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Abdominal acupuncture (AA) reduces laser-evoked potentials (LEP) amplitude and laser pain perception in healthy subjects (Pazzaglia et al., 2014). The aim of the current study was to investigate the site of AA analgesic effect. We recorded LEPs in 6 healthy volunteers by using 32 EEG scalp electrodes. The experimental protocol included 3 times: (1) baseline, in which LEPs evoked to stimulation of the bilateral dorsal wrist and right foot were recorded before acupuncture; (2) acupuncture, in which LEPs were recorded during AA performed in the abdominal area corresponding to right wrist; (3) rest, in which LEPs were recorded 15 min after the needle removal. Compared to baseline, N2/P2 LEP amplitude evoked by stimulation of both wrists was reduced in the acupuncture and rest times while LEP amplitude evoked by foot stimulation was not modified. Our results suggest that the AA analgesic effect occurs at spinal level.

Ulnar neuropathy at elbow (UNE) is often related to postures and work-hobby activities. The use of mobile-phones has drastically increased in the last decades leading to prolonged phone posture (PPP) with flexed elbow. We aimed to assess the effect of PPP in patients with symptoms of UNE and in symptom-free subjects. Patients with pure sensory symptoms of UNE and negative neurophysiological tests (min-UNE) and symptoms-free subjects were enrolled. We evaluated ulnar motor nerve conduction velocity across elbow at baseline and after 6, 9, 12, 15, 18 min of PPP. Thirty-eight symptom-free subjects and thirty-eight patients were enrolled and 121 ulnar nerves were studied. Conduction velocity of ulnar nerve across the elbow significantly changed over PPP time both in control group and, at a greater extent, in patients with min-UNE. Conduction velocity during PPP showed different evolution between the two groups. The changes became significantly different after 6 min of PPP and progressively increased, with the greatest difference at 15 min. In conclusion, PPP causes a modification of nerve function, expressed by slowing of motor nerve conduction velocity, which is greater in patients with min-UNE although it also occurs in symptom-free subjects. Excessive PPP should be avoided in patients with UNE-symptoms.

We studied patients with neuropathy and anti-myelin-associated glycoprotein antibodies nerve ultrasound (US). 28 patients with anti-MAG neuropathy underwent nerve US. Echotexture, nerve cross sectional area (CSA), intra-nerve and inter-nerve CSA variability were assessed. Patients with IgM paraproteinemic neuropathy without anti-MAG antibodies and with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) associated with IgM paraprotein were studied as controls. US findings were correlated with disease duration and clinical severity (INCAT disability score). 26/28 patients had increased CSA (23 at atleast one nerve outside entrapment sites). Intra-nerve CSA variability was abnormal in 21/28 patients (in 14 for increased nerve CSA outside entrapment sites). Inter-nerve CSA variability was abnormal in 16 patients (in half of whom for CSA increase out of entrapment sites). No correlation was found between US findings and INCAT disability score or disease duration. Patients with IgM paraproteinemic neuropathy without anti-MAG antibodies had similar US abnormalities. Instead 4/5 patients with CIDP and IgM paraprotein presented significant and diffuse nerve CSA enlargement. The US findings in anti-MAG antibody neuropathy, different from those of CIDP, might express the diverse pathogenic mechanisms and contribute to diagnosis in atypical cases.

Immune-mediated neuropathies include clinically heterogeneous disorders such as Guillain–Barre syndrome (GBS) and its variants, chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), multifocal motor neuropathy (MMN), neuropathy with monoclonal gammopathy and others. High-resolution ultrasound (US) is a helpful technique for the evaluation of peripheral nerves. In previous studies on immune-mediated neuropathies, nerve US showed diffuse enlargement of cross sectional area (CSA) of peripheral nerves trunks and cervical roots and morphological alterations at conduction block site. Data are however heterogeneous, correlations with clinical history or disease severity are lacking and there are no longitudinal studies in literature. The objective of the protocol is to prospectively evaluate, through a multicenter longitudinal study, nerve US findings in patients with newly diagnosed immune-mediated neuropathies and evaluate the relationship with clinical and neurophysiological findings and changes over time (natural history) or in response to therapy. The protocol includes clinical assessment, neurophysiological examination, US examination of median, ulnar, radial, fibular, tibial, sural nerves (and brachial plexus in extended protocol) with evaluation of maximal/minimal CSA for each nerve, inter- and intra-nerve variability, US classification depending on echogenicity and fascicles enlargement. US and neurophysiological follow-up timing examinations follow different schedules in acute and chronic immune-mediated disease. We present preliminary results and feasibility of the protocol.

