fibular at the knee; tibial at the knee and ankle; and sural at the ankle., Results: In general, nerve cross-sectional area increased with age. Nerve size correlated most closely with age, but a correlation was also seen with body mass index., Conclusions: Nerve cross-sectional area increases with age, which is important to note when using ultrasound to evaluate children and geriatric patients., (Copyright © 2012 Wiley Periodicals, Inc.)

Introduction: Nerve and muscle ultrasound has been studied in several conditions, but validity and reliability have not been assessed systematically., Methods: Nerve cross-sectional area and muscle thickness were measured ultrasonographically at several sites in 4 cadavers, which were then dissected, and actual measurements were obtained. To assess intrarater and interrater reliability, between 3 and 5 ultrasonographers, with varying experience levels, made repeated measurements on healthy volunteers., Results: Correlation coefficients for nerve and muscle validity were >0.968 (P < 0.001), and for intrarater reliability were >0.901 (P < 0.001) for still and real-time images. Correlation coefficients for interrater reliability were more varied, but for still images they were all significant at the P < 0.001 (0.542-0.998) level, and for real-time images they were significant at the P < 0.05 level for half the sites (0.243-0.981)., Conclusion: Overall, nerve and muscle ultrasound is a valid and reliable diagnostic imaging technique., (Copyright © 2012 Wiley Periodicals, Inc.)

Neuromuscular clinicians are often asked to evaluate the diaphragm for diagnostic and prognostic purposes. Traditionally, this evaluation is accomplished through history, physical exam, fluoroscopic sniff test, nerve conduction studies, and electromyography (EMG). Nerve conduction studies and EMG in this setting are challenging, uncomfortable, and can cause serious complications, such as pneumothorax. Neuromuscular ultrasound has emerged as a non-invasive technique that can be used in the structural and functional assessment of the diaphragm. In this study we review different techniques for assessing the diaphragm using neuromuscular ultrasound and the application of these techniques to enhance diagnosis and prognosis by neuromuscular clinicians., (Copyright © 2012 Wiley Periodicals, Inc., a Wiley company.)

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.

Introduction: Intensive care unit acquired weakness (ICU-AW) results from a complex mixture of nerve and muscle pathology, and early identification is challenging. This pilot study was designed to examine the ultrasonographic changes that occur in muscles during ICU hospitalization., Methods: Patients admitted to the ICU for acute respiratory failure were enrolled prospectively and underwent serial muscle ultrasound for thickness and gray-scale assessment of the tibialis anterior, rectus femoris, abductor digiti minimi, biceps, and diaphragm muscles over 14 days., Results: Sixteen participants were enrolled. The tibialis anterior (P = 0.001) and rectus femoris (P = 0.041) had significant decreases in gray-scale standard deviation when analyzed over 14 days. No muscles showed significant changes in thickness., Conclusions: Ultrasound is an informative technique for assessing muscles of patients in the ICU, and lower extremity muscles demonstrated increased homogeneity during ICU stays. This technique should be examined further for diagnosing and tracking those with ICU-AW., (Copyright © 2012 Wiley Periodicals, Inc.)

Electrical impedance myography (EIM), a non-invasive, electrophysiological technique, has preliminarily shown value as an ALS biomarker. Here we perform a multicenter study to further assess EIM's potential for tracking ALS. ALS patients were enrolled across eight sites. Each subject underwent EIM, handheld dynamometry (HHD), and the ALS Functional Rating Scale-revised (ALSFRS-R) regularly. Techniques were compared by assessing the coefficient of variation (CoV) in the rate of decline and each technique's correlation to survival. Results showed that in the 60 patients followed for one year, EIM phase measured from the most rapidly progressing muscle in each patient had a CoV in the rate of decline of 0.62, compared to HHD (0.82) and the ALSFRS-R (0.74). Restricting the measurements to the first six months gave a CoV of 0.55 for EIM, 0.93 for HHD, and 0.84 for ALSFRS-R. For both time-periods, all three measures correlated with survival. Based on these data, a six-month clinical trial designed to detect a 20% treatment effect with 80% power using EIM would require only 95 patients/arm compared to the ALSFRS-R, which would require 220 subjects/arm. In conclusion, EIM can serve as a useful ALS biomarker that offers the prospect of greatly accelerating phase 2 clinical trials.

