Quantitative measures of the resting EEG in stroke: a systematic review on clinical correlation and prognostic value.

OBJECT: Quantitative electroencephalography (qEEG) has shown promising results as a predictor of clinical impairment in stroke. We systematically reviewed published papers that focus on qEEG metrics in the resting EEG of patients with mono-hemispheric stroke, to summarize current knowledge and pave the way for future research. METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we systematically searched the literature for papers that fitted our inclusion criteria. Rayyan QCRR was used to allow deduplication and collaborative blinded paper review. Due to multiple outcomes and non-homogeneous literature, a scoping review approach was used to address the topic. RESULTS: Or initial search (PubMed, Embase, Google scholar) yielded 3200 papers. After proper screening, we selected 71 papers that fitted our inclusion criteria and we developed a scoping review thar describes the current state of the art of qEEG in stroke. Notably, among selected papers 53 (74.3%) focused on spectral power; 11 (15.7%) focused on symmetry indexes, 17 (24.3%) on connectivity metrics, while 5 (7.1%) were about other metrics (e.g. detrended fluctuation analysis). Moreover, 42 (58.6%) studies were performed with standard 19 electrodes EEG caps and only a minority used high-definition EEG. CONCLUSIONS: We systematically assessed major findings on qEEG and stroke, evidencing strengths and potential pitfalls of this promising branch of research.

EEG spectral exponent as a synthetic index for the longitudinal assessment of stroke recovery.

OBJECTIVE: Quantitative Electroencephalography (qEEG) can capture changes in brain activity following stroke. qEEG metrics traditionally focus on oscillatory activity, however recent findings highlight the importance of aperiodic (power-law) structure in characterizing pathological brain states. We assessed neurophysiological alterations and recovery after mono-hemispheric stroke by means of the Spectral Exponent (SE), a metric that reflects EEG slowing and quantifies the power-law decay of the EEG Power Spectral Density (PSD). METHODS: Eighteen patients (n = 18) with mild to moderate mono-hemispheric Middle Cerebral Artery (MCA) ischaemic stroke were retrospectively enrolled for this study. Patients underwent EEG recording in the sub-acute phase (T0) and after 2 months of physical rehabilitation (T1). Sixteen healthy controls (HC; n = 16) matched by age and sex were enrolled as a normative group. SE values and narrow-band PSD were estimated for each recording. We compared SE and band-power between patients and HC, and between the affected (AH) and unaffected hemisphere (UH) at T0 and T1 in patients. RESULTS: At T0, stroke patients showed significantly more negative SE values than HC (p = 0.003), reflecting broad-band EEG slowing. Most important, in patients SE over the AH was consistently more negative compared to the UH and showed a renormalization at T1. This SE renormalization significantly correlated with National Institute of Health Stroke Scale (NIHSS) improvement (R = 0.63, p = 0.005). CONCLUSIONS: SE is a reliable readout of the neurophysiological and clinical alterations occurring after an ischaemic cortical lesion. SIGNIFICANCE: SE promise to be a robust method to monitor and predict patients' functional outcome.

Third order spectral analysis robust to mixing artifacts for mapping cross-frequency interactions in EEG/MEG.

We present a novel approach to the third order spectral analysis, commonly called bispectral analysis, of electroencephalographic (EEG) and magnetoencephalographic (MEG) data for studying cross-frequency functional brain connectivity. The main obstacle in estimating functional connectivity from EEG and MEG measurements lies in the signals being a largely unknown mixture of the activities of the underlying brain sources. This often constitutes a severe confounder and heavily affects the detection of brain source interactions. To overcome this problem, we previously developed metrics based on the properties of the imaginary part of coherency. Here, we generalize these properties from the linear to the nonlinear case. Specifically, we propose a metric based on an antisymmetric combination of cross-bispectra, which we demonstrate to be robust to mixing artifacts. Moreover, our metric provides complex-valued quantities that give the opportunity to study phase relationships between brain sources. The effectiveness of the method is first demonstrated on simulated EEG data. The proposed approach shows a reduced sensitivity to mixing artifacts when compared with a traditional bispectral metric. It also exhibits a better performance in extracting phase relationships between sources than the imaginary part of the cross-spectrum for delayed interactions. The method is then applied to real EEG data recorded during resting state. A cross-frequency interaction is observed between brain sources at 10Hz and 20Hz, i.e., for alpha and beta rhythms. This interaction is then projected from signal to source level by using a fit-based procedure. This approach highlights a 10-20Hz dominant interaction localized in an occipito-parieto-central network.

