Cubital tunnel syndrome resulting from delayed intraneural ...
0011: Intraneural Ganglia
1
and intraneural ganglia, developing within the nerve. At the lateral calf, the superficial peroneal neuropathy can be encountered in patients who have a history of ankle sprains or trauma to the leg leading to sensory disturbances on the dorsal ankle and foot. US can demonstrate the nerve injury as a fusiform hypoechoic thickening of the superficial peroneal nerve at the point where the nerve pierces the fascia. The tarsal tunnel syndrome refers to the entrapment of the tibial nerve and/or of its divisional branches at the medial ankle. US can provide exact information on the nature and extent of constricting findings. Repetitive minor contusion traumas can cause impingement of the deep peroneal nerve that occurs on the dorsal aspect of the midfoot leading to local burning pain. Similarly, the interdigital nerves can be impinged against the distal edge of the intermetatarsal ligament forming a Morton neuroma.Ultrasound (US) can give direct demonstration of a wide range of neuropathies of the lower extremity. In the hip, the entrapment of the sciatic, femoral and lateral femorocutaneous nerves can be depicted with US. Main signs of nerve compression include echotex- tural abnormalities, displacement of the affected nerve from its normal course by space-occupying masses and selective changes in the inner- vated muscles related to denervation edema and fatty infiltration. At the lateral knee, the entrapment of the common peroneal nerve typically occurs between the bone and the fascia as the nerve winds around the fibular neck. In most cases, nerve traumas result from external pressure at the fibular neck. Ganglion cysts are one of the leading causes of peroneal nerve compression at this site: these cysts may be divided in extraneural ganglia, which develop outside the nerve and compress it later and intraneural ganglia, developing within the nerve. At the lateral calf, the superficial peroneal neuropathy can be encountered in patients who have a history of ankle sprains or trauma to the leg leading to sensory disturbances on the dorsal ankle and foot. US can demonstrate the nerve injury as a fusiform hypoechoic thickening of the superficial peroneal nerve at the point where the nerve pierces the fascia. The tarsal tunnel syndrome refers to the entrapment of the tibial nerve and/or of its divisional branches at the medial ankle. US can provide exact information on the nature and extent of constricting findings. Repetitive minor contusion traumas can cause impingement of the deep peroneal nerve that occurs on the dorsal aspect of the midfoot leading to local burning pain. Similarly, the interdigital nerves can be impinged against the distal edge of the intermetatarsal ligament forming a Morton neuroma. 0010 Upper Limb Nerve Entrapment Syndromes Sean McPeake, Benson Radiology, Australia As an imaging modality, ultrasound has enjoyed fantastic advances in the past 15 years meaning that many of the large peripheral nerves (and even their smaller branches) can be reviewed in fantastic detail. We will follow the peripheral nerves of the upper limb down from the brachial plexus and consider the common points of nerve entrapment, the effect this entrapment has on the limb and what role ultrasound has to play in the workup of these conditions. A constant theme of the presentation will be to answer the question; when should I look for that? Understanding nerve entrapment syndromes is important! Carpal Tun- nel Syndrome and Cubital Tunnel Syndrome are common clinical entities and as such all musculoskeletal sonologists and sonographers should have a sound knowledge of these conditions and their ultra- sound appearance. In addition to these common conditions we will review the less com- mon nerves entrapment syndromes of the upper limb such as Radial and Ulnar Tunnel Syndromes. References Duncan I, Sullivan P, Lomas F. Sonography in the diagnosis of Carpal Tunnel Syndrome. AJR 1999; 173:681-684. Gassner E et al. Persistent Median Artery in the Carpal Tunnel. Colour Doppler Ultrasonographic Findings. J Ultrasound Med 21:455-461, 2002. Tayfun Altinok M et al. Sonographic Evaluation of the Carpal Tunnel after Provocative Exercises. J Ultrasound Med 2004; 23: 1301-1306. Beekman R, Visser LH. Sonography in the Diagnosis of Carpal Tunnel Syndrome: A critical review of the Literature. Muscle Nerve 2003; 27: 26-33. Bodner G et al. Ultrasonographic Appearance of Supinator Syndrome. J Ultrasound Med 21: 1289-1293. Beltran J, Rosenberg Z. Nerve Entrapment. Musculoskeletal Radiol- ogy. 1998; 2:175-84. Cross-Sectional Imaging of Peripheral Nerve Sheath Tumors:Charac- teristic Signs on CT, MR Imaging, and Sonography. John Lin. AJR: 176, January 2001. Sonography and MR Imaging of Posterior Interosseous Nerve Syn- drome with Surgical Correlation. Alexander J. Chien et al AJR:181, July 2003. Sonographic Evaluation of the Median Nerve at the Wrist. David A. Jamadar. J Ultrasound Med 20:1011-1014, 2001. 