High-resolution ultrasound (US) is a helpful technique for the evaluation of peripheral nerves and literature data show that US may crucially influence diagnosis and clinical care in entrapment in nerve tumours. We report the case of a 48 year-old woman complaining of pain and electric shocks radiated in sciatic course and trigger point in the gluteal region. It was suspected radiculopathy due to disk herniation. MRI showed mild L5–S1 bulging. Due to the trigger, US of sciatic nerve was suggested, nevertheless the trigger was in a region where usually sciatic nerve is not depictable (commonly accepted that is not depictable proximally to plica glutea). The clinical examination and EMG were normal. We performed an ultrasound examination to study sciatic nerve from its distal formation by the union of peroneal and tibial nerves and along its proximal tract. The right sciatic nerve was visualizable along all its tract, even proximally to plica glutea. At the middle-third of gluteus the nerve showed a round-oval shape formation with homogeneous hypoechoic US image. After accurate evaluation the formation seemed on the nerve edge and nerve fibers seemed dislocated laterally, moreover the proximal edge was clearly visualizable. The morphology suggested a probable neurinoma. MRI confirmed dislocation of fascicles and surgical excision was planned. This case report shows the importance of trying ultrasound sciatic nerve examination even proximal to plica glutea.

Our work shows the association of neurophysiology and ultrasound in the assessment of peripheral nerve tumors. In these cases, neurophysiologic examination presents an important role to define the possible lack of function of the nerve. Ultrasonography allows us to visualize the peripheral nerves and underline the morphologic changes in nerve structure. We present a literature revision about ultrasound in peripheral nerve tumor study and a collection of 10 cases where the combined use of clinic, neurophysiology and ultrasound guided the diagnostic process of nerve tumors. All the patients presented a clinic pattern of nerve involvement and everyone was evaluated with neurophysiology which confirmed a mononeuropathy, but without the possibility of a sure diagnosis. The following ultrasound evaluation allowed to visualize a focal lesion, compatible with a nerve tumor. These cases show that neurophysiology and ultrasound together contribute in diagnosis of peripheral nerve tumors. Ultrasonography is not able to certainly define the type of tumor, but it gives suggestions about discrimination between schwannoma and neurofibroma. Nerve ultrasound is useful in the assessment of peripheral nerve tumors.

