Thick Nerve Research Articles

ROLE OF KUKKUTANDA TWAK BHASMA AND NIRGUNDI TAILA MATRA BASTI IN RAJONIVRITTIJANYA KATISHULA W.S.R TO SCIATICA

Katishula (Backache) is one of the major disabling health conditions among menopausal women involving the muscles and bones of the lower back which hampers day-to-day activities. In Ayurveda, Katishula comes under Vaatvyadhi in which prakupit vata affects Asthi (bones)-Sandhi(Joints). According to Anshansha kalpana of Katishula, the vata is vitiated due to Ruksha and Sheeta guna which leads to Dhatukshaya and causes age-related degeneration in bones. Sciatica refers to pain caused by a problem with the sciatic nerve. The sciatic nerve is the longest and thickest nerve in the body, almost a finger’s width in thickness. It runs from the lower back and then down the back of the legs. Kukkutanda twak have the kapha vata shamaka properties, which can subside the vitiation of kapha and vata in katishula. It is an excellent source of calcium and is useful in improving bone density. Just as the destruction of roots kills a plant, Basti administration destroys disease hence basti is called “Ardha chikitsa”. Asthi is sthana of vata and basti is the best treatment for vata dosha. The Matra basti (Enema) is one of the types of Anuvasana basti that is applicable in all Vata Sthangat Vyadhis so here we use Nirgundi oil for Basti which possesses Vatashamaka properties due to its Katu, Tikta rasa, and Ushna virya and thus suppresses the disease.

Study on the Crush Injury Model of the Sciatic Nerve in Rabbits by Conventional Ultrasound and Elastography.

The crush injury model of the sciatic nerve in rabbits is a common nerve injury model, but there is little literature on the evaluation of nerve stiffness by ultrasound elastography. To explore the value of ultrasound elastography in diagnosing crush injury of the sciatic nerve in rabbits. Forty cases of crush injury model of the sciatic nerve in rabbits were examined by conventional ultrasound and elastography. The sonographic manifestations and stiffness of the model were analyzed, and the regularity of nerve injury with time was summarized. Ultrasound could clearly show the location, range, and thickness of the injured nerve in this model. The thickness of the injured area reached a peak in the 2nd week and returned to normal thickness in the 8th week. The nerve stiffness of the injured area increased gradually with time. Conventional ultrasound combined with elastography can comprehensively and quantitatively evaluate the morphological changes and mechanical properties of the injured sciatic nerve in rabbits, which may be of great significance to the repair and rehabilitation of peripheral nerve crush injuries.

Reoperative and Non Reoperative Hirschsprung’s Disease in Associated with Clinicopathological Profile of the Proximal End of Resection in the Department of Anatomical Pathology, FMUI/CMH 2015-2019

Background
 Hirschsprung’s disease (HD) is a developmental disorder of the enteric nervous system, which is characterized by the absence of ganglion cells in the submucosal and myenteric plexuses. The success of surgery is influenced by many factors, one of which is the presence of histopathological abnormalities in the proximal part of the HD rectosigmoid resection. The aim of this study is to determine whether there are any histological characteristics associated with Hirschsprung's disease that would necessitate reoperation at the Department of Anatomical Pathology Faculty of Medicine Universitas Indonesia/Dr. Cipto Mangunkusumo Hospital (FMUI/CMH).
 Methods
 This was an analytical study using a cross-sectional design and secondary data from the Department of Anatomical Pathology Faculty of Medicine Universitas Indonesia/Dr. Cipto Mangunkusumo Hospital (FMUI/CMH) archives between 2015 and 2019. At the proximal end, histopathological examinations were performed to determine mature ganglion, nerve thickening, normal ganglion number, perineural inflammation, and serositis. The patient's age at the time of surgery, gender, the type of surgery, and the patient's age at the time of reoperation were all recorded.
 Results
 From the 64 resection cases, 15 reoperation resection cases and 49 non-reoperation resection cases were obtained. Of the 15 reoperation cases, the histopathological investigation revealed fifteen cases of mature ganglion, ten cases of nerve thickening, and fourteen cases of normal ganglion. There was no perineural inflammation in fifteen cases, and no serositis in fourteen cases. A p value of 0.026 was obtained for the patient's age at the time of the operation.
 Conclusion
 There are several factors that determine pasients with Hirschsprung disease who undergo reoperation after resection. The age of the patient at the time of resection is one of the factors that can affect the occurence of reoperation in patients with Hirschsprung disease.

