Diagnosis of Carpal Tunnel Syndrome using Shear Wave Elastography and High-frequency Ultrasound Imaging

Published:September 11, 2020DOI:https://doi.org/10.1016/j.acra.2020.08.011

      Objectives

      The performance of ultrasound features from shear wave elastography (SWE) and high-frequency ultrasound imaging was evaluated independently and in combination to diagnose carpal tunnel syndrome (CTS).

      Materials and Methods

      Twenty-five subjects were imaged in a sitting position with an arm extended and palm facing up. SWE of the medial nerve (MN) was acquired at the wrist level (site 1) and proximal to the pronator quadratus muscle (site 2). Cross-sectional area (CSA) and vascularity of the MN were assessed at the wrist using a 24 MHz probe. Color and power Doppler imaging (CDI and PDI), monochrome and color-coded Superb Microvascular Imaging (SMI) were performed for vascularity assessments. The diagnosis and severity of CTS was determined by clinical and electrodiagnostic tests. Diagnostic performance of the ultrasound features was assessed by t-tests, ANOVAs, and ROC analysis.

      Results

      The study included 20 control hands and 27 hands with CTS. All ultrasound features except for the stiffness ratio were significantly different between the CTS and control wrists (p<0.04). The stiffness of MN at site 1 showed a higher accuracy than at site 2. The combination of CSA and MN stiffness from site 2 showed an overall accuracy of 95% with a specificity and sensitivity of 100% and 93%, respectively. The CSA, MN stiffness from site 2, and CDI combination improved the accuracy to 96% with specificity and sensitivity of 100% and 93%, respectively. However, no ultrasound features (independently or in combination) differentiated all stages of CTS severity.

      Conclusions

      SWE with high-frequency ultrasound imaging showed potential for the diagnosis of CTS.

      Key Words

      Abbreviations:

      SWE (shear wave elastography), CTS (carpal tunnel syndrome), MN (median nerve), CSA (cross-sectional area), CDI (color Doppler imaging), PDI (power Doppler imaging), SMI (Superb Microvascular Imaging), mSMI (monochrome Superb Microvascular Imaging), cSMI (color-coded Superb Microvascular Imaging), ROI (region of interest), ANOVA (analysis of variance), ROC (receiver operating characteristic)
      To read this article in full you will need to make a payment

      Subscribe:

      Subscribe to Academic Radiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      REFERENCES