Introduction: The purpose of this study was to develop an evidence-based guideline for the use of neuromuscular ultrasound in the diagnosis of carpal tunnel syndrome (CTS)., Methods: Two questions were asked: (1) What is the accuracy of median nerve cross-sectional area enlargement as measured with ultrasound for the diagnosis of CTS? (2) What added value, if any, does neuromuscular ultrasound provide over electrodiagnostic studies alone for the diagnosis of CTS? A systematic review was performed, and studies were classified according to American Academy of Neurology criteria for rating articles of diagnostic accuracy (question 1) and for screening articles (question 2)., Results: Neuromuscular ultrasound measurement of median nerve cross-sectional area at the wrist is accurate and may be offered as a diagnostic test for CTS (Level A). Neuromuscular ultrasound probably adds value to electrodiagnostic studies when diagnosing CTS and should be considered in screening for structural abnormalities at the wrist in those with CTS (Level B)., (Copyright © 2012 Wiley Periodicals, Inc.)

Neuromuscular ultrasonography can be used both descriptively and quantitatively in the evaluation of patients with neuromuscular disorders. This article reviews the quantitative use of this technology, particularly measurements of the size and echogenicity of nerve and muscle, as a tool for assessing the severity, progression, and response of these tissues to therapeutic interventions. Neuromuscular ultrasonography has several features, including portability and noninvasiveness, that make it an attractive research tool for advancing the diagnosis and treatment of neuromuscular disorders., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objective: To determine the prevalence of carpal tunnel syndrome (CTS) in Latino poultry-processing workers., Methods: Symptoms and nerve conduction studies were used to prospectively assess 287 Latino poultry-processing workers and 226 Latinos in other manual-labor occupations., Results: The prevalence of CTS was higher in poultry-processing (8.7%) compared with nonpoultry manual workers (4.0%; P < 0.0001). The adjusted odds ratio for the prevalence of CTS in poultry workers was 2.51 (95% confidence interval, 1.80-3.50) compared with nonpoultry workers. Within the poultry workers, those who performed packing, sanitation, and chilling had a trend toward less CTS than those who performed tasks requiring more repetitive and strenuous hand movements., Discussion: Latino poultry-processing workers have a high prevalence of CTS, which likely results from the repetitive and strenuous nature of the work.

Introduction: High-resolution ultrasound has been used to evaluate several neuromuscular conditions, but it has only been used on a limited basis in amyotrophic lateral sclerosis (ALS) patients. It has not been used to assess their peripheral nerves. This study was designed to use neuromuscular ultrasound to investigate nerve cross-sectional area and muscle thickness in ALS., Methods: Twenty individuals with ALS and 20 matched controls underwent neuromuscular ultrasound to measure the cross-sectional area of their median and sural nerves and the thickness of their biceps/brachialis muscle complex., Results: The cross-sectional area of the median nerve in the mid-arm was smaller in the ALS group than in controls (10.5 mm(2) vs. 12.7 mm(2) , P = 0.0023), but no difference was seen in the sural nerve (4.5 mm(2) vs. 5.0 mm(2) , P = 0.1927). The ALS group also had thinner biceps/brachialis than controls (2.1 cm vs. 2.9 cm, P = 0.0007)., Conclusions: Neuromuscular ultrasound demonstrates nerve and muscle atrophy in ALS and should be further explored as a disease biomarker., (Copyright © 2011 Wiley Periodicals, Inc.)

Introduction: Neuromuscular ultrasound is a painless, radiation-free, high-resolution imaging modality for assessment of the peripheral nervous system. The purpose of this study was to use neuromuscular ultrasound to assess the changes that occur in the median nerve after steroid injection for carpal tunnel syndrome (CTS)., Methods: Ultrasound and nerve conduction studies were performed at baseline and 1 week, 1 month, and 6 months after steroid injection in 19 individuals (29 wrists) with CTS., Results: Significant changes were noted in median nerve cross-sectional area (P < 0.001), mobility (P = 0.001), and vascularity (P = 0.042) at the distal wrist crease after steroid injection, and the nerve cross-sectional area correlated with symptom score and electrodiagnostic parameters. Changes in the ultrasonographic parameters were seen within 1 week of injection., Conclusions: These findings suggest neuromuscular ultrasound is potentially helpful for the assessment of individuals undergoing treatment for CTS, as typical changes can be expected after successful treatment injection., (Copyright © 2011 Wiley Periodicals, Inc.)

