Kalliopi Pitarokoili

Cross sectional area reference values for sonography of peripheral nerves and brachial plexus.

OBJECTIVE Ultrasound measurements of the cross sectional area (CSA) variability have been recently introduced to quantify pathological changes in peripheral nerves (PN). METHODS Reference values from 75 healthy subjects and their correlation to age, height, weight and sex are reported. RESULTS The mean values in PN were: (1) intranerve CSA-variability: median 1.05 (SD ± 0.13), ulnar 1.53 (SD ± 0.51), fibular 1.33 (SD ± 0.37), tibial 1.39 (SD ± 0.39), (2) internerve CSA-variability 1.76 (SD ± 0.37), (3) intraplexus CSA-variability 1.52 (SD ± 0.37), (4) side-to-side difference ratio of the CSA-variability: median 1.21 (SD ± 0.04), ulnar 1.2 (SD ± 0.25), fibular 1.19 (SD ± 0.23), tibial 1.28 (SD ± 0.24) and brachial plexus 1.19 (SD ± 0.23). CSA did not correlate with height in PN, but correlated with weight in the ulnar nerve [Guyons canal, r = 0.411, p = 0.0237, elbow r = 0.409, p = 0.0248]. Significant changes between sex were found only in the ulnar (Guyons canal, p = 0.0265), fibular (popliteal fossa, p = 0.0336) and sural nerve (p = 0.048). CSA decreased with age in the median (axilla, p = 0.0236), and radial nerve (spiral groove, p = 0.0037) and increased in the tibial nerve (ankle, p < 0.0001). CONCLUSIONS The CSA reference values reported seem to correlate at certain sites with age, weight and sex but not with height. SIGNIFICANCE The new CSA variability measures may be helpful in investigating pathologies of the PN.

Correlation of Nerve Ultrasound, Electrophysiological and Clinical Findings in Chronic Inflammatory Demyelinating Polyneuropathy

We present the nerve ultrasound findings in chronic inflammatory demyelinating polyneuropathy (CIDP) and examine their correlation with electrophysiology and functional disability.

Natalizumab Therapy for Highly Active Pediatric Multiple Sclerosis

IMPORTANCE Given the high frequency of failure of first-line therapies, there is an urgent need for second-line treatment strategies for pediatric patients with multiple sclerosis (MS). OBJECTIVE To report the use of natalizumab in pediatric MS. Natalizumab, a humanized monoclonal antibody targeting α4 integrin, is effective against active relapsing-remitting MS in adults. DESIGN Retrospective study. SETTING Eleven centers for neurology and pediatric neurology in Germany and Austria. PARTICIPANTS A total of 20 pediatric patients with MS who started treatment with natalizumab prior to 18 years of age. These patients underwent magnetic resonance imaging as clinically indicated, despite the fact that 19 of these 20 patients were undergoing first-line disease-modifying therapy. The mean (SD) age at initiation of natalizumab therapy was 16.7 (1.1) years, and the mean (SD) pretreatment period was 18 (10) months. INTERVENTION Natalizumab, 300 mg every 4 weeks. MAIN OUTCOME MEASURES Annualized relapse rates, Expanded Disability Status Scale scores, number of new T2/fluid-attenuated inversion recovery lesions and contrast-enhancing lesions on magnetic resonance imaging, number of adverse events, the prevalence of neutralizing antibodies against natalizumab, and serum JC virus-antibody status. RESULTS Treatment with natalizumab was associated with reductions in mean annualized relapse rates (3.7 without treatment vs 0.4 with treatment; P < .001), median Expanded Disability Status Scale scores (2 without treatment vs 1 with treatment; P < .02), and mean number of new T2/fluid-attenuated inversion recovery lesions per year (7.8 without treatment vs 0.5 with treatment; P < .001). Two patients developed high-titer neutralizing antibodies against natalizumab and had to stop therapy. Adverse events included headaches, asthenia, infections, and hypersensitivity. Abnormal laboratory results were found for 8 patients. JC virus antibodies were found in 5 of 13 patients. After the discontinuation of natalizumab therapy, relapse activity occurred in 6 of 8 patients within 6 months. CONCLUSIONS AND RELEVANCE Our data indicate that natalizumab may be safe and effective against MS in pediatric patients with breakthrough disease.

