Mid forearm enlargement
Patient, woman 47 years old, presenting with hand numbness, mostly right hand for several years. Later addition of symptoms in her feet.
Standard carpal tunnel electroneurography exam concluded a probable polyneuropathy of both motor and sensory nerves to a different extent in different regions, with no signs of carpal tunnel syndrome. Median nerve conduction velocity was 30-34 m/s in the right arm and 40-41 m/s in the left arm.
Electromyography showed findings that could be consistent with proximal impact of brachial plexus lower part (C8).
Echoneurography of brachial plexus and median, radial, ulnar nerve was performed. Median nerve had very pronounced morphological changes wich you can see below. The nerve roots were also very enlarged.
Enlarged median nerve at mid forearm level can be seen in various conditions. It is possible to find clues as to wich condition is most likely the case, using the combined information from different exams and existing results of various studies. In this case the patients symtoms started after age of 30, median nerve conduction velocity is approx 30-40 m/s. Echoneurography shows enlarged fascicles and mid forearm cross sectional area of 25 mm2. These findings are consistent with Charcot Marie Tooth 1B, cince median nerve CSA of >20 mm2 at mid forearm is documented in CMT1A and CM1B and nothing close to this patients CSA values in the other genetic or non genetic conditions. CMT1A is excluded because patients symptom onset is in adulthood and her median nerve conduction velocity is relatively high in this context. Other echoneurographical findings that suggest this conclusion are also present. This is of course a diagnosis that can’t be confirmed other then with gene testing. Inflammatory or other unknown conditions can’t be excluded either. But these findings are a good reason to proceed with continuation of diagnostic evaluation in order to help the patient. In this case a lumbar punction and proper genetic testing are a viable choise. If evidence of neuroinflammation is found in the spinal fluid then there is a good chance that patient can get better with available treatment options. If CMT is confirmed then the treatment is for now unknown. The patient will in that case have a conclusive answer and physicians can be aware of the sensitivity of the patient to certain medicines that can worsen the symptoms of CMT, wich is a condition that fortunately does not effect life expectancy.
Image sequence from carpal tunnel to axilla showing a pronounced median nerve enlargement throughout the arm. Mid forearm 25 mm2, mid upper arm 35 mm2. Normal value approx 10 mm2. Patient also had very enlarged nerve roots, especially C6-C8, wich you can see in the brachial plexus case file.
Mid forearm enlargement
Patient, woman 47 years old, presenting with hand numbness, mostly right hand for several years. Later addition of symptoms in her feet.
Standard carpal tunnel electroneurography exam concluded a probable polyneuropathy of both motor and sensory nerves to a different extent in different regions, with no signs of carpal tunnel syndrome. Median nerve conduction velocity was 30-34 m/s in the right arm and 40-41 m/s in the left arm.
Electromyography showed findings that could be consistent with proximal impact of brachial plexus lower part (C8).
Echoneurography of brachial plexus and median, radial, ulnar nerve was performed. Median nerve had very pronounced morphological changes wich you can see below. The nerve roots were also very enlarged.
Enlarged median nerve at mid forearm level can be seen in various conditions. It is possible to find clues as to wich condition is most likely the case, using the combined information from different exams and existing results of various studies. In this case the patients symtoms started after age of 30, median nerve conduction velocity is approx 30-40 m/s. Echoneurography shows enlarged fascicles and mid forearm cross sectional area of 25 mm2. These findings are consistent with Charcot Marie Tooth 1B, cince median nerve CSA of >20 mm2 at mid forearm is documented in CMT1A and CM1B and nothing close to this patients CSA values in the other genetic or non genetic conditions. CMT1A is excluded because patients symptom onset is in adulthood and her median nerve conduction velocity is relatively high in this context. Other echoneurographical findings that suggest this conclusion are also present. This is of course a diagnosis that can’t be confirmed other then with gene testing. Inflammatory or other unknown conditions can’t be excluded either. But these findings are a good reason to proceed with continuation of diagnostic evaluation in order to help the patient. In this case a lumbar punction and proper genetic testing are a viable choise. If evidence of neuroinflammation is found in the spinal fluid then there is a good chance that patient can get better with available treatment options. If CMT is confirmed then the treatment is for now unknown. The patient will in that case have a conclusive answer and physicians can be aware of the sensitivity of the patient to certain medicines that can worsen the symptoms of CMT, wich is a condition that fortunately does not effect life expectancy.
Image sequence from carpal tunnel to axilla showing a pronounced median nerve enlargement throughout the arm. Mid forearm 25 mm2, mid upper arm 35 mm2. Normal value approx 10 mm2. Patient also had very enlarged nerve roots, especially C6-C8, wich you can see in the brachial plexus case file.