Pseudobulbar affect (PBA) is an affective disinhibition syndrome characterized by sudden, involuntary outbursts of inappropriate crying or laughing. We have previously reported the prevalence of PBA in movement disorders using an interviewer-administered questionnaire that had not been validated. In the current study, a validated self-administered screening instrument, the Center for Neurologic Study-Lability Scale (CNS-LS), was used to study the prevalence of PBA, its association with mood symptoms, and the quality of life impact. Two hundred sixty-nine patients met inclusion criteria (consent, age > 18 years, formal diagnosis, and completion of the CNS-LS). The CNS-LS was used to assess PBA at a cutoff score of 17 (utilized from multiple sclerosis studies). The Beck Depression Inventory (BDI) scale and Parkinson's disease questionnaire (PDQ-39) were used to assess depressive symptoms and quality of life. Logistic regression analysis was used to predict associations with PBA. PBA was prevalent in 7.1% (n = 19) of movement disorder patients. No significant difference in prevalence was observed by patient diagnosis: 7.1% (12/168) in Parkinson's disease (PD), 11.4% (4/35) in essential tremor, 0% (0/13) in dystonia, 0% (0/16) in psychogenic movement disorders, and 10.7% (3/28) in patients with other movement disorders. Patients with PBA had higher BDI depression scores (p < 0.0001) and lower PDQ-39 emotional well-being subscores (p < 0.0001). Patients taking antidepressant medications had significantly higher rates of PBA (p = 0.0008). The prevalence of PBA symptoms was 7.1% in PD and all movement disorders patients. Patients with PBA tend to have more depressive symptoms and poorer quality of life.

Patients with Parkinson's disease (PD) and essential tremor (ET) tend to lose weight progressively over years. Weight gain following deep brain stimulation (DBS) of the subthalamic nucleus (STN) for treatment of PD has been documented in several studies that were limited by small sample size and exclusive focus on PD patients with STN stimulation. The current study was undertaken to examine weight change in a large sample of movement disorder patients following DBS. A retrospective review was undertaken of 182 patient charts following DBS of the STN, ventralis intermedius nucleus of the thalamus (VIM), and globus pallidus internus (GPi). Weight was collected preoperatively and postoperatively up to 24 months following surgery. Data were adjusted for baseline weight and multivariate linear regression was performed with repeated measures to assess weight change. Statistically significant mean weight gain of 1.8 kg (2.8% increase from baseline, p = 0.0113) was observed at a rate of approximately 1 kg per year up to 24 months following surgery. This gain was not predicted by age, gender, diagnosis, or stimulation target in a multivariate model. Significant mean weight gain of 2.3 kg (p = 0.0124) or 4.2% was observed in our PD patients. Most patients with PD and ET gain weight following DBS, and this gain is not predicted by age, gender, diagnosis, or stimulation target.

We describe a previously unreported phenomenon: positional dysphagia secondary to a Chiari I malformation. A 38-year-old woman presented with progressive dysphagia and cough. Flexible endoscopic evaluation of swallowing detected severe pharyngeal dysphagia and aspiration, as well as an intermittent cough reflex with all consistencies in the upright position. Various compensatory strategies were attempted to relieve the aspiration, but only assumption of the supine position was successful. Subsequent magnetic resonance imaging detected a herniation of the cerebellar tonsils to the level of C2 and the presence of a cervical syrinx-findings consistent with a Chiari I malformation. After surgical decompression of the malformation, the patient's symptoms completely resolved.

Ulnar neuropathy at the elbow (UNE) is the second most common entrapment neuropathy. It is diagnosed with electrodiagnostic studies, but they can yield false-negative results. Ultrasound was used to examine 4 patients with UNE and negative electrodiagnostic findings, and it showed ulnar nerve enlargement near the elbow in all cases, with a mean cross-sectional area of 20.1 mm. This indicates that ultrasound may be a useful tool for assessing those with UNE symptoms and normal electrodiagnostic findings., (Copyright 2010 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

High-resolution ultrasound has become increasingly useful in the evaluation of peripheral nerves. As we have gained experience, clinically helpful ultrasonographic signs have been detected. One of these is the ultrasonographic Tinel sign, in which paresthesias are produced when the transducer compresses a nerve lesion. This sign has not been previously described. We present a case in which the ultrasonographic Tinel sign helped accurately guide a nerve biopsy in a woman with mononeuritis multiplex.