Movement-induced uncoupling of primary sensory and motor areas in focal task-specific hand dystonia.

INTRODUCTION: Due to growing evidence of sensorimotor integration impairment in focal task-specific hand dystonia, we aimed at describing primary sensory (S1) and primary motor (M1) cortex source activities and their functional cross-talk during a non-dystonia-inducing sensorimotor task free of biases generated by the interfering with the occurrence of dystonic movements. METHOD: Magnetoencephalographic brain signals and opponens pollicis (OP) electromyographic activities were acquired at rest and during a simple isometric contraction performed either alone or in combination with median nerve stimulation. The task was performed separately with the right and left hand by eight patients suffering from focal task-specific hand dystonia and by eight healthy volunteers. Through an ad hoc procedure Functional Source Separation (FSS), distinct sources were identified in S1 (FSS1) and M1 (FSM1) devoted to hand control. Spectral properties and functional coupling (coherence) between the two sources were assessed in alpha [8,13]Hz, beta [14,32]Hz and gamma [33,45]Hz frequency bands. RESULTS: No differences were found between spectral properties of patients and controls for either FSM1 or FSS1 cerebral sources. Functional coupling between FSM1 and FSS1 (gamma band coherence), while comparable between dystonic patients and healthy controls at rest, was selectively reduced in patients during movement. All findings were present in both hemispheres. DISCUSSION: Because previous literature has shown that gamma-band sensory-motor synchronization reflects an efficiency index of sensory-motor integration, our data demonstrate that, in dystonic patients, uncoupling replaces the functional coupling required for efficient sensory-motor control during motor exertion. The presence of bi-hemispheric abnormalities in unilateral hand dystonia supports the presence of an endophenotypic trait.

A contralesional EEG power increase mediated by interhemispheric disconnection provides negative prognosis in acute stroke.

BACKGROUND AND PURPOSE: Despite similar clinical onset, recovery from stroke can be largely variable. We searched for electrophysiological prognostic indices, believing that they can guide future neuromodulation treatments boosting clinical recovery. METHODS: 19-channels resting electroencephalogram (EEG) was collected in 42 patients after 4-10 days (t0) from a unilateral ischemic stroke in the middle cerebral artery (MCA) territory and 20 controls. National Health Institute Stroke Scale (NIHSS) was collected at t0 and 6 months later (t1). Standard spectral band powers and interhemispheric coherences between homologous MCA regions were calculated in both hemispheres. RESULTS: Total spectral, delta and theta band powers were higher bilaterally in patients than in controls and directly correlated with NIHSSt0 in both hemispheres. A linear regression model including each EEG patient's variable differing from those of controls and correlating with effective recovery [ER = (NIHSSt0-NIHSSt1)/(NIHSSt0-NIHSS in healthy conditions)] showed contralesional delta power as the only valid predictor of ER. A further regression model including also NIHSSt0 confirmed that contralesional delta power can add prognostic information to acute clinical impairment. Contralesional delta activity increase was best explained, in addition to the increasing ipsilesional delta activity, by a reduction of interhemispheric functional coupling--which did not explain a significantly portion of effective recovery variability by itself. CONCLUSIONS: Contralesional EEG delta activity retains relevant negative prognostic information in acute stroke patients. Present results point to the interhemispheric interplay as a decisive target in setting up enriched rehabilitations.

Sensorimotor Cortex Reorganization in Alzheimer's Disease and Metal Dysfunction: A MEG Study.