s of Poster Presentations / Clinical Neurophysiology 125, Supplement 1 (2014) S1–S339 S213 P605 Peroneal nerve damage after knee dislocation. Clinic, neurophysiology and ultrasound in diagnosis, prognosis, treatment and rehabilitation D. Coraci1, V. Santilli1, G. Granata2, I. Paolasso2, H. Tsukamoto3, L. Padua2,4 1Sapienza University, Board of Physical Medicine and Rehabilitation, Rome, Italy; 2Universita Cattolica del Sacro Cuore, Institute of Neurology, Rome, Italy; 3Teikyo University, Institute of Neurology, Tokyo, Japan; 4Don Gnocchi ONLUS Foundation, Milan, Italy Question: Peroneal nerve palsy may occur after a close traumatic knee dislocation. Ultrasound shows its usefulness in traumatic nerve injures. Methods: We present 5 patients with a history of knee dislocation associated with peroneal nerve damage, evaluated by clinical, neurophysiologic and ultrasonographic (US) examination. All the patients were examined in follow-up. At the first evaluation, the patients presented a severe clinic and neurophysiologic damage of peroneal nerve. US showed an increase of the cross sectional area (CSA) of the involved peroneal nerve, between popliteal fossa and fibular head. Results: Among these, 4 subjects presented a CSA four-seven times larger than normal, while one subject had the damaged nerve CSA only double compared to the other side. The first 4 patients did not present improvement in clinical, neurophysiologic and ultrasonographic follow-up. The latter one showed a general improvement in the later evaluations. Conclusions: This observation let us consider that larger is the CSA of the involved peroneal nerve and worse is the prognosis for the patient. Associating neurophysiology to US evaluation, we can obtain a guide for diagnosis, treatment and rehabilitation. In fact this combined evaluation gives data about the specific details and the changes over the time of the condition. This allow us to perform the best management for every individual case. P606 Ultrasonic evaluation as a method for determining diagnosis underlying clinical symptoms of carpal tunnel syndrome N. Wolfram, U. van Deurs, M. Lauritzen Glostrup Hospital, Department of Clinical Neurophysiology, Glostrup, Denmark Background: High resolution ultrasound (HRUS) was used to differentiate carpal tunnel syndrome (CTS) from other pathologies in the media nerve. Materials and methods: Forty-one patients, referred for diagnosis of CTS, were examined with HRUS supplemental to electrodiagnostic (EDX) evaluation when the medical history gave suspicion of polyneuropathy, cervical root affection on MRI scans, trauma or EDX changes not typical for CTS. Results: Twelve patients showed CTS in both EDX (29%) and HRUS, two patients had a bifid median nerve, one was supplemental investigated for HNPP. Seventeen patients had normal EDX (42%). Eight had normal findings by HRUS, five had CTS in HRUS, whereas four patients showed other pathologies including neurovascular contacts, bifid median nerve, partial nerve compression under the flexor retinaculum, palmaris muscle contacts and arthritis. Twelve patients showed atypical changes in EDX (29%). In this group, eight patients showed CTS in HRUS, four patients showed other pathologies including fibrolipomatous harmatoma, intraneural venous congestion, partial traumatic neuroma and flexor muscle compression under the flexor retinaculum. Conclusion: HRUS is not only relevant in confirming the diagnosis of CTS but also to reveal other clinical relevant pathologies when electrodiagnostic evaluation is normal or atypical. P607 Intraneural collateral circulation in the median nerve after radiocephalic fistula N. Wolfram, U. van Deurs, M. Lauritzen Glostrup Hospital, Clinical Neurophysiology, Glostrup, Denmark Introduction: Carpaltunnel Syndrome (CTS) is a known complication to chronic renal failure and radiocephalic fistula for hemodialysis, but the cause of median nerve affection is unknown. Case report: A 61 year old male with chronic renal failure, hemodialysis and radiocephalic fistula in the left forearm was referred for CTS, because of pain in the left thumb, progressive in flexion of the wrist and parestesia in finger 1 + 2. Electrodiagnostic (EDX) evaluation showed normal distal motor latency and motor velocity in the forearm, but reduced motor amplitude from the elbow. Normal sensory velocity from finger 2 and palm to wrist, with reduced sensory amplitudes. High resolution ultrasound (HRUS) (Esaote MyLAb Twice, 6-18 MHz) revealed intraneural arterial blood flow, presumably located in the intraneural venous plexus of the left median nerve at the level of the radiocephalic fistula, as well as hypo-eccogenic changes in the nerve fascicles. Discussion: Clinically, CTS may be mimicked by proximal nerve damage followed by intraneural collateral circulation in patients with radiocephalic fistula. This condition can easily and non-invasively be visualized using HRUS of the median nerve. P608 Ultrasound as a novel instrument for tremor evaluation and intervention S. Kim1, S. Ahn2, J.-H. Shin2 1Hanyang University, Seoul, Republic of Korea; 2National Rehabilitation Center, Rehabilitation, Seoul, Republic of Korea Question: Tremor is a common movement disorder, as which a varied neurological disorders can be presented and pharmacological treatment was firstly tried. Botulinum toxin type A (BoNT-A) has been adopted as another treatment method, and recently ultrasonography-guided injection has been emphasized for accuracy. We hypothesized ultrasonography could takes another role as an objective indicator for tremor. Methods: We report two case studies in which tremor were the chief complaint. Case 1. A 29-year-old male patient with a postural and rest tremor of right hand consistent with Holmes tremor secondary to left pontine hemorrhage visited. His tremor gradually spread to wrist and elbow with the characteristics of 1.4-2 Hz, irregular flexion-extension oscillation being present at rest. Ultrasonography-guided BoNT-A injections were administered at extensor pollicis longus (40 U) muscles, and flexor digitorum superficialis 2nd, 3rd and 4th digits (20 U, each), which showed plainest contraction in real time ultrasonography. Ultrasonography revealed the frequency of tremor decreased from 1.4-2 Hz (baseline) to 0-0.5 Hz (2 weeks after injection), as calculated by each muscle contraction. Case 2. A 30-year-old female patient with bilateral tremor secondary to hypoxic brain damage visited. Her muscle contraction was 0.2-0.4 Hz at her left extensor carpi radialis, extensor policis longus, flexor carpi ulnaris muscles with the help of ultrasonography. BoNT-A injections were administered at extensor carpi radialis (20 U), extensor policis longus (15 U), and flexor carpi ulnaris (20 U) muscles with ultrasonography. The frequency of muscle contraction decreased to 0.1-0.2 Hz at 2 weeks after injection. Conclusion: Ultrasonography has an advantage of objective evaluation of tremor as well as selecting the target muscles. We regard ultrasonography as a novel tool in increasing the accuracy of evaluation and intervention. LP36 Intraoperative high-resolution ultrasound in the managment of traumatic nerve lesions: a new technique K. Scheglmann1, M.-T. Pedro2, R. Koenig2 1Klinikum Augsburg, Neurology, Augsburg, Germany; 2University Ulm, Neurosurgery, Guenzburg, Germany Introduction: Surgical treatment of nerve lesion in continuity remains difficult even in the most experienced hands. Their regenerative potential is evaluated either by intraoperative electrophysiology and/or intraneural dissection. The values of preoperative ultrasound is often hampered due to low tissue penetration and trauma related artifacts. Therefore the present study for the first time examines feasibility and value of intraoperative high-frequency ultrasound as an imaging tool in the management of traumatic nerve lesions in continuity. Material and methods: After development of intraoperative application of high-frequency ultrasound we examined 19 traumatic or iatrogenic nerve lesions of different extent. The information obtained was correlated to intraoperative electrophysiology, the findings of microsurgical intraneural dissection and histopathology of the resected nerve segments. Results: The intraoperative application of high-frequency ultrasound enabled morphological ultrastructural examination of traumatic nerve lesions with excellent imaging quality. The assessment of the severity of the