0011 Intraneural Ganglia Neil Simmons, Dr Jones & Partners, Australia Intraneural ganglia are rarely reported conditions affecting peripheral nerves. Lack of knowledge of these lesions is probably the reason for the few reports. The author has scanned at least five such lesions, but was only able to report one [the most recent] correctly due to ignorance of the condition. It is hoped that increased awareness will result in more of these lesions being reported as they are easily treated surgically. The literature has been reviewed. The theories on how these ganglia form, their patterns of spread and nerves most commonly affected will be discussed. The importance of identifying articular nerve connections will be emphasised. 0012 Imaging Before Carotid Intervention, What’s Enough? Philip Walker, University of Queensland, Department of Vascular Surgery, RBWH, Australia The options for carotid intervention have expanded from the situation where carotid endarterectomy (CEA) was the sole option for the treatment of carotid bifurcation disease, to the situation where carotid artery stenting (CAS) is an alternative for selected patients. There has also been an evolution in the availability and application of the various imaging modalities employed before embarking on carotid interven- tion. Initially angiography was the only available option. When carotid duplex ultrasound (CDUS) emerged it was initially employed as a screening test, but over time became the sole preoperative imaging modality prior to carotid endarterectomy for many patients, with com- plementary angiography reserved for selected patients. CT angiography (CTA) and MRA / MRI have emerged as non-invasive alternatives to catheter angiography (albeit with their own set of limitations) and allow interrogation of the carotid vessels from the arch to the intracranial circulation, together with the ability to combine with cerebral imaging. Because of the limited efficacy of carotid intervention for asymptom- atic carotid stenosis interest has turned to attempting to identify the “vulnerable carotid plaque” in an effort to better select that small group of patients who might benefit from intervention. The advent of CAS mandates imaging of the arch and proximal carotid vessels to assess Abstracts S3
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and intraneural ganglia, developing within the nerve. At the lateral calf,the superficial peroneal neuropathy can be encountered in patients whohave a history of ankle sprains or trauma to the leg leading to sensorydisturbances on the dorsal ankle and foot. US can demonstrate thenerve injury as a fusiform hypoechoic thickening of the superficialperoneal nerve at the point where the nerve pierces the fascia. Thetarsal tunnel syndrome refers to the entrapment of the tibial nerveand/or of its divisional branches at the medial ankle. US can provideexact information on the nature and extent of constricting findings.Repetitive minor contusion traumas can cause impingement of the deepperoneal nerve that occurs on the dorsal aspect of the midfoot leadingto local burning pain. Similarly, the interdigital nerves can be impingedagainst the distal edge of the intermetatarsal ligament forming a Mortonneuroma.Ultrasound (US) can give direct demonstration of a widerange of neuropathies of the lower extremity. In the hip, the entrapmentof the sciatic, femoral and lateral femorocutaneous nerves can bedepicted with US. Main signs of nerve compression include echotex-tural abnormalities, displacement of the affected nerve from its normalcourse by space-occupying masses and selective changes in the inner-vated muscles related to denervation edema and fatty infiltration. At thelateral knee, the entrapment of the common peroneal nerve typicallyoccurs between the bone and the fascia as the nerve winds around thefibular neck. In most cases, nerve traumas result from external pressureat the fibular neck. Ganglion cysts are one of the leading causes ofperoneal nerve compression at this site: these cysts may be divided inextraneural ganglia, which develop outside the nerve and compress itlater and intraneural ganglia, developing within the nerve. At the lateralcalf, the superficial peroneal neuropathy can be encountered in patientswho have a history of ankle sprains or trauma to the leg leading tosensory disturbances on the dorsal ankle and foot. US can demonstratethe nerve injury as a fusiform hypoechoic thickening of the superficialperoneal nerve at the point where the nerve pierces the fascia. Thetarsal tunnel syndrome refers to the entrapment of the tibial nerveand/or of its divisional branches at the medial ankle. US can provideexact information on the nature and extent of constricting findings.Repetitive minor contusion traumas can cause impingement of the deepperoneal nerve that occurs on the dorsal aspect of the midfoot leadingto local burning pain. Similarly, the interdigital nerves can be impingedagainst the distal edge of the intermetatarsal ligament forming a Mortonneuroma.