Objective. To verify whether systemic biometals dysfunctions affect neurotransmission in living Alzheimer's disease (AD) patients. Methods. We performed a case-control study using magnetoencephalography to detect sensorimotor fields of AD patients, at rest and during median nerve stimulation. We analyzed position and amount of neurons synchronously activated by the stimulation in both hemispheres to investigate the capability of the primary somatosensory cortex to reorganize its circuitry disrupted by the disease. We also assessed systemic levels of copper, ceruloplasmin, non-Cp copper (i.e., copper not bound to ceruloplasmin), peroxides, transferrin, and total antioxidant capacity. Results. Patients' sensorimotor generators appeared spatially shifted, despite no change of latency and strength, while spontaneous activity sources appeared unchanged. Neuronal reorganization was greater in moderately ill patients, while delta activity increased in severe patients. Non-Cp copper was the only biological variable appearing to be associated with patient sensorimotor transmission. Conclusions. Our data strengthen the notion that non-Cp copper, not copper in general, affects neuronal activity in AD. Significance. High plasticity in the disease early stages in regions controlling more commonly used body parts strengthens the notion that physical and cognitive activities are protective factors against progression of dementia.

Calibration of a multichannel MEG system based on the signal space separation method.

For an efficient use of multichannel MEG systems, an accurate sensor calibration is extremely important. This includes the knowledge of both channel sensitivities and channel arrangement, which can deviate from original system plans, e.g., because of thermal stresses. In this paper, we propose a new solution to the calibration of a multichannel MEG sensor array based on the signal space separation (SSS) method. It has been shown that an inaccurate knowledge of sensor calibration limits the performances of the SSS method, resulting in a mismatch between the measured neuromagnetic field and its SSS reconstruction. Given a set of known magnetic sources, we show that an objective function, which strongly depends on sensor geometry, can be derived from the principal angle between the measured vector signal and the SSS basis. Hence, the MEG sensor array calibration is carried out by minimizing the objective function through a standard large-scale optimization technique. Details on the magnetic sources and calibration process are presented here. Finally, an application to the calibration of the 153-channel whole-head MEG system installed at the University of Chieti is discussed.

Extrauterine maturation of somatosensory pathways in preterm infants: a somatosensory evoked potential study.

OBJECTIVE: To evaluate the reliability of somatosensory evoked potential (SEP) recordings in preterm infants to monitor the intra-uterine and extrauterine maturation of somatosensory pathways. METHODS: We performed SEPs in 35 neurologically normal preterm babies (range 23-35 weeks gestational age--GA). Twenty-four of all infants were evaluated after the first 2 weeks of life, at a minimum post-menstrual age (PMA) of 31 weeks, and 31 at term corrected age. In 15 infants we obtained longitudinal recordings at both epochs. Cross-sectional and longitudinal values of first cortical potential (N1) were analyzed in relation of PMA and matched with those measured in a group of 11 fullterm babies. RESULTS: Reproducible cortical SEPs were found in 92% of preterm babies at first recording, and in all 31 neonates at follow-up. A significant inverse correlation between the latency values of N1 and PMA at the time of first recording was observed, showing that latencies of these components rapidly decrease with increasing PMA. Regression analysis showed no significant effect on N1 latency at term correct age in dependence of GA, suggesting that extrauterine life does not affect maturation of somatosensory pathways. Interestingly, the occurrence of idiopathic respiratory distress (RDS) during clinical course after birth correlated with a delayed N1 latency at term corrected age. CONCLUSIONS: Extrauterine life does not affect maturation of somatosensory pathways in preterms without neurological deficit. Finally, the mild negative influence of RDS on maturational changes was evident. SIGNIFICANCE: SEPs could be considered a useful tool for a non-invasive assessment of somatosensory pathways integrity in preterm infants.

Sensorimotor integration in focal task-specific hand dystonia: a magnetoencephalographic assessment.

To obtain a direct sensorimotor integration assessment in primary hand cortical areas (M1) of patients suffering from focal task-specific hand dystonia, magnetoencephalographic (MEG) and opponens pollicis electromyographic (EMG) activities were acquired during a motor task expressly chosen not to induce dystonic movements in our patients, to disentangle abnormalities indicating a possible substrate on which dystonia develops. A simple isometric contraction was performed either alone or in combination with median nerve stimulation, i.e. when a non-physiological sensory inflow was overlapping with the physiological feedback. As control condition, median nerve stimulation was also performed at rest. The task was performed bilaterally both in eight patients and in 16 healthy volunteers. In comparison with results in controls we found that in dystonic patients: i) MEG-EMG coherence was higher; ii) it reduced much less during galvanic stimulation in the hemisphere contralateral to the dystonic arm, simultaneously with iii) stronger inhibition of the sensory areas responsiveness due to movement; iv) the cortical component including contributions from sensory inhibitory and motor structures was reduced and v) much more inhibited during movement. It is documented that a simultaneous cortico-muscular coherence increase occurs in presence of a reduced M1 responsiveness to the inflow from the sensory regions. This could indicate an unbalance of the fronto-parietal functional impact on M1, with a weakening of the parietal components. Concurrently, signs of a less differentiated sensory hand representation--possibly due to impaired inhibitory mechanisms efficiency--and signs of a reduced repertoire of voluntary motor control strategies were found.

