Detektion von mikroembolischen Signalen und Impedanzaggregometrie bei Patienten mit akut-symptomatischen Stenosen der Arteria carotis interna

Ziel der Dissertation war die Korrelation zwischen mikroembolischen Signalen (MES) und der Effektivität der thrombozytenaggregationshemmenden Therapie bei symptomatischen Arteria carotis (ACI) Stenosen zu überprüfen. 32 Patienten mit einer symptomatischen ACI Stenose wurden rekrutiert. 23 Patienten erhielten Acetylsalicylsäure und 9 Clopidogrel. Nach dem Beginn der Therapie wurde eine Impedanzaggregometrie sowie ein 30min transkranielles Doppler (TCD) Monitoring durchgeführt. Die Impedanzaggregometrie erbrachte eine insuffiziente (low-responders) Thrombozytenaggregationshemmung bei 8 und eine suffiziente (responders) bei 24 Patienten der Studiengruppe. Bei 6/8 low-responders (75.0%) waren >1 MES zu detektieren, während dies bei nur 7/24 responders (29,2%) der Fall war (p=0.038). Zusammenfassend, die Detektion von >1 MES während eines 30 min TCD-Monitorings bei symptomatischen ACI Stenosen könnte als möglicher Marker der Wirksamkeit der thrombozytenaggregationshemmenden Therapie dienen

Subcutaneous immunoglobulin in treating inflammatory neuromuscular disorders

Objective: Intravenous immunoglobulin administration has long been used in the treatment of autoimmune neuromuscular disorders. Immunoglobulins may be administered by intramuscular, intravenous or subcutaneous routes. Methods: This is a report on the long-term clinical follow up of six patients with inflammatory neuromuscular disorders, that is, three chronic inflammatory demyelinating polyneuropathy (CIDP), one multifocal motor neuropathy (MMN), one inclusion body myositis (IBM) and one myasthenia gravis (MG), treated with subcutaneous immunoglobulins for a mean of 3.25 years. Results: One MMN and two CIDP patients received a weekly dose of subcutaneous immunoglobulins equivalent to intravenous immunoglobulin. One CIDP patient received a 50% dose reduction, the IBM patient received a 30% reduction and the MG patient a 20% reduction. The lower dose chosen in the majority of patients was based not only on clinical effects, but also on studies of primary immunodeficiency syndromes. One patient with CIDP showed clinical fluctuation, which was successfully treated with an adaptation of the dose of subcutaneous immunoglobulins, while the remaining patients with neuromuscular disorders had a stable clinical course for 2 years. No serious side effects were observed. Conclusions: Our results suggest that subcutaneous immunoglobulins can be an attractive alternative therapy in autoimmune neuromuscular disorders

Role of the neuromuscular ultrasound in the diagnostic of the multifocal motor neuropathy

Multifocal motor neuropathy (MMN) is the one of the most common acquired immune-mediated inflammatory disorders of the peripheral nervous system. The diagnosis is based on the distribution pattern of the neurological semiology and the pathological changes of nerve conduction studies (NCS) in classical cases. However, in cases with subtle clinical presentation, an extended diagnostic workup may be needed, such as cerebrospinal fluid examination, laboratory tests, and nerve biopsy. NCS remain nowadays fundamental not only for the diagnosis, but also for the follow-up and measurement of response to immune-treatment in MMN. New challenges arose though, on how best to acquire a static and dynamic imaging of the peripheral nerves, aiming to provide a holistic approach to the nerve impairment. According to the literature, neuromuscular ultrasound is able to detect in MMN patients thickened or swollen cervical roots, peripheral nerves or brachial plexus, findings that suggest ongoing inflammation. This review provides a timely update on the nerve ultrasound findings in MMN

Guidelines for neuromuscular ultrasound training

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High-resolution nerve ultrasound to assess nerve echogenicity, fascicular count, and cross-sectional area using semiautomated analysis

BACKGROUND AND PURPOSE Little is known about echogenicity and fascicular structure observed in high-resolution nerve ultrasound (HRUS) in both healthy subjects and patients with peripheral nerve disease. The aim of this study was to evaluate the reliability of echogenicity, fascicle count, and fascicle size analysis, to create standard values and compare these parameters to patients with chronic inflammatory demyelinating polyneuropathy (CIDP). METHODS Median, ulnar, radial, tibial, and fibular nerve of 79 healthy subjects and patients were scanned by one examiner using HRUS. Image analysis regarding echogenicity, fascicle count, and fascicle cross-sectional area (CSA) was performed by two independent raters semiautomatically using ImageJ. Pearson correlation coefficient $\it r$ reflected interrater reliability (IR), and intraclass correlation coefficient (ICC) determined intrarater reliability (IAR). Results of healthy subjects were compared to 20 patients with CIDP by analysis of variance. RESULTS IR was very good for echogenicity ($\it r$ = .9) and good for fascicle count and size of the largest fascicle ($\it r$ = .64/.56). IAR was very good for all three parameters (ICC = .9/.83/.74). Healthy subjects had a wide range of values. CIDP patients were in range of healthy subjects. Clinically progressive CIDP patients (defined as an increase in Overall Disability Sum Score by $\geq$1 point) had a lower fraction of black than healthy controls and stable CIDP patients ($\it P$ < .001). CONCLUSION Semiautomated evaluation of echogenicity, fascicle count, and fascicle CSA is reliable. Cutoff values to differentiate between healthy persons and CIDP do not exist. Echogenicity is useful for detecting clinically progressive CIDP patients and should be used in clinical context or intraindividual course

Guidelines for neuromuscular ultrasound training

Neuromuscular ultrasound has become an essential tool in the diagnostic evaluation of various neuromuscular disorders, and, as such, there is growing interest in neuromuscular ultrasound training. Effective training is critical in mastering this modality. Our aim was to develop consensus-based guidelines for neuromuscular ultrasound training courses. A total of 18 experts participated. Expert opinion was sought through the Delphi method using 4 consecutive electronic surveys. A high degree of consensus was achieved with regard to the general structure of neuromuscular ultrasound training; the categorization of training into basic, intermediate, and advanced levels; the learning objectives; and the curriculum for each level. In this study, a group of neuromuscular ultrasound experts established consensus-based guidelines for neuromuscular ultrasound training. These guidelines can be used in the development of the specialty and the standardization of neuromuscular ultrasound training courses and workshops. © 2019 Wiley Periodicals, Inc