We present 5 patients with a peroneal nerve palsy, following a close traumatic knee dislocation, evaluated by clinical, neurophysiologic and ultrasound (US) examination. A follow-up was performed in all of these patients. At the moment of the first US evaluation, the patients presented an increase of the cross sectional area (CSA) of the damaged peroneal nerve, in the tract between popliteal fossa and fibular head. In particular 4 of them showed a CSA four-seven times larger than normal. These 4 patients did not present improvement in clinical, neurophysiologic and ultrasonographic long term follow-up. A patient instead had a CSA of the damaged nerve only double compared to the other side. This subject showed a general improvement in the follow-up. On the basis of these preliminary findings, we may hypothesize that larger is the CSA of the damaged peroneal nerve worse the prognosis. Furthermore, this study suggests that US evaluation can aim the diagnostic process providing data about morphology of the involved nerve, exact site of the injury, conditions of surrounding structures and changes over the time.

At the point where it crosses the inguinal ligament, the lateral femoral cutaneous nerve (LFCN) can be entrapped, causing a clinical syndrome (Meralgia Paresthetica) consisting of numbness and sensory disturbances in the territory of nerve distribution. The causes of MP include conditions associated with obesity, pregnancy and orthopedic procedures. The diagnosis of MP is based on clinical history, physical examination, neurophysiological findings and exclusion of other causes of pain or sensory disturbances. Routine neurophysiological tests are not commonly accepted as sensitive although several methods have been developed. Sonographic examination (US) of the LFCN could be useful as a screening test in the diagnosis. The nerve is accessible to US from a few centimeters before it exits the pelvis down to the third proximal part of the thigh. The main US signs of LCFN neuropathy include detection of a fusiform nerve swelling and nerve flattening under or within the ligament. The true sensitivity are not assessed because of absence of gold standard diagnostic test. We present 8 cases of clinical MP confirmed by US.