Clinical and imaging characteristics of optic nerve tumors as the differencial diagnosis of optic neuritis

Objective: To investigate the clinical and imaging features of optic nerve tumors that require differential diagnosis from optic neuritis. Methods: A retrospective case series study was conducted. Clinical data of patients diagnosed with optic nerve tumors from January 2017 to December 2021 at the Second Affiliated Hospital of Zhejiang University School of Medicine were collected. A total of 29 patients (39 eyes) with clinical and magnetic resonance imaging (MRI) findings similar to optic neuritis or optic neuropathy were included. There were 15 cases of optic nerve sheath meningioma (ONSM) (17 eyes), 4 cases of optic nerve glioma (ONG) (5 eyes), and 10 cases of infiltrative optic nerve lesions (ION) (17 eyes). All patients underwent best-corrected visual acuity (BCVA), anterior and posterior segment examinations, visual field examination, and orbital or cranial MRI examination. Patient data were observed and analyzed, treatment and follow-up information were recorded, and clinical and imaging features were summarized and compared with those of optic neuritis or optic neuropathy. Results: Among the 29 patients with optic nerve tumors, 10 were male and 19 were female, with an average age of (43.3±13.8) years and a range of 11 to 72 years. The follow-up time was 6.8 (2.0, 11.0) months, with a range of 1 to 33 months. Sixteen patients (21 eyes) with optic nerve tumors were initially misdiagnosed as having acute optic neuritis and showed poor response to steroid treatment. Of these, 9 cases (11 eyes) were ONSM, 4 cases (6 eyes) were ION, and 3 cases (4 eyes) were ONG. The diagnostic delay time was 7.1 (1.5, 12.0) months, with a range of 1 to 24 months. The main clinical symptoms of all affected eyes were acute vision loss in 23 eyes, slow vision loss in 5 eyes, transient blackouts in 4 eyes, and no obvious visual symptoms in 7 eyes. The median BCVA of all affected eyes was 0.1, ranging from light perception to 1.0. Fundus examination results showed optic disc edema in 34 eyes and normal optic disc in 5 eyes among the 39 eyes with optic nerve tumors. A total of 27 patients (33 eyes) completed visual field examinations, which revealed an enlarged physiological blind spot in 11 eyes, a concentric or tubular visual field contraction in 8 eyes, a diffuse decrease in light sensitivity in 7 eyes, an arcuate scotoma in 4 eyes, and a normal visual field in 3 eyes. All affected eyes completed orbital or cranial MRI examinations, which showed mild optic nerve thickening in 22 eyes, significant thickening in 6 eyes with distortion, and no significant thickening in 6 eyes. Contrast-enhanced T1-weighted imaging (T1WI) MRI showed optic nerve parenchymal thickening in 5 eyes, all of which were ONG, and 2 of them had optic nerve parenchymal enhancement. Optic nerve sheath thickening and enhancement without optic nerve parenchymal thickening or enhancement were observed in 28 eyes, including 17 eyes of ION and 11 eyes of ONSM. There were 6 eyes with no obvious optic nerve thickening, which were all ONSM, showing mild or significant thickening and enhancement of the optic nerve sheath without optic nerve parenchymal thickening or enhancement. Conclusions: Optic nerve tumors can present with ophthalmic clinical features similar to optic neuritis, such as optic disc edema, and demonstrate MRI findings that resemble those of optic neuritis. Therefore, differentiation between the two is crucial, based on differences in their natural course and response to steroid therapy.