Age dependence of primary motor cortex plasticity induced by paired associative stimulation.

OBJECTIVE: The increase of elderly population prompted growing research for the understanding of cerebral phenomena sustaining learning abilities, with inclusion of long-term potentiation (LTP)-like plasticity phenomena. Aim of the present study was to characterize LTP-like plasticity dependence on age and gender. METHODS: A LTP-like primary motor cortex plasticity inducing a potentiation of the motor evoked potential (MEP) to focal transcranial magnetic stimulation as a consequence of a paired associative stimulation (PAS) was induced in a 50 healthy subject cohort, equally distributed for gender and age groups (25 young subjects, mean age+/-SD=29.8+/-4.5 years; elderly 61.1+/-4.1 years). RESULTS: Resting motor thresholds' excitability level increased in the elderly group, the basal MEP did not depend on gender or age. The PAS-induced primary motor cortex (M1) plastic excitability modulation was similar in young females and males, while it decreased with age in females only. CONCLUSIONS: A reduction of the PAS-induced M1 plasticity in females after menopause was documented, possibly due to an impairment of intracortical excitatory network activity. SIGNIFICANCE: A LTP-like plasticity dependence on age was found in female only, suggesting caution in interpreting behavioural studies on learning abilities in dependence on age.

'Free' copper in serum of Alzheimer's disease patients correlates with markers of liver function.

Non-ceruloplasmin bound copper ('free') seems slightly elevated in Alzheimer's disease (AD) patients. To test the hypothesis of a correlation between 'free' copper and liver function in AD. We evaluated 51 AD patients and 53 controls through typical tests for chronic liver disease (AST, ALT, gamma-GT, Albumin, prothrombin time - PT-, bilirubins), along with copper, ceruloplasmin, iron, cholesterol in the serum and apolipoprotein E epsilon4 (APOE4) genotype. Absolute serum copper and 'free' copper were higher, albumin was lower and PT longer in AD patients than in controls. 'Free' copper correlated negatively with markers of liver function, in that albumin and albumin/PT ratio (r = -0.43, p = 0.004), and positively with direct bilirubin. Copper and 'free' copper were higher in the APOE4 carriers. These results suggest that abnormalities in copper metabolism might have an effect on liver function in AD.

Interhemispheric asymmetry of primary hand representation and recovery after stroke: a MEG study.

In patients affected by monohemispheric stroke in the middle cerebral artery territory, who do not regain a normal neurological function, a positive contribution to the clinical recovery seems to be made by the involvement of primary hand representation areas in the affected hemisphere (AH), excessively asymmetric to its homologous in the unaffected hemisphere (UH). We investigated primary sensory hand areas in 41 chronic patients who had improved their clinical status without reaching complete recovery. The location and strength of the first cerebral sources activated by a contralateral galvanic median nerve stimulation (M20 and M30) were evaluated in both hemispheres, together with their interhemispheric differences. The source displacement in the AH with respect to the UH was positively correlated with clinical recovery (Spearman's rho=0.584, p=0.003). The excessive interhemispheric asymmetry - as defined on the basis of reference ranges in the healthy population - could be interpreted as the involvement of neuronal pools in the AH outside the hand 'omega zone' of the Rolandic sulcus, revealing the presence of plasticity phenomena. The present data provide support to a positive role of cerebral plasticity phenomena, partially contributing to post-stroke recovery in patients unable to achieve normal neurological function.

Sensory-motor interaction in primary hand cortical areas: a magnetoencephalography assessment.