        • Stevens J.C.
        AAEM minimonograph #26: the electrodiagnosis of carpal tunnel syndrome. American Association of Electrodiagnostic Medicine.
        Muscle Nerve. 1997; 20 (12<1477:aid-mus1>3.0.co;2-5): 1477‐1486https://doi.org/10.1002/(sici)1097-4598(199712)20
        • Padua L.
        • Coraci D.
        • Erra C.
        • et al.
        Carpal tunnel syndrome: clinical features, diagnosis, and management.
        Lancet Neurol. 2016; 15: 1273-1284https://doi.org/10.1016/S1474-4422(16)30231-9
        • Ardakani A.A.
        • Afshar A.
        • Bhatt S.
        • et al.
        Diagnosis of carpal tunnel syndrome: A comparative study of shear wave elastography, morphometry and artificial intelligence techniques.
        Pattern Recognit Lett. 2020; 133: 77-85https://doi.org/10.1016/j.patrec.2020.02.020
        • Werner R.A.
        • Andary M.
        Carpal tunnel syndrome: pathophysiology and clinical neurophysiology.
        Clin Neurophysiol. 2002; 113: 1373-1381https://doi.org/10.1016/s1388-2457(02)00169-4
        • Karahan A.Y.
        • Arslan S.
        • Ordahan B.
        • Bakdik S.
        • Ekiz T.
        Superb Microvascular Imaging of the Median Nerve in Carpal Tunnel Syndrome: An Electrodiagnostic and Ultrasonographic Study.
        J Ultrasound Med. 2018; 37: 2855-2861https://doi.org/10.1002/jum.14645
        • Visser L.H.
        • Smidt M.H.
        • Lee M.L.
        High-resolution sonography versus EMG in the diagnosis of carpal tunnel syndrome.
        J Neurol Neurosurg Psychiatry. 2008; 79: 63-67https://doi.org/10.1136/jnnp.2007.115337
        • Kanikannan M.A.
        • Boddu D.B.
        • Umamahesh Sarva S.
        • Durga P.
        • Borgohain R.
        Comparison of high-resolution sonography and electrophysiology in the diagnosis of carpal tunnel syndrome.
        Ann Indian Acad Neurol. 2015; 18: 219-225https://doi.org/10.4103/0972-2327.150590
        • Borire A.
        • Hughes A.
        • Lueck C.
        • Colebatch J.
        • Krishnan A.
        Sonographic differences in carpal tunnel syndrome with normal and abnormal nerve conduction studies.
        J Clin Neurosci. 2016; 34: 77-80https://doi.org/10.1016/j.jocn.2016.05.024
        • Miyamoto H.
        • Halpern E.J.
        • Kastlunger M.
        • et al.
        Carpal tunnel syndrome: diagnosis by means of median nerve elasticity–improved diagnostic accuracy of US with sonoelastography.
        Radiology. 2014; 270: 481-486https://doi.org/10.1148/radiol.13122901
        • Cingoz M.
        • Kandemirli S.G.
        • Alis D.C.
        • Samanci C.
        • Kandemirli G.C.
        • Adatepe N.U.
        Evaluation of median nerve by shear wave elastography and diffusion tensor imaging in carpal tunnel syndrome.
        Eur J Radiol. 2018; 101: 59-64https://doi.org/10.1016/j.ejrad.2018.02.005
        • Tai T.W.
        • Wu C.Y.
        • Su F.C.
        • Chern T.C.
        • Jou I.M.
        Ultrasonography for diagnosing carpal tunnel syndrome: a meta-analysis of diagnostic test accuracy.
        Ultrasound Med Biol. 2012; 38: 1121-1128https://doi.org/10.1016/j.ultrasmedbio.2012.02.026
        • Kutlar N.
        • Bayrak A.O.
        • Bayrak İ.K.
        • Canbaz S.
        • Türker H.
        Diagnosing carpal tunnel syndrome with Doppler ultrasonography: a comparison of ultrasonographic measurements and electrophysiological severity.
        Neurol Res. 2017; 39: 126-132https://doi.org/10.1080/01616412.2016.1275455
        • Chen J.
        • Chen L.
        • Wu L.
        • et al.
        Value of superb microvascular imaging ultrasonography in the diagnosis of carpal tunnel syndrome: Compared with color Doppler and power Doppler.
        Medicine (Baltimore). 2017; 96: e6862https://doi.org/10.1097/MD.0000000000006862
        • Ghasemi-Esfe A.R.
        • Khalilzadeh O.