Strabismus and Exophthalmos in Children: Think of Optic Nerve Glioma

Introduction: Optic nerve gliomas are rare tumors that are mainly observed in children. Exophthalmos and strabismus are the main signs of the disease. Neuroimaging and in particular magnetic resonance imaging is of great help in the diagnosis and follow-up of these tumors. The therapeutic management of these gliomas involves different means: surgical removal, chemotherapy, radiotherapy or abstention under surveillance. The indications must be discussed on a case-by-case basis. We report in this work a case of optic nerve glioma revealed by a strabismus and a unilateral exophthalmos. Case Report: This is a 3-year-old girl from a non-consanguineous marriage, with no specific pathological ATCD, who presented with divergent strabismus with left exophthalmos evolving for 3 months. The ophthalmologic examination noted a constant wide-angle divergent strabismus on the left eye with moderate exophthalmos on the same side. Corrected visual acuity was reduced to near finger count on the left and 5/10 on the right. Somatic examination found café au lait spots on the back and trunk. Cerebral CT showed a bilateral thickening of the optic nerves, fusiform and regular, more marked on the left, isodense to spontaneous contrast, homogeneously enhancing after injection of PDC. On the left, it is responsible for a downward refoulement of the eyeball with grade 1 exophthalmos. An MRI was ordered revealing a regular well-limited fusiform thickening of the optic nerves in T1 isosignal, intermediate in T2 and FLAIR, in diffusion hypersignal without ADC restriction, intensely and finely heterogeneous enhancing after injection of contrast medium. This thickening is responsible for a grade I left exophthalmos, with widening of the optic canals posteriorly and filling of the intraconical fat evoking a glioma appearance. The child was referred to neurosurgery for management. Conclusion: The diagnosis of optic nerve glioma in children is rare, with atypical presentations both in terms .........

Curious Cases of Painful Ophthalmoplegia (P1-9.012)

<h3>Objective:</h3> Importance of various investigations for diagnoses by exclusion and importance of starting treatment, which might be common for specific pathologies irrespective of different etiologies. (in a resource-limited environment) <h3>Background:</h3> There were two cases of adult women (Patient G and Patient V) residing in the same neighborhood. They presented with similar complaints of right-sided orbital pain, headache, and sixth cranial nerve palsy. <h3>Design/Methods:</h3> On individual evaluation, Patient G had prominent right-sided dull orbital pain for 3 weeks with right-sided headache and diplopia for 1 week. Examination showed ipsilateral sixth nerve paresis. Investigations like Complete Blood Count, Complete Metabolic Panel, Chest X-ray, ANA, CSF Analysis (including Adenosine deaminase), ESR, and CRP were negative. MRI showed a single hypointense extra-axial lesion in right anteromedial temporal region, anterolateral to ipsilateral cavernous sinus. The lesion appeared to partially encase right sixth cranial nerve and approaching right superior orbital fissure. Patient V had similar complaints of right-sided headache for 4 weeks and diplopia for 1 week. Examination showed complete paralysis of ipsilateral sixth nerve palsy. Similarly, investigations were negative (including serum ACE levels). MRI revealed a single extra-axial hypointense lesion along right medial temporal region along with partial invasion of ipsilateral cavernous sinus. Mild asymmetric thickening of right fifth and sixth cranial nerves was seen. <h3>Results:</h3> Investigations were necessary to rule out differential diagnoses like tuberculous meningoencephalitis, thyroid ophthalmopathy, and other infectious, autoimmune, or neoplastic etiologies. By diagnosis of exclusion, patient G was diagnosed with <b>Tolosa-Hunt syndrome</b>. Though biopsy results were unavailable for patient V, she was provisionally diagnosed with <b>Neurosarcoidosis</b>. Both were started on Corticosteroids. On respective follow-up visits, both patients reported significant improvement in their symptoms. This further solidified the respective diagnoses in these patients. <h3>Conclusions:</h3> In a resource-limited environment, response to treatment is as important as other investigations to diagnose rare diseases by exclusion. <b>Disclosure:</b> Mr. Shah has nothing to disclose.

Ultrasonographic measurement of median nerve and wrist skin thickness in patients with carpal tunnel syndrome: relationship with clinical, electrophysiologic and functionality.