Correlation of nerve ultrasound, electrophysiological, and clinical findings in post Guillain-Barré syndrome.

We aimed to correlate functional disability, electrophysiology, and nerve ultrasound in patients after Guillain‐Barré syndrome (GBS). Seventy‐five healthy controls and 41 post‐GBS patients (mean 3.4 years, SD ± 2.91 years after onset) underwent clinical, sonographic, and electrophysiological evaluation. Compared to healthy controls, the post‐GBS patients showed: (1) a mean Rasch‐built Overall Disability Scale score of 31.8 (SD ± 11.6), modified Rasch‐built fatigue severity scale score of 15.6 (SD ± 3.2), Medical Research Council sum score of 22 (SD ± 5.6); (2) electrophysiological signs of permanent axonal loss in the majority of the peripheral nerves; (3) sonographical evidence of higher cross‐sectional area values (CSA) of the ulnar (elbow, p < 0.001), radial (spiral groove, p < 0.001), tibial nerve (popliteal fossa, p < 0.001) and brachial plexus (supraclavicular space, p < 0.001). No correlation between sonographic and electrophysiological findings was found. Neither nerve ultrasound nor electrophysiology correlated with muscle strength, overall disability, and fatigue scale. Compared to healthy controls, post‐GBS patients had significant functional disability. Despite significant abnormalities in both electrophysiology and ultrasound compared to healthy controls, neither electrophysiology nor nerve ultrasound correlated with functional disability of these patients.

Multifocal motor neuropathy: correlation of nerve ultrasound, electrophysiological, and clinical findings

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.

Nerve ultrasound protocol in differentiating chronic immune-mediated neuropathies

Introduction: In this study we evaluated a new neuropathy ultrasound protocol (NUP) for differentiating chronic immune‐mediated neuropathies. Methods: The NUP was evaluated in 110 patients with clinical presentations of chronic immune‐mediated neuropathy. All patients were first evaluated clinically and electrophysiologically and divided into 4 polyneuropathy groups: (a) symmetric demyelinating; (b) symmetric axonal; (c) asymmetric demyelinating; and (d) asymmetric axonal. During step 2, the NUP was evaluated prospectively for all 4 study groups. Results: Overall, the NUP led to correct classification in 42 of 49 (85.7%) patients with chronic inflammatory demyelinating polyneuropathy (CIDP), 13 of 15 (86.9%) with multifocal motor neuropathy (MMN), and 5 of 5 (100%) with multifocal‐acquired demyelinating sensory and motor neuropathy (MADSAM). The NUP had >80% sensitivity and specificity in distinguishing CIDP, MMN, and MADSAM in all 4 study groups. Conclusions: The NUP is a useful addition in the differential diagnosis of chronic immune‐mediated neuropathies in everyday practice. Muscle Nerve 54: 864–871, 2016

Nerve Ultrasound and Electrophysiology for Therapy Monitoring in Chronic Inflammatory Demyelinating Polyneuropathy.

We evaluated prospectively nerve ultrasound and electrophysiology as monitoring methods of intravenous immunoglobulin (IVIG) therapy in chronic inflammatory demyelinating polyneuropathy (CIDP).