Movement control requires continuous and reciprocal exchange of information between activities of motor areas involved in the task program execution and those elaborating proprioceptive sensory information. Our aim was to investigate the sensorimotor interactions in the region dedicated to hand control in healthy humans, focusing onto primary sensory and motor cortices, by selecting the time window at very early latencies. Through magnetoencephalographic recordings, we obtained a simultaneous assessment of sensory cortex activity modulation due to movement and of motor cortex activity modulation due to sensory stimulation, by eliciting a galvanic stimulation to the nerve (the median nerve) innervating a muscle (the opponens pollicis), at rest or during voluntary contraction. The primary sensory and motor cortices activities were investigated respectively through excitability in response to sensory stimulation and the cortico-muscular coherence. The task was performed bilaterally. A clear reduction of the cortico-muscular coherence was found in the short time window following stimuli (between around 150-450 ms). In the same time period, the motor control of isometric contraction was preserved. This could suggest that cortical component of voluntary movement control was transiently mediated by neuronal firing rate tuning more than by cortico-muscular synchronization. In addition to the known primary sensory cortex inhibition due to movement, a more evident reduction was found for the component known to include a contribution from primary motor areas. Gating effects were lower in the dominant left hemisphere, suggesting that sensorimotor areas dominant for hand control benefit of narrowing down gating effects.

Long-term effects of stroke on neuronal rest activity in rolandic cortical areas.

To understand the relationship between neuronal function and clinical state in the framework of stroke, the long-term poststroke rolandic spontaneous neuronal activity was studied by means of magnetoencephalography. Fifty-six patients who had suffered a unilateral stroke within the middle cerebral artery were enrolled. Median time since stroke was 2.8 years. In association with lesion features and clinical picture, total and relative band powers and the spectral entropy were analyzed in the affected (AH) and unaffected (UH) hemispheres in comparison with an age-matched control group. An increase of absolute and relative slow band powers and a reduction of relative fast band powers were found in patients' AH with respect to both UH and control values. Absolute delta band was higher than in controls also in UH. New findings were the increase of rolandic rest activity power also in the alpha band and the decrease of spectral entropy in AH with respect to both UH and control values. Moreover, our results in chronic stroke patients indicate frequency-selective alterations related to specific dysfunctions: global clinical status was mostly impaired in patients with larger lesions and increased total and slow band activity powers, whereas hand functionality was mostly disrupted in patients with subcortical involvement and reduction of high-frequency rhythms and spectral entropy. Total power increase and spectral richness decrease are in agreement with a higher synchrony of local neuronal activity, a reduction of the intracortical inhibitory network's efficiency, and an increase of neuronal excitability.

[Exposure to traffic noise and effects on attention]. / Effetti sull'attenzione per esposizione a rumore da traffico urbano.

This study was aimed to evaluate if workers exposed to environmental stressors, including the urban traffic noise, might show significant differences compared to a control group in neuro-psychological and emotional profile as well as neurophysiological functions. In particular if these differences could be evidenced by the application of the "oddball paradigm" for event related potential P300 component. The study consisted of the following examinations: (1) exposed workers vs. controls under the odd-ball paradigm and the Stroop test in baseline condition; (2) amplitude and latency ofP300 (in baseline condition and after administration of acute urban traffic noise and Stroop test). The research was carried on a sample of 81 volunteers: 39 workers exposed to environmental stressors and 42 controls. The phonometric measurements showed mean levels of noise due urban traffic like 74 dBAeq. In baseline condition significative differences in exposed workers vs. control were found in Raven's Matrices PM 38 (p = 0.002) and Arithmetic reasoning from WAIS-R (p = 0.0024). Attention capacities as measured by Digit Span Forward and Visual Search, emotional functioning as measured by state- and trait-anxiety test and mood profile were not different in the two groups. Either in baseline condition or after acute stimuli no significant changes were found in two groups concerning the odd-ball paradigm. Exposed workers showed a higher execution time at Stroop test compared to controls (p = 0.047). No differences were found in the number of errors at the Stroop test. Before the acute stimulus, P300 amplitude was significant higher in the exposed workers than in controls (p = 0.002) while the latency was not different between two groups. Both noise (p = 0.001) and Stroop test (p = 0.002) stimulation increased the P300 latency of the whole sample, without significant differences between exposed workers and controls. A significative decrease of P300 amplitude due noise both in the exposed workers (p = 0.001) and in controls (p = 0.012) was found, without significant difference between the two groups. These results are interpreted as follows: (1) there are chronic effects on cognitive functioning in the exposed group vs. controls in baseline condition, like showed by significant differences in Raven PM38 and WAIS-R; (2) the exposed workers have a smaller cognitive flexibility, as shown by the Stroop test results; (3) in baseline condition the greater P300 amplitude in exposed workers reflect a greater division of attentive resources vs. controls, probably linked to the chronic stimulation by environmental stressors, especially noise, to which these workers are exposed; (4) the effects on P300 latency and amplitude can document the physiological response both in the exposed and not exposed to the acute stimulus and that the lack of significative differences in P300 latency and amplitude may be due to adaptative response to acute stimuli in exposed too. Our results allow us to consider that in workers exposed to urban stressor, such as noise, there are effects on cognitive functioning, especially on attention, without auditory damages. The valuation of P300 might represent a valid diagnostic instrument to evaluate the effects on cognitive functions especially on attention, in workers chronically and acutely exposed to urban stressors.