Ultrasound is emerging as a useful tool for evaluation of neuromuscular conditions, because it can provide high-resolution anatomic information to complement electrodiagnostic data. There have been few studies in which ultrasound was used to assess the peripheral nerves of individuals with Charcot-Marie-Tooth (CMT) disease and none involving CMT type 1B. In this study we compared nerve cross-sectional area in individuals from a single large family with CMT 1B with normal, healthy controls. We also assessed for cranial nerve enlargement in those with CMT 1B with cranial neuropathies compared to those with CMT 1B without cranial neuropathies. Individuals with CMT 1B have significantly larger median and vagus nerves than healthy controls, but no difference was seen in cranial nerve size between those with versus those without cranial neuropathies. This is the first study to characterize the ultrasonographic findings in the peripheral nerves of individuals with CMT 1B.

We report a child with genetically proven incontinentia pigmenti who had bilateral strokes at 5 days of age, and was subsequently found to have recurrent acute strokes on magnetic resonance imaging both at 10 days and 3 months of age. Brain magnetic resonance imaging at 5 days of age showed multiple areas of restricted diffusion throughout both hemispheres. The child was started on antiplatelet therapy after a second stroke was noted on magnetic resonance imaging at 10 days of age. Despite this treatment, she had a third punctate infarct on magnetic resonance imaging 3 months later. A magnetic resonance imaging at 10 months of age showed maturation of the old infarcts but no new strokes. The purpose of this article is to describe a unique presentation of recurrent stroke secondary to incontinentia pigmenti and to highlight the need for a better understanding of the pathophysiology of incontinentia pigmenti to develop appropriate treatment of stroke in incontinentia pigmenti.

Serious adverse events related to IVIg treatment are unusual, and interventions can be taken to reduce the risk of anaphylaxis, congestive heart failure and renal failure. Stroke and other thromboembolic (TE) events have also been associated with IVIg administration but the risk factors are unknown. This paper investigates whether typical cardiovascular risk factors increase the risk of thromboembolic (TE) events during intravenous immunoglobulin infusion. This case-control study compares 19 patients (mean age = 71 +/- 9 years) who experienced a TE event within 2 weeks of IVIg infusion with 38 age-matched controls who received IVIg without experiencing an event. No single cardiovascular risk factor increased the risk of TE event, but the risk was elevated when 2 or more cardiovascular risk factors were present (odds ratio = 1.39, 95 % CI: 0.45, 4.30) and became statistically significant when 4 or more risk factors were present (odds ratio = 10.50, 95 % CI: 1.91, 57.58). The 30 day mortality rate was high in cases (15.8 %) and controls (18.4 %) but not significantly different between the groups.The risk of TE events was increased in individuals with 4 or more cardiovascular risk factors, but, given the wide confidence intervals in our results, the degree of increased risk is difficult to predict. The data suggest that elderly, hospitalized patients receiving IVIg are at moderately elevated risk for TE events and 30 day mortality. Clinicians prescribing IVIg should carefully consider the risk of stroke and myocardial infarction in elderly patients with multiple cardiovascular risk factors, and this risk should be discussed with patients receiving IVIg. Prospective studies of TE events would most accurately demonstrate the incidence and risk factors for these complications.

Background and Purpose: Several studies have evaluated the cross-sectional area of the median nerve at the wrist, but none have examined other sites along the median nerve. Nerve enlargement has been demonstrated in entrapment, hereditary and acquired neuropathies, as well as with intraneural masses, and cross-sectional area reference values at sites along the nerve will help in the evaluation of these conditions. In addition, muscle intrusion into the carpal tunnel has been implicated in carpal tunnel syndrome, but the normal amount of muscle intrusion has not been quantified., Methods: Fifty asymptomatic volunteers (100 arms) were evaluated to determine the mean cross-sectional area of the median nerve at 6 sites and the mean amount of muscle intruding into the carpal tunnel., Results: The cross-sectional area of the nerve was consistent along its course (7.5 to 9.8 mm(2)). The amount of muscle within the carpal tunnel varied greatly, with the mean area of flexor digitorum being 15.5 mm(2) and lumbricals 13.5 mm(2)., Conclusions: These reference values are necessary for advancing the field of neuromuscular ultrasound, because they facilitate studies of the median nerve in conditions such as entrapment, hereditary neuropathy, acquired neuropathy, and intraneural masses.

High-resolution ultrasound can demonstrate focal nerve enlargement in entrapment neuropathies. We hypothesized that a ratio between the nerve cross-sectional area at the site of maximal enlargement and at an unaffected site may improve diagnostic accuracy in ulnar neuropathy at the elbow (UNE), when compared to a single measurement at the site of maximal enlargement. Ultrasound was used to measure the cross-sectional area of the ulnar nerve at three sites in 30 normal, healthy controls and 26 individuals with UNE. In individuals with UNE, the ratio was 2.9:1 when the site of maximal swelling was compared with a distal ulnar nerve site and 2.8:1 when compared with a proximal site. This represented a significant increase compared with the ratio of 1.1:1 for both comparisons in controls (P < 0.0001). This type of ratio may be particularly useful for assessing entrapment in those with polyneuropathy or obesity, both of which can cause diffuse nerve enlargement.