The study aimed to investigate the relationship between the proximal and distal cross-sectional area (CSA) of the median nerve and wrist skin thickness measured by ultrasound in patients with carpal tunnel syndrome (CTS), demographics, disease characteristics, electrophysiological measurements, symptom severity, functionality, and symptom severity. 98 patients with electrophysiological diagnoses of CTS in the dominant hand were included in the study. Proximal and distal CSAs of the median nerve and wrist skin thickness were measured ultrasonographically. Demographic and disease characteristics of the patients were recorded. Patients were evaluated with the Historical-Objective scale (Hi- Ob) for clinical staging, the Functional status scale (FSS) for functional status, and the Boston symptom severity scale (BSSS) for symptom severity. Ultrasonographic findings were correlated with demographic and disease characteristics, electrophysiological findings, Hi-Ob scala, Functional status scale (FSS), and Boston symptom severity scale (BSSS). Proximal median nerve CSA median was 11.0 (7.0-14.0) mm2, distal median nerve CSA median was 10.5 (5.0-18.0) mm2, and wrist skin thickness was measured 1.10 (0.6-1.40) mm. Median nerve CSAs were positively correlated with the CTS stage and FSS, negatively correlated with the sensory nerve action potential of the median nerve (SNAP) and the compound muscle action potential of the median nerve (CMAP) ( p<0.05). Wrist skin thickness was positively correlated with disease characteristics, including the presence of paresthesia and loss of dexterity and FSS and BSSS levels. Ultrasonographic measurements in CTS are associated with functionality rather than demographics. Especially the increase in wrist skin thickness leads to an increase in symptom severity.

VEGFA-modified DPSCs combined with LC-YE-PLGA NGCs promote facial nerve injury repair in rats

ObjectiveThe aim of this research was to investigate the effect of vascular endothelial growth factor A (VEGFA)-overexpressing rat dental pulp stem cells (rDPSCs) combined with laminin-coated and yarn-encapsulated poly(l-lactide-co-glycolide) (PLGA) nerve guidance conduit (LC-YE-PLGA NGC) in repairing 10 mm facial nerve injury in rats. Study DesignrDPSCs isolated from rat mandibular central incisor were cultured and identified in vitro and further transfected with the lentiviral vectors (Lv-VEGFA). To investigate the role and mechanisms of VEGFA in neurogenic differentiation in vitro, semaxanib (SU5416), Cell Counting Kit-8 (CCK-8), real-time quantitative polymerase chain reaction (qPCR) and Western blotting were performed. Ten-millimeter facial nerve defect models in rats were established and bridged by LC-YE-PLGA NGCs. The repair effects were detected by transmission electron microscopy (TEM), compound muscle action potential (CMAP), immunohistochemistry and immunofluorescence. ResultsExtracted cells exhibited spindle-shaped morphology, presented typical markers (CD44+CD90+CD34−CD45−), and presented multidirectional differentiation potential. The DPSCs with VEGFA overexpression were constructed successfully. VEGFA enhanced the proliferation and neural differentiation ability of rDPSCs, and the expression of neuron-specific enolase (NSE) and βIII-tubulin was increased. However, these trends were reversed with the addition of SU5416. This suggests that VEGFA mediates the above effects mainly through vascular endothelial growth factor receptor 2 (VEGFR2) binding. The LC-YE-NGC basically meet the requirements of facial nerve repair. For the in vivo experiment, the CMAP latency period was shorter in DPSCS-VEGFA-NGC group in comparison with other experimental groups, while the amplitude was increased. Such functional recovery correlated well with an increase in histological improvement. Further study suggested that VEGFA-modified DPSCs could increase the myelin number, thickness and axon diameter of facial nerve. NSE, βIII-tubulin and S100 fluorescence intensity and immunohistochemical staining intensity were significantly enhanced. ConclusionVEGFA-modified rDPSCs combined with LC-YE-PLGA NGCs have certain advantages in the growth and functional recovery of facial nerves in rats.

Ulnar nerve thickness at the elbow on longitudinal ultrasound view in control subjects

IntroductionUlnar mononeuropathy at the elbow is the second most frequent neuropathy in humans. Diagnosis is based on clinical and electrophysiological criteria and, more recently, also on ultrasound. Cross-sectional ultrasound is currently the most valued, although longitudinal ultrasound allows assessment of the entire affected trajectory of the nerve in a single view, but always in a straight line with no changes in direction, as in the extended elbow. The main aim of this work is to propose normative values ​​for longitudinal ultrasound of the ulnar nerve at the elbow.MethodsThe neurological exploration of upper extremity, and electrophysiological and ultrasound parameters at the elbow of ulnar nerve were evaluated in 76 limbs from 38 asymptomatic subjects.ResultsThe diameters of the nerve as well as the distal and proximal areas were larger at the proximal region of the ulnar groove, and even more so in older individuals. In most of these elderly subjects, we found a small, non-significant slowdown in motor conduction velocity at the elbow with respect to the forearm (less than 5 m/s).ConclusionsWe observed a good correlation between the longitudinal and cross-sectional ultrasounds of the ulnar nerve at the elbow. Longitudinal ultrasound proved to be sensitive, reliable, simple and rapid, but its greatest contribution was allowing the visualization of the entire nerve trajectory in an integrated way, providing an image with good definition of the outline, proportions and intraneural characteristics of the nerve.