Multifocal motor neuropathy (MMN) is an immune-mediated disorder characterized by slowly progressive asymmetric muscle weakness and electrophysiological findings of motor conduction block. The immunological hypothesis for pathogenesis of MMN is supported by the association, in 30–80% of cases, with high title Anti-GM1 antibodies and positive response to intravenous immunoglobulin (IVIg) therapy. Ultrasound (US) is recently gaining a crucial role in the assessment of immune-related neuropathies. We report the clinical, electrophysiological and US follow-up of five cases of patients affected with MMN treated with IVIg. In two patients (male 44 years old, female 37 years old) who started IVIg treatment soon after onset, US demonstrated complete or partial normalization. Conversely, in the other three patients (two males 49 and 70 years old, female 48 years old) who started IVIg respectively four months, twenty years and 1 year after onset, we observed an incomplete clinical, electrophysiological and ultrasound IVIg response.

Immune-mediated neuropathies include Guillain–Barre syndrome (GBS) and its variants, chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), multifocal motor neuropathy (MMN), paraproteinemic neuropathies. High-resolution ultrasound (US) is a helpful technique for the evaluation of peripheral nerves. In previous studies on immune-mediated neuropathies, nerve US showed diffuse enlargement of cross sectional area (CSA) of peripheral nerves trunks and cervical roots and morphological alterations at conduction block site. Data are however heterogeneous, correlations with clinical history or disease severity are lacking and there are no longitudinal studies in literature. The objective is to prospectively evaluate, through a multicenter longitudinal study, US findings in newly diagnosed patients with immune-mediated neuropathies and changes during time and relationship with clinical and neurophysiological findings. The proposal of the protocol is to enroll patients with immune-mediated neuropathies. We will perform clinical assessment, neurophysiological examination; US examination will study median, ulnar, radial, fibular, tibial, sural nerves (and brachial plexus in extended protocol). Maximal/minimal CSA for each nerve, inter- and intra-nerve variability, classification depending on echogenicity and fascicles enlargement will be considered. The protocol and its timing of follow-up evaluations, depending on acute/subacute or chronic disease, will be discussed so that the final version will be based on consensus among expert committees or clinical experience.

Ultrasound (US) can aim clinical and neurophysiologic assessment of the nerve lesions. After a case report we previously reported (Liotta et al., 2010), we present further three cases in which US allowed to depict concomitant nerve lesions far from the trauma sites. The first one is a man with humerus fracture immediately followed by a radial muscles plegia.Three months after the trauma, he presented no clinical/neurophysiologic recovery of fingers and wrist extensor muscles. US showed an enlargement of radial nerve in the fracture site and a contemporary marked enlargement of posterior interosseous nerve close to Frohse’s arcade. The other cases concern two patients with trauma at the level of clavicle and following plexopathy. Clinical/neurophysiologic examination in both cases showed a discrepancy between biceps brachii muscle (complete denervation) and the all other muscles (mild involvement). US showed a marked enlargement of the muscolocutaneous nerve distally to axilla. The nerve damage in a point far from the fracture site is probably due to the nerve traction caused by the trauma. These findings suggest a new mechanism of damage, that must be hypothesized in atypical muscles involvement after trauma, and the role of US in these cases for diagnosis, prognosis and treatment.

A 50-year old man received a cut injury to the left forearm with involvement of median and ulnar nerves and consequent hand motor and sensory deficits. He underwent surgical revision of the wound, but 6 months later the patient did not present recovery. A following neurophysiological examination showed sporadic fibrillation potentials with reduced voluntary recruitment in the first dorsal interosseus muscle and complete denervation in muscles innervated by distal median nerve, indicating an axonal ulnar neuropathy and a possible median nerve axonotmesis or neurotmesis. Ultrasound examination showed: median nerve neurotmesis and amputation neuroma with a gap of about 7–8 cm between proximal and distal stumps; a slight focal increase in cross-sectional area of the ulnar nerve close to the scar. The patient newly underwent surgery. A reconstruction of the left median nerve by a sural nerve graft and neurolysis of the ulnar nerve were performed. In the following days the patient reported an improvement in the cold and hot sensitivity on the ulnar nerve distribution in the left hand. In conclusion ultrasound nerve examination played a key role in decision-making.