Objective: To determine the accuracy of the ultrasonographic measurement of ulnar nerve to cubital tunnel area for diagnosis of ulnar neuropathy at the elbow., Design: Patients with confirmed ulnar neuropathy at the elbow and normative, healthy volunteers were evaluated with high-resolution ultrasound. The cross-sectional areas (CSAs) of the ulnar nerve and cubital tunnel were measured with the elbow extended and flexed, and results from the 2 groups were compared., Setting: Electromyography laboratory and radiology department of a tertiary care center., Participants: Twenty-seven patients with ulnar neuropathy at the elbow and 20 controls., Interventions: Not applicable., Main Outcome Measure: The ratio of ulnar nerve to cubital tunnel CSA with the elbow flexed., Results: The ulnar nerve, with the elbow flexed, was larger in those with ulnar neuropathy at the elbow, and this group also had larger cubital tunnels than did controls. In those with ulnar neuropathy at the elbow, the ratio of the ulnar nerve to cubital tunnel was .31, and in the controls it was .32, which was not significantly different (P=.89)., Conclusions: The ratio of ulnar nerve to cubital tunnel did not differentiate those with ulnar neuropathy at the elbow from controls.

Ultrasound allows for a non-invasive structural assessment of nerves, muscles, and surrounding tissues, and therefore it is increasingly being used as a supplement to traditional electrodiagnostic studies. As investigators have begun to use ultrasound to explore peripheral nerves, it has become clear that conditions such as entrapment, hereditary neuropathies, acquired neuropathies, trauma, and nerve tumors result in an increase in nerve cross-sectional area. Reference values have not been published for the cross-sectional area of many nerves commonly studied in diseases of the peripheral nervous system, so our goal was to obtain reference values for the nerve cross-sectional area at the following sites: radial at antecubital fossa; radial at distal spiral groove; musculocutaneous in upper arm; trunks of the brachial plexus; vagus at carotid bifurcation; sciatic in distal thigh; tibial in popliteal fossa; tibial in proximal calf; tibial at ankle; peroneal in popliteal fossa; peroneal at fibular head; and sural in distal calf. Mean cross-sectional area, as well as side-to-side differences, are reported for each site, and qualitative data are provided to guide imaging at each site. The information provided in this study should serve as the starting point for quantitatively evaluating these nerve sites with ultrasound.

The cubital tunnel is the most common site of ulnar nerve entrapment. Previous ultrasound studies have demonstrated enlargement of the ulnar nerve in cubital tunnel syndrome but did not report on the cubital tunnel itself. Twenty-two individuals with cubital tunnel syndrome were evaluated with nerve conduction studies and ultrasound. The ultrasound measurement that most strongly correlated with conduction velocity was the ratio of ulnar nerve to cubital tunnel cross-sectional area with the elbow flexed. Measurement of this ratio may improve the diagnostic accuracy of ultrasound in cubital tunnel syndrome, although further investigation is needed.

The current approach for localizing and assessing the severity of traumatic peripheral nerve injuries involves clinical evaluation and electrodiagnostic studies. However, the ability of this approach to determine the extent of nerve damage within the first 6 weeks after trauma is limited. This is problematic because outcome is improved with early surgical intervention after complete nerve transection. This led us to explore alternative techniques, such as imaging, for assessing peripheral nerve injuries. Twelve fresh cadavers were obtained and after inspection 20 arms were deemed suitable for inclusion in the study. Random sites were transected in median, ulnar, and radial nerves, and sham skin incisions were performed throughout the arm. These nerves were then systematically scanned by an ultrasonographer blinded to the nerve transection sites, who made a final decision as to whether the nerve was transected. High-resolution ultrasound was able to identify transected nerves in the upper extremity with 89% sensitivity and 95% specificity in fresh cadavers. This proof-of-concept study shows that ultrasound can accurately identify nerve transection, which should lead to further ultrasound studies in patients with traumatic peripheral nerve injuries.