Peroneal Nerve Injury Due to Hip Surgery Located at the Knee Level: A Case Report

Background: The hip surgery may be complicated with an iatrogenic peroneal nerve injury. The spontaneous recovery of these patients is usually poor, and majority of them require additional surgical treatment. In this paper, we presented a case of iatrogenic peroneal nerve injury following posttraumatic hip surgery, which was decompressed at the knee level, and achieved complete postoperative recovery.&#x0D; The case: A 32-year-old woman was admitted to our department due to EMNG-verified peroneal nerve lesion. Eight months before, the patient was injured in a traffic accident, followed by knee dislocation, hip dislocation, and acetabular fracture. After open reduction of the acetabular fracture performed by the orthopedic surgeons, the peroneal nerve palsy followed. At the admission, the clinical findings included left sided incomplete peroneal nerve palsy (MRC=2), pain in the lateral lower leg (VAS=3), and gait disturbances. Using EMNG, the nerve lesion was located at the knee level, while US indicated suspectable nerve compression, due to visible nerve thickening. The PNSQoL and SF-36 scores indicated a significant decline in patients' quality of life (QOL). Following GETA, the external neurolysis, decompression, and complete nerve deliberation were performed at the knee level, with preservation of all nerve branches. The patient reported immediate relief, while completely recovered 8 months following the surgery (MRC = 5, VAS = 0). In order to assess postoperative QOL, a prolonged follow-up is needed.&#x0D; Conclusion: The iatrogenic peroneal nerve injury following hip surgery may not always be located in the hip region. A proper anamnesis, physical examination, and diagnostic evaluation are necessary for proper treatment of these patients.

Role of ultrasonography in evaluation of post ganglionic brachial plexus injury in correlation with magnetic resonance and intraoperative findings

Background: Anatomical, structural as well as severity of brachial plexus injuries is evaluated by magnetic resonance imaging which determines the type of treatment as well as the prognosis. However, limitations such as static imaging, availability, cost-effectiveness & complexity of procedure has led to search of cheaper diagnostic modalities like ultrasonography which has potency to overcome such limitations. Therefore, this study was carried out to assess efficacy of ultrasound in post ganglionic brachial plexus injury.Materials and Methods: A cross sectional comparative study was conducted in the department of Radio-diagnosis of Mahatma Gandhi Medical College and Research Institute from January 2021 to June 2022 amongst 23 patients diagnosed with traumatic & clinically consistent brachial plexus injury who underwent surgical intervention. The outcome measures assessed were level of injury, site of injury, neuroma, rupture, neuropraxia / nerve thickening / probable scar block.Results: The majority of the subjects were males, with left sided injuries accounting for 52.2%. Root injuries (47.8%) were more common than trunk, division (26% each). USG showed 81.8% sensitivity & 100% specificity for rupture; 100% sensitivity & 92.3% specificity for neuroma & 50% sensitivity for nerve thickening. We recorded sensitivity & specificity rate of 100% for rupture, neuroma & nerve thickening on assessment by MRI. USG could not pick up T1 root injuries and lower trunk injuries.Conclusion: Ultrasonography recorded a high degree of accuracy in identifying the postganglionic brachial plexus injury associated with proximal roots, divisions, upper and middle trunks in the lateral region of the neck while the imaging in lower trunk was limited. Therefore, we conclude that ultrasonography supersedes limitations of MRI such as static imaging, expensive & technique sensitivity, which makes it a more lucrative diagnostic modality for studying the brachial plexus in adjunct or absence of MRI.