0010
Upper Limb Nerve Entrapment SyndromesSean McPeake, Benson Radiology, Australia
As an imaging modality, ultrasound has enjoyed fantastic advances inthe past 15 years meaning that many of the large peripheral nerves (andeven their smaller branches) can be reviewed in fantastic detail.We will follow the peripheral nerves of the upper limb down from thebrachial plexus and consider the common points of nerve entrapment,the effect this entrapment has on the limb and what role ultrasound hasto play in the workup of these conditions. A constant theme of thepresentation will be to answer the question; when should I look forthat?Understanding nerve entrapment syndromes is important! Carpal Tun-nel Syndrome and Cubital Tunnel Syndrome are common clinicalentities and as such all musculoskeletal sonologists and sonographersshould have a sound knowledge of these conditions and their ultra-sound appearance.In addition to these common conditions we will review the less com-mon nerves entrapment syndromes of the upper limb such as Radial
and Ulnar Tunnel Syndromes.ReferencesDuncan I, Sullivan P, Lomas F. Sonography in the diagnosis of CarpalTunnel Syndrome. AJR 1999; 173:681-684.Gassner E et al. Persistent Median Artery in the Carpal Tunnel. ColourDoppler Ultrasonographic Findings. J Ultrasound Med 21:455-461,2002.Tayfun Altinok M et al. Sonographic Evaluation of the Carpal Tunnelafter Provocative Exercises. J Ultrasound Med 2004; 23: 1301-1306.Beekman R, Visser LH. Sonography in the Diagnosis of Carpal TunnelSyndrome: A critical review of the Literature. Muscle Nerve 2003; 27:26-33.Bodner G et al. Ultrasonographic Appearance of Supinator Syndrome.J Ultrasound Med 21: 1289-1293.Beltran J, Rosenberg Z. Nerve Entrapment. Musculoskeletal Radiol-ogy. 1998; 2:175-84.Cross-Sectional Imaging of Peripheral Nerve Sheath Tumors:Charac-teristic Signs on CT, MR Imaging, and Sonography. John Lin. AJR:176, January 2001.Sonography and MR Imaging of Posterior Interosseous Nerve Syn-drome with Surgical Correlation. Alexander J. Chien et al AJR:181,July 2003.Sonographic Evaluation of the Median Nerve at the Wrist. David A.Jamadar. J Ultrasound Med 20:1011-1014, 2001.
0011
Intraneural GangliaNeil Simmons, Dr Jones & Partners, Australia
Intraneural ganglia are rarely reported conditions affecting peripheralnerves. Lack of knowledge of these lesions is probably the reason forthe few reports. The author has scanned at least five such lesions, butwas only able to report one [the most recent] correctly due to ignoranceof the condition. It is hoped that increased awareness will result in moreof these lesions being reported as they are easily treated surgically.The literature has been reviewed. The theories on how these gangliaform, their patterns of spread and nerves most commonly affected willbe discussed. The importance of identifying articular nerve connectionswill be emphasised.
0012
Imaging Before Carotid Intervention, What’s Enough?Philip Walker, University of Queensland, Department of VascularSurgery, RBWH, Australia
The options for carotid intervention have expanded from the situationwhere carotid endarterectomy (CEA) was the sole option for thetreatment of carotid bifurcation disease, to the situation where carotidartery stenting (CAS) is an alternative for selected patients. There hasalso been an evolution in the availability and application of the variousimaging modalities employed before embarking on carotid interven-tion. Initially angiography was the only available option. When carotidduplex ultrasound (CDUS) emerged it was initially employed as ascreening test, but over time became the sole preoperative imagingmodality prior to carotid endarterectomy for many patients, with com-plementary angiography reserved for selected patients. CT angiography(CTA) and MRA / MRI have emerged as non-invasive alternatives tocatheter angiography (albeit with their own set of limitations) and allowinterrogation of the carotid vessels from the arch to the intracranialcirculation, together with the ability to combine with cerebral imaging.Because of the limited efficacy of carotid intervention for asymptom-atic carotid stenosis interest has turned to attempting to identify the“vulnerable carotid plaque” in an effort to better select that small groupof patients who might benefit from intervention. The advent of CAS
mandates imaging of the arch and proximal carotid vessels to assess