Sarcoid neuropathy: Correlation of nerve ultrasound, electrophysiological and clinical findings

INTRODUCTION We present the nerve ultrasound findings in sarcoid neuropathy and examine their correlation with electrophysiology and functional disability. MATERIALS AND METHODS 40 healthy controls and 13 patients with sarcoid neuropathy underwent clinical, sonographic and electrophysiological evaluation, a mean of 2.1 years (SD ± 0.7) after disease onset. RESULTS Nerve ultrasound revealed significantly higher cross sectional area (CSA) values of the ulnar (elbow, p<0.001), fibular (fibular head, p<0.001), sural (between the lateral and the medial head of the gastrocnemius muscle, p<0.001) and tibial nerves (ankle and popliteal fossa, p<0.001), when compared to controls. The electroneurography documented significantly lower values of the 1) compound muscle action potentials (cMAPs) in the median, fibular and tibial nerves (p<0.001), and 2) sensory nerve action potential (sNAP) in the median, ulnar and sural nerves (p<0.001). A significant correlation between sonographic and electrophysiological findings in the group with sarcoid neuropathy was found only between cMAP and CSA of the ulnar nerve at the elbow (r=0.894, p<0.001). Neither nerve sonography nor electrophysiology correlated with functional disability. DISCUSSION Sarcoid neuropathy seems to show predominantly CSA enlargement in peripheral nerves of the lower extremities, without any significant correlation to electrophysiological findings. The electroneurography documented signs of sensorimotor axonal loss in various peripheral nerves. Neither nerve sonography nor electrophysiology correlated with functional disability.

Comparison of clinical, electrophysiological, sonographic and MRI features in CIDP

INTRODUCTION We investigated the applicability of nerve ultrasound and magnetic resonance imaging (MRI) in chronic inflammatory demyelinating polyneuropathy (CIDP). METHODS We systematically examined several nerves with ultrasound and the lumbar roots and tibial nerve in the popliteal fossa of nine CIDP patients with MRI additionally to the nerve conduction studies. RESULTS Patients with overall disability sum score (ODSS) 2-3 were characterised by normal fascicular structure in MRI and ultrasound. Patients with higher ODSS showed isolated enlarged fascicles and increased cross sectional area (CSA) of the peripheral nerves and of the diameter of the cauda equina and L5 root, whereas two of them showed atrophic fascicles in both imaging techniques. CONCLUSIONS Nerve ultrasound and MRI findings show the same morphological fascicle alterations in peripheral nerves in correlation to ODSS. Nerve ultrasound as an affordable tool, easy and quick to perform, could replace MRI in daily routine for monitoring peripheral nerve morphology.

Increased cerebrospinal fluid protein and motor conduction studies as prognostic markers of outcome and nerve ultrasound changes in Guillain-Barré syndrome.

OBJECTIVE Our study examined the prognostic role of increased cerebrospinal fluid protein and motor conduction studies on outcome and nerve ultrasound changes in Guillain-Barré syndrome (GBS). METHODS Fifty post-GBS patients underwent clinical and nerve ultrasound examination, with a mean of 3.4 years (SD=2.8) after disease onset. Outcome was measured using the Medical Research Council Sum Score (MRC), the Rasch-built Overall Disability Scale (R-ODS) and the Rasch-built fatigue severity scale (R-FSS). Ιn addition, the results of the motor conduction studies and cerebrospinal fluid (CSF) examination at disease onset were retrospectively evaluated. RESULTS No significant changes in outcome were noted between patients with (p-CSF) and without increased CSF protein (n-CSF). The p-CSF group showed significant lower cross-sectional area (CSA) values of the radial nerve in spiral groove (p<0.001) and higher values of the internerve-CSA variability (p<0.001) compared to n-CSF patients. GBS patients with axonal affection in motor studies (GBS-a) showed significantly lower values of the R-ODS and MRC sum scores (p>0.001), but not of the R-FSS Score (p=0.018). Sonographically the GBS-a patients showed significant lower values of the median and ulnar nerve in the upper arm (p<0.001). DISCUSSION Axonal affection in motor studies, but not increased CSF protein at disease onset, seems to be an infavourable prognostic factor for outcome in GBS. Both axonal affection and increased CSF protein have a minor prognostic role in the development of nerve ultrasound changes.