TISSUE EXPRESSION OF NEURONAL PROTEINS DURING SCIATIC NERVE REGENERATION AND INFLUENCE OF DIFFERENT SPECTRUM LASER RADIATION

Aim: To determine the effect of laser irradiation of different spectrum on the expression of neuronal proteins (GFAP, S100, NSE and NF-L) in the sciatic nerve during its regeneration after crossing and surgical suturing. Materials and methods: The experiment was performed on 60 laboratory rats of the Wistar line (200-250 g) with crossing of the left sciatic nerve and sutur¬ing with an epineural suture end to end 30 minutes after neurotomy. 90 days later, an immunohistochemical study was performed using specific antibodies (Thermo Fisher Scientific; USA). Results: A study of the marker of non-myelin Schwann GFAP cells showed their pronounced activation with germination in nerve thickness and the formation of weaves of processes around regenerated nerve fibers. The number of S-100-positive myelin Schwann cells decreased, the heterogeneity of their color and the loss of processes were determined. It showed a general decrease in the intensity of NSE- and NF-L-positive staining of nerve fibers regenerated after neurotomy, which was less pronounced when irradiated with a laser with a wavelength of 450-480 nm and 520 nm. Conclusions: In general, the use of laser radiation had a positive effect on the repair of nerve fibers after neurotomy. According to the immunohistochemical study of neuromarkers, the effect of laser irradiation of the blue spectrum was the most effective.

Could recurrent painful ophthalmoplegic neuropathy be caused by a neurovascular conflict?: A case report

Objective: Describe and discuss a typical case with recurrent painful ophthalmoplegic neuropathy (RPON), and demonstrate a likely extrinsic compression of the sixth cranial nerve by a vascular loop. Background: RPON is a rare, but well-known entity, characterized by attacks of ophthalmoplegia associated with ipsilateral headache. The etiology is unknown, but a neurovascular conflict (NVC) has been suggested as a cause. Method: A 62-year-old woman presented in the emergency department with a horizontal diplopia that developed a few hours after the onset of a left temporal headache. In the past she had presented to the clinic with the same problem several times. She had been thoroughly examined, but no cause had been found. The symptoms had resolved by themselves. In addition to a classic finding in RPON, gadolinium enhancement and thickening of a cranial nerve, the new MRI scanning detected an NVC. Herein we discuss the relevance of this finding. Conclusion: A neurovascular conflict causing inflammatory demyelination of a single cranial nerve and relapsing remitting painful ophthalmoplegic neuropathy is an alluring idea. However, it is hard to conceive theoretically, and more reported cases with compelling data are needed to give credibility to such an idea.

Giant Lipofibromatous Hamartoma of Median Nerve in a Child

Lipofibromatous hamartoma (LFH) is a rare fibrofatty tumor of adipocytes within peripheral nerves, affecting mainly children. It typically presents as a palpable mass surrounding the nerves of the upper limbs, causing pain and neurological deficits in the affected nerve distribution. We report the case of a child with a 2-years presentation of a mass in the right wrist associated with pain and paresthesia, who underwent investigation with magnetic resonance imaging (MRI). It showed thickening of the median nerve with spaghetti-like appearance associated with lipomatous tissue in a coaxial cable-like pattern, both features characteristic of LFH. This case illustrates the importance of MRI in the differential diagnosis of limb masses in the pediatric population.

Evaluation of Tibial nerve morphology by high resolution ultrasonography in diabetic patients with clinically suspected diabetic peripheral neuropathy: A cross sectional study