        • Mazloumi M.
        • et al.
        Combination of high-resolution and color Doppler ultrasound in diagnosis of carpal tunnel syndrome.
        Acta Radiol. 2011; 52: 191-197https://doi.org/10.1258/ar.2010.100299
        • Joy V.
        • Therimadasamy A.K.
        • Chan Y.C.
        • Wilder-Smith E.P.
        Combined Doppler and B-mode sonography in carpal tunnel syndrome.
        J Neurol Sci. 2011; 308: 16-20https://doi.org/10.1016/j.jns.2011.06.042
        • Moran L.
        • Royuela A.
        • de Vargas A.P.
        • Lopez A.
        • Cepeda Y.
        • Martinelli G.
        Carpal Tunnel Syndrome: Diagnostic Usefulness of Ultrasound Measurement of the Median Nerve Area and Quantitative Elastographic Measurement of the Median Nerve Stiffness.
        J Ultrasound Med. 2020; 39: 331-339https://doi.org/10.1002/jum.15111
        • Orman G.
        • Ozben S.
        • Huseyinoglu N.
        • Duymus M.
        • Orman K.G.
        Ultrasound elastographic evaluation in the diagnosis of carpal tunnel syndrome: initial findings.
        Ultrasound Med Biol. 2013; 39: 1184-1189https://doi.org/10.1016/j.ultrasmedbio.2013.02.016
        • Miyamoto H.
        • Morizaki Y.
        • Kashiyama T.
        • Tanaka S.
        Grey-scale sonography and sonoelastography for diagnosing carpal tunnel syndrome.
        World J Radiol. 2016; 8: 281-287https://doi.org/10.4329/wjr.v8.i3.281
        • Kantarci F.
        • Ustabasioglu F.E.
        • Delil S.
        • et al.
        Median nerve stiffness measurement by shear wave elastography: a potential sonographic method in the diagnosis of carpal tunnel syndrome.
        Eur Radiol. 2014; 24: 434-440https://doi.org/10.1007/s00330-013-3023-7
        • Gupta R.
        • Gray M.
        • Chao T.
        • Bear D.
        • Modafferi E.
        • Mozaffar T.
        Schwann cells upregulate vascular endothelial growth factor secondary to chronic nerve compression injury.
        Muscle & Nerve. 2005; 31: 452-460https://doi.org/10.1002/mus.20272
        • Farias Zuniga A.
        • Ghavanini A.A.
        • Israelian G.
        • Keir P.J.
        Blood flow velocity but not tendon mechanics relates to nerve function in carpal tunnel syndrome patients.
        J Neurol Sci. 2020; 411116694https://doi.org/10.1016/j.jns.2020.116694
        • Machado P.
        • Segal S.
        • Lyshchik A.
        • Forsberg F.
        A Novel Microvascular Flow Technique: Initial Results in Thyroids.
        Ultrasound Q. 2016; 32: 67-74https://doi.org/10.1097/RUQ.0000000000000156
        • Tuncali D.
        • Barutcu A.Y.
        • Terzioglu A.
        • Aslan G.
        Carpal tunnel syndrome: comparison of intraoperative structural changes with clinical and electrodiagnostic severity.
        Br J Plast Surg. 2005; 58: 1136-1142https://doi.org/10.1016/j.bjps.2005.05.010
        • Sunderland S.
        The nerve lesion in the carpal tunnel syndrome.
        J Neurol Neurosurg Psychiatry. 1976; 39: 615-626https://doi.org/10.1136/jnnp.39.7.615
        • Wee T.C.
        • Simon N.G.
        Ultrasound elastography for the evaluation of peripheral nerves: A systematic review.
        Muscle Nerve. 2019; 60: 501-512https://doi.org/10.1002/mus.26624
        • Tatar I.G.
        • Kurt A.
        • Yavasoglu N.G.
        • Hekimoglu B.
        Carpal tunnel syndrome: elastosonographic strain ratio and cross-sectional area evaluation for the diagnosis and disease severity.
        Med Ultrason. 2016; 18: 305-311https://doi.org/10.11152/mu.2013.2066.183.tat
        • Yoshii Y.
        • Tung W.L.
        • Ishii T.
        Measurement of Median Nerve Strain and Applied Pressure for the Diagnosis of Carpal Tunnel Syndrome.
        Ultrasound Med Biol. 2017; 43: 1205-1209https://doi.org/10.1016/j.ultrasmedbio.2017.02.018
        • Cingoz M.
        • Kandemirli S.G.