Objective: To provide a detailed description of the ultrasonographic findings along the entire length of the normative ulnar nerve., Design: Volunteers were recruited to undergo ultrasonography of both upper extremities. Age, sex, height, weight, body mass index, arm length, and hand length were recorded, and cross-sectional measurements of the ulnar nerve were obtained at 7 predetermined sites., Setting: The diagnostic neurology laboratory of a referral medical center., Participants: Thirty volunteers (60 arms) were recruited. Volunteers were screened by history and physical examination, and those with evidence of peripheral nervous system disease were excluded., Interventions: Not applicable., Main Outcome Measure: The average cross-sectional area (CSA) of the ulnar nerve at 7 predetermined sites along the entire course of the nerve., Results: The following average ulnar nerve CSAs were obtained: distal wrist crease, 5.9 mm2; arterial split, 6.3 mm2; 2 cm distal to tip of the medial epicondyle, 6.4 mm2; tip of the medial epicondyle, 6.5 mm2; 2cm proximal to tip of the medial epicondyle, 6.7 mm2; mid-humerus, 6.1 mm2; and axilla, 6.2 mm2. There was no statistical difference in nerve size when dominant and nondominant arms were compared, but women did have smaller nerves than men. Of all the variables measured, nerve size correlated most closely with weight, with a correlation coefficient of .59., Conclusions: The ulnar nerve was easily visualized and measured along its entire course, and the CSA of the nerve was consistent at multiple sites. The reference values obtained in this study will facilitate the analysis of abnormal nerve conditions, and the information on side-to-side variation and sex-specific differences should be particularly helpful.

Purpose: Ulnar neuropathy at the cubital tunnel (UCT) is diagnosed on the basis of history, physical examination, and nerve conduction studies (NCSs); however, the wide spectrum of findings often makes the diagnosis difficult. The purpose of this study was to document the ultrasonographic differences in ulnar nerve size between patients with UCT and control subjects, and to correlate those differences with clinical examination findings and NCS abnormalities, thereby testing the validity of ultrasound (US) as an additional adjunct diagnostic modality for UCT., Methods: Fifteen elbows in 14 patients with symptoms, clinical examination, and NCS findings consistent with UCT had US of the ulnar nerve. Patients were excluded if they had a history of polyneuropathy, acute trauma involving the upper extremity, previous trauma in the region of the elbow (including previous surgery), or brachial plexus injury. The control group consisted of 60 elbows from 30 normal volunteers that also had US. Maximal cross-sectional areas (CSAs) were measured and compared for the 2 groups and a correlation analysis was performed between nerve size and NCS findings., Results: The average CSA of the ulnar nerve was 0.065 cm(2) in the control group, whereas in the UCT group it was 0.19 cm(2), indicating a significant statistical difference in ulnar nerve size between the 2 groups. The Pearson correlation coefficient between motor nerve conduction velocity of the ulnar nerve and the CSA was 0.80., Conclusions: High-resolution US is a noninvasive, safe, and reliable modality for imaging the ulnar nerve at the elbow and it may provide a valuable adjunct to NCS in the diagnosis of UCT.

Purpose: Traditional evaluation of suspected carpal tunnel syndrome (CTS) involves a thorough history, physical examination, and nerve conduction velocity studies (NCS). Ultrasound is used widely in Europe and has gained acceptance in the United States in the diagnosis of various musculoskeletal disorders. The purpose of this study was to document the ultrasonographic measurement difference in median nerve size between patients with CTS and controls and to correlate these findings with NCS findings, thereby allowing us to test the validity of ultrasound as a diagnostic modality for CTS., Methods: Forty-four wrists in 26 CTS patients and 86 wrists in 43 asymptomatic volunteers were imaged using a real-time ultrasound scanner with a 12/5 MHz linear-array transducer. The cross-sectional area of the median nerve was measured at the level of the distal wrist crease in both CTS patients and controls. All CTS patients had NCS. The ultrasonographic median nerve area was compared for the 2 groups and correlation analysis between ultrasonographic nerve sizes and NCS findings was performed., Results: The average cross-sectional area of the median nerve at the distal wrist crease was 9 mm(2) in asymptomatic volunteers and 14 mm(2) in CTS patients. For the CTS patients the Pearson correlation coefficient between ultrasound nerve measurement and NCS values was 0.37, suggesting that higher values of ultrasound measurements are associated with abnormal NCS findings., Conclusions: Our results indicate that high-resolution ultrasound is informative in the evaluation of CTS and shows enlargement of the median nerve at the distal wrist crease in symptomatic patients. Therefore it is a reliable modality for imaging the wrist in patients with CTS. In addition ultrasound is well tolerated and safe., Type of Study/level of Evidence: Diagnostic, Level I.