Background: Diabetic peripheral neuropathy is diagnosed by nerve conduction studies by presence of atypical parameters with respect to amplitude, latency as well as conduction velocity of nerve. In adjunct to current screening modalities, use of ultrasonography for evaluation of peripheral neuropathy in diabetic patients has been advocated as a promising diagnostic tool. The purpose of this study is to evaluate & measure Cross-sectional area of tibial nerve & maximum thickness of nerve fascicles of tibial nerve in diabetic patients with clinical suspicion of diabetic peripheral neuropathy by ultrasonography & its correlation with clinical symptoms, duration of diabetes & HbA1c. Materials and methods: This cross-sectional study was conducted in Mahatma Gandhi Medical College and Research Institute from January 2021 to June 2022 amongst 30 clinically suspected diabetic peripheral neuropathy patients. Results: The mean age, Hb1Ac & duration of diabetes was found to be 67.83, 10.08 & 21.27, with a male predominance (26 males & 4 females). Average Cross sectional area of tibial nerve, maximum thickness of nerve fascicles of tibial nerve & average total Toronto clinical neuropathy score was found to be 23.82 mm2, 0.68 mm & 10.23 respectively. Correlation of duration of diabetes, HbA1c as well as Toronto neuropathy score against average Cross sectional area of tibial nerve, average maximum thickness of nerve fascicles of tibial nerve in both limbs was found to be statistically significant with a strong positive correlation. Conclusion: High resolution ultrasonography is efficient in detecting morphological changes in tibial nerve in clinically suspected diabetic neuropathic patients. Cross-sectional area and maximum thickness of nerve fascicles of tibial nerve were found to be significantly higher than typical cut off values used in this study and high-resolution ultrasound is an important tool for diagnosis of diabetic peripheral neuropathy.

Verrucous Haemangioma with Histoid Leprosy: A Case Report

Verrucous Haemangioma (VH) is a rare, congenital vascular malformation of cutaneous and subcutaneous tissue. It usually presents as macular lesion at birth which progresses with age, and may become bluish papules, nodules, and warty plaques. Linear presentation of this disease is even rarer. Here the present case report presents a case of a 30-year-old male patient with multiple raised erythematous hyperkeratotic papules and plaques over right forearm since birth which was arranged in a linear pattern.The patient also had asymptomatic papules on right thigh and lower back region, associated with sensory loss and peripheral nerve thickening. Dermoscopy of forearm showed reddish-blue lacunae, alveolar pattern, and whitish veils. Colour Doppler showed intradermal dilated venous channels with thrombosis which was suggestive of haemangioma. Histopathological examination confirmed the diagnosis of linear VH on forearm and slit skin Ziehl-Neelsen staining was suggestive of histoid leprosy. Linear VH is a rare congenital venous malformation, progresses proportionately with age. Dermoscopy can help in early diagnosis of vascular lesions. Complete surgical excision is the treatment of choice.

Epidemiological and Clinical Pattern of Leprosy in a Tertiary Care Centre in Bareilly, Uttar Pradesh, India- A Retrospective Study

Introduction: Leprosy also known as Hansen’s Disease (HD), is a chronic infectious granulomatous disease caused by Mycobacterium leprae. It affects the skin and peripheral nerves. It is characterised by the formation of nodules or macules that enlarge and spread with loss of sensation due to nerve involvement which can progress to paralysis and eventually lead to deformities. Aim: To describe the clinical and epidemiological pattern of leprosy patients in a tertiary care hospital in Bareilly, Uttar Pradesh, India. Materials and Methods: This retrospective study was conducted at a tertiary level, Military Hospital in Bareilly, Uttar Pradesh, India, from June 2022 to August 2022. Medical records of 263 Leprosy patients, who were diagnosed as HD clinically and histopathologically were part of the study. All their data pertaining to the history, onset, time of detection, clinical features in the form, type and number of patches, presence of peripheral nerve thickenings, investigations which included skin slit smear for Acid Fast Bacilli (AFB) (Lepra) and histopathological examination, duration of drug therapy, reactions encountered and the disabilities were collected. Results: A total of 263 case records of leprosy patients (225 males (85.55%) and 38 females (14.45%), mean age of 35.36±13.79 years) were analysed. Majority of the cases were Borderline Tuberculoid (BT) Hansen’s 113 (42.96%). Average time taken by the patients before reporting to the Leprosy centre from onset of symptoms was 18 months. The most common clinical manifestation was multiple light coloured numb patches in 169 patients. A total of 245 patients had peripheral nerve thickening with Ulnar nerve 205 (77.95%) being the most commonly affected nerve. A total of 98 patients had Type-1 reaction and 13 had Type-2 reaction. The Grade-2 disability was seen in 22 cases with claw hand deformity being the commonest 10 (45.45%). Conclusion: In present study, majority patients were male with the most common clinical manifestation being multiple numb patches all over the body. The most common type of leprosy which presented was BT HD.