        • Alis D.C.
        • Samanci C.
        • Kandemirli G.C.
        • Adatepe N.U.
        Evaluation of median nerve by shear wave elastography and diffusion tensor imaging in carpal tunnel syndrome.
        Eur J Radiol. 2018; 101: 59https://doi.org/10.1016/j.ejrad.2018.02.005
        • Zhang C.
        • Li M.
        • Jiang J.
        • et al.
        Diagnostic Value of Virtual Touch Tissue Imaging Quantification for Evaluating Median Nerve Stiffness in Carpal Tunnel Syndrome.
        J Ultrasound Med. 2017; 36: 1783-1791https://doi.org/10.1002/jum.14213
        • Paluch Ł.
        • Pietruski P.
        • Walecki J.
        • Noszczyk B.H.
        Wrist to forearm ratio as a median nerve shear wave elastography test in carpal tunnel syndrome diagnosis.
        J Plast Reconstr Aesthet Surg. 2018; 71: 1146-1152https://doi.org/10.1016/j.bjps.2018.03.022
        • Bedewi M.A.
        • Coraci D.
        • Ruggeri F.
        • Giovannini S.
        • Gentile L.
        • Padua L.
        Shear wave elastography of median nerve at wrist and forearm. Heterogeneity of normative values.
        J Plast Reconstr Aesthet Surg. 2019; 72: 137-171https://doi.org/10.1016/j.bjps.2018.09.015
        • Zhu B.
        • Yan F.
        • He Y.
        • et al.
        Evaluation of the healthy median nerve elasticity: Feasibility and reliability of shear wave elastography.
        Medicine (Baltimore). 2018; 97: e12956https://doi.org/10.1097/.0000000000012956
        • Bortolotto C.
        • Turpini E.
        • Felisaz P.
        • et al.
        Median nerve evaluation by shear wave elastosonography: impact of "bone-proximity" hardening artifacts and inter-observer agreement.
        J Ultrasound. 2017; 20 (Published 2017 Nov 17): 293-299https://doi.org/10.1007/s40477-017-0267-0
        • Dąbrowska-Thing A.
        • Zakrzewski J.
        • Nowak O.
        • Nitek Ż.
        Ultrasound elastography as a potential method to evaluate entrapment neuropathies in elite athletes: a mini-review.
        Pol J Radiol. 2019; 84: e625‐e629https://doi.org/10.5114/pjr.2019.92422
        • Sucher B.M.
        Grading severity of carpal tunnel syndrome in electrodiagnostic reports: why grading is recommended.
        Muscle Nerve. 2013; 48: 331-333https://doi.org/10.1002/mus.23824
        • Shiina T.
        • Nightingale K.R.
        • Palmeri M.L.
        • et al.
        WFUMB guidelines and recommendations for clinical use of ultrasound elastography: Part 1: basic principles and terminology.
        Ultrasound Med Biol. 2015; 41: 1126-1147https://doi.org/10.1016/j.ultrasmedbio.2015.03.009
        • Lee E.S.
        • Lee J.B.
        • Park H.R.
        • et al.
        Shear Wave Liver Elastography with a Propagation Map: Diagnostic Performance and Inter-Observer Correlation for Hepatic Fibrosis in Chronic Hepatitis.
        Ultrasound Med Biol. 2017; 43: 1355-1363https://doi.org/10.1016/j.ultrasmedbio.2017.02.010
        • Habibzadeh F.
        • Habibzadeh P.
        • Yadollahie M.
        On determining the most appropriate test cut-off value: the case of tests with continuous results.
        Biochem Med (Zagreb). 2016; 26: 297‐307https://doi.org/10.11613/BM.2016.034
        • Klauser A.S.
        • Halpern E.J.
        • De Zordo T.
        • et al.
        Carpal tunnel syndrome assessment with US: value of additional cross-sectional area measurements of the median nerve in patients versus healthy volunteers.
        Radiology. 2009; 250: 171‐177https://doi.org/10.1148/radiol.2501080397
        • Moschovos C.
        • Tsivgoulis G.
        • Kyrozis A.
        • et al.
        The diagnostic accuracy of high-resolution ultrasound in screening for carpal tunnel syndrome and grading its severity is moderated by age.
        Clin Neurophysiol. 2019; 130: 321-330https://doi.org/10.1016/j.clinph.2018.12.005