Does cerebrovascular disease affect the coupling between neuronal activity and local haemodynamics?

The relationship between neurophysiological and cerebrovascular-metabolic findings in patients affected by severe cerebrovascular deficits was investigated by comparing magnetoencephalographic (MEG-evoked fields) and blood oxygen level-dependent functional MRI (BOLD fMRI) responses to median nerve electric stimulation. Despite the use of identical stimuli, the two techniques elicited always-detectable responses in the control group (10 subjects), but demonstrated uncorrelated activation properties in our patient sample (10 subjects). All patients showed clear MEG signals in both the affected and unaffected hemispheres, indicating well synchronized, stimulus-locked firing of neurons in the primary sensorimotor cortex, but some patients showed no fMRI activation in either the affected or the unaffected hemisphere. In order to clarify the origin of this uncoupling, we investigated the possible role of lesion site, white matter hyperintensities, current medication, risk factors, anatomy of the neck vessels, and cerebral vasomotor reactivity (VMR) as measured by transcranial Doppler (TCD) during CO2 inhalation. Neither neuronal activation properties nor any of the considered factors were related to the lack of fMRI activation, with the exception of altered vasomotor reactivity, which was, on the contrary, strongly related. Preserved VMR was paired with absent BOLD bilaterally in the only patient affected by microangiopathy. This finding suggests that BOLD contrast could be more sensitive than TCD to chronic microvascular impairments, measuring small- rather than large- vessel reactivity.

Detection of fetal auditory evoked responses by means of magnetoencephalography.

MagnetoEncephaloGraphy (MEG) is proposed as a non-invasive technique to detect the physiological activity of fetal brain, due to its ability to record brain activity without direct contact with the head and the transparency of magnetic signals in passing through extracerebral fetal layers and the mother's abdomen. Healthy women with uncomplicated pregnancies and fetuses in breech presentation were examined; gestational ages at time of study ranged between 36 and 40 weeks. In order to evaluate fetal well-being, ultrasound and cardiotocographic data were assessed a few days before and after MEG recording sessions. The participating women were placed in a semi-reclining position in a magnetically shielded room; here the presentation of the fetus and precise region of the mother's abdomen corresponding to the fetal head were determined by ultrasound investigation in order to place the MEG detecting system as near as possible to the fetal brain. MEG recordings were performed by means of a 28-channel neuromagnetic system. Every MEG recording session was performed during the acoustic stimulation of fetuses, in order to detect the cerebral events evoked by peripheral stimuli. The auditory stimuli were delivered from a plastic tube placed on mother's abdomen, near the fetal head, and consisted of a 300 ms 103 dB pure tone at 500 and 1000 Hz, presented at a 0.4 c/s repetition rate. In six cases following accurate digital subtraction of maternal and fetal electrocardiographic (EKG) signals we remained with a stimulus-related response peaking at about 250 ms; this was considered to originate from the fetal brain. In favour of this in three cases a clear dipolar distribution was evident at the peak of brain response centered on the fetal head and consistent with a brain generator. Despite several technical problems requiring solution before a possible routine clinical application, MEG has been found to be suitable for the non-invasive exploration of the fetal brain.