To Study Utility and Practicality of High-Frequency Ultrasonography to Demonstrate Nerve Involvement in Leprosy

ABSTRACT Background: Nerve examination in leprosy is subjective. There is a paucity of literature on objective methods to evaluate nerve involvement in Leprosy. Aims and Objectives: (1) To measure cross-sectional area (CSA) of nerves and identify echotexural changes in nerves in patients of leprosy by high-frequency ultrasonography (HFUS). (2) To compare HFUS findings in CSA and echotexture of nerves at baseline and after treatment. (3) To compare clinical grading and HFUS grading of nerves before and after treatment. Methods: Both newly diagnosed and treated patients of leprosy were included in the study. Nerve examination was done clinically and clinical grading of nerve thickening was done. Then, thickened nerves were subjected to HUFS to examine CSA (CSA) and echotextural changes. Nerves were also graded by HFUS grading. Parameters such as CSA, echotextural changes, and clinical and HFUS grading were compared before and after completion of treatment. Observations: Sixty-four leprosy patients were studied. Most of the patients in our study were in the third and fourth decade with a male preponderance and the mean age of presentation is 35.75 years. A total of 154 peripheral nerves were studied in 64 leprosy patients. Borderline tuberculoid leprosy (BTH) was the most common type of leprosy. The ulnar nerve was the most commonly imaged nerve followed by the greater auricular nerve. There was a statistically significant difference in CSA of nerves before and after treatment. Only 7 of 23 patients, who were found to have features of neuritis on USG, were clinically symptomatic. Three patients were diagnosed to have nerve abscesses. Conclusion: HFUS appears to be an objective, simple method to evaluate nerve involvement in leprosy. It is also useful to diagnose silent neuritis and nerve abscess. Limitations: All the peripheral nerves were not examined in healthy controls and leprosy patients.

The transition zone in Hirschsprung's bowel contains abnormal hybrid ganglia with characteristics of extrinsic nerves

The aganglionic bowel in short-segment Hirschsprung's disease is characterized both by the absence of enteric ganglia and the presence of extrinsic thickened nerve bundles (TNBs). The relationship between the TNBs and the loss of enteric ganglia is unknown. Previous studies have described decreasing numbers of ganglia with increasing density of TNBs within the transition zone (TZ) between ganglionic and aganglionic gut, and there is some evidence of spatial contact between them in this region. To determine the cellular interactions involved, we have analysed the expression of perineurial markers of TNBs and enteric ganglionic markers for both neural cells and their ensheathing telocytes across four cranio-caudal segments consisting of most proximal ganglionic to most distal aganglionic from pull-through resected colon. We show that in the TZ, enteric ganglia are abnormal, being surrounded by perineurium cells characteristic of TNBs. Furthermore, short processes of ganglionic neurons extend caudally towards the aganglionic region, where telocytes in the TNB are located between the perineurium and nerve fibres into which they project telopodes. Thus, enteric ganglia within the TZ have abnormal structural characteristics, the cellular relationships of which are shared by the TNBs. These findings will help towards elucidation of the cellular mechanisms involved in the aetiology of Hirschsprung's disease.

Recurrent Painful Ophthalmoplegic Neuropathy Mistaken for Oculomotor Schwannoma: A Case Report

AbstractRecurrent painful ophthalmoplegic neuropathy (RPON) is a headache disorder classified as a cranial neuropathy. It is characterized by episodes of unilateral headache followed by ipsilateral ophthalmoplegia due to ocular cranial nerve palsy. Symptoms usually subside spontaneously within weeks to months. RPON commonly occurs in childhood, though it is overlooked at times as a possible differential diagnosis. The pathophysiology of RPON is not entirely clear. Typical magnetic resonance imaging (MRI) findings in children include nerve thickening and gadolinium enhancement. However, these findings are not specific to this condition. Nerve thickening in RPON can resemble schwannomas, thereby causing a diagnostic dilemma. Here, we present a 13-year-old boy with a history of unilateral headaches associated with ipsilateral ptosis and diplopia. The first MRI indicated thickening and gadolinium enhancement of the right oculomotor nerve, which was interpreted as a schwannoma. However, his symptoms resolved after a few weeks and the follow-up MRI showed resolution of nerve changes. This clinical presentation was consistent with RPON. This case demonstrates the need for a careful follow-up of RPON patients.