[Ultrasonography features of the diaphragmatic crura: normal anatomy and its variants]. / Aspetti ecografici dei pilastri diaframmatici. Anatomia normale e sue varianti.

PURPOSE: To report the various US patterns of the diaphragmatic crura and the changes occurring during the different phases of respirations. The diaphragm has two US patterns: the central membranous part appears highly reflective while the posterior, upper and lateral muscular portions are hypoechoic and thick. The crura can sometimes appear quite bulky, which appearance is easy to misinterpret. MATERIAL AND METHODS: We carried out a three-stage work: first we reviewed the US examinations of 23 subjects with a nodular appearance of the posteromedial bundles and studied the changes in thickness during respiration. Second we studied the diaphragmatic crura in 30 subjects aged 18-71 years, 15 men and 15 women. We used a commercially available unit with sector and convex 3.5 MHz probes at baseline and during breath hold and acquired multiple parasagittal and transverse scans. The crura thickness was measured in all patients. Last, we studied the diaphragmatic regions of 10 patients with right pleural effusion and of 8 patients with associated ascites and pleural effusion using 2.0-5.0 MHz convex phased-array transducers. RESULTS: We found focal thickening of the crura in 11 of 23 patients with US findings of diaphragmatic nodules, but only in deep inspiration. The thickening was 1.5-2.2 cm long and maximum thickness was 10 mm. In the other 12 subjects we found 9 small lobules in the right and 3 in the left crus. In the anatomic study, we observed a 3-band appearance of the diaphragmatic crura, probably referable to muscle bundles, in 30 subjects on sagittal images, in 12 on coronal images and in 28 on anterior transverse images. The diaphragmatic crura were identified in 26 subjects only. The left posterior crus was identified in 29 subjects on left coronal images and in 15 on anterior transverse images; it was demonstrated on anterior sagittal images in close proximity to the aorta in only 4 subjects. Right crus thickness, measured on sagittal scans, ranged 3-10 mm in deep inspiration and 1-4 mm in expiration while the left crus was 3-6 mm in inspiration and 1-2 mm in expiration. The length of the right crus, studied in the preaortic portion, ranged from 7 cm in deep inspiration to 9.7 cm in expiration while the left one was 6.5 to 8.8 cm. The right lateral diaphragmatic bundles were seen in 28 subjects only on repeated subcostal oblique scans and the the left ones in 11 subjects only. Finally the thin anterior bundles were shown on parasagittal images in 13 cases in the right side and in 2 in the left. A 2-band appearance of the diaphragm was seen in 10 patients with pleural effusion and in 8 patients with associated ascites. A single band was found only in the tendinous portion of the diaphragm. DISCUSSION AND CONCLUSIONS: US is presently considered the imaging method of choice in the assessment of changes in thickness and length of the diaphragmatic crura. These structures have different US patterns and can sometimes appear quite bulky and thus be easily mistaken for other anatomic or abnormal structures; orthogonal scans may be required for the differential diagnosis.

[Echo-color Doppler in thyroid disease]. / Eco-color-Doppler nella patologia tiroidea.

One-hundred and sixty-six patients affected with thyroid diseases were examined, together with 41 healthy volunteers, by means of color-Doppler US. Four main reference patterns were identified: no appreciable glandular flow (I); presence of signal in perinodular location (II); peri- and intranodular flow (III); increased vascularization (IV). In 72 cases, parenchymal and nodular goiters, with no signs of thyroid hyperfunction, were characterized as belonging to pattern III, while pattern II was observed in 57 nodular lesions; only in 7 patients was pattern III detected. Hyperfunctioning autonomous nodules exhibited pattern III in 10/11 cases and the same pattern was followed by the six carcinomas. Pattern IV resulted peculiar to Basedow disease and to glandular hyperplasia related to high values of circulating thyroid hormone (6 cases). When color-Doppler specificity in typifying the major thyreopathies can be confirmed, the possibility is actually in sight of reducing, in the near future, the number of thyroid scintigraphies and of US-guided needle biopsies.