Velfærdsløftet er lige om hjørnet København den 23. oktober 2013 Projekt DiaNerve – Tidlig Opsporing af Nerveskade giver ny Viden og forebygger Amputationer Niels Ejskjær MD PhD Klinisk Forskning og Fundraising

PLATFORM Fondsgiver. UNIK Partnerskabet Teknologi PLATFORM Fondsgiver UNIK Partnerskabet Teknologi Siemens A/S Health Sector DK Regnskab Aarhus Universitet Forskning Dansk Diabetes Akademi Klinik Aarhus Universitetshospital Data-analyse Aalborg Universitet Rådgivning Odense Universitetshospital

Type 1 Diabetes

Type 2 Diabetes

Diabetes i Danmark T1D: 25.000 T2D: 300.000 diagnostiserede T2D: 200.000 ikke-diagnostiserede T2D: 250.000 forstadier T2D: 750.000?

23.000 nye tilfælde / år 64 nye tilfælde / dag Type 2 diabetes 23.000 nye tilfælde / år 64 nye tilfælde / dag

1 af 7 diabetikere får et fodsår

1000 større amputationer i DK årligt 500 amputationer kunne undgås

Nedsat følesans er den stærkeste risikofaktor for fodsår og amputation

Undersøgelser nerver Ultralyd Følesans Let berøring Smerte Vibrationssans Nerveledningshastighed Nervebiopsi Ultralyd MR-scanning

Mention a patient with symptoms in toes and hands Mention a patient with symptoms in toes and hands. Likely to be two processes

Nervefibre

Peripheral nerve [1]A.G. Filler et al Neurol Clin 2004 Disorders in DPN Several pieces of evidence suggest that the low-protein endoneurial fluid is what is seen most prominently in T2 neurography images. The endoneurial fluid is a low-protein liquid that lies within the privileged space of the endoneurium and bathes the axons. It has a bulk proximal to distal flow along the nerve that may be disrupted by nerve compression and edema. Although endoneurial fluid is responsible for only a fraction of the imagable protons in a nerve, it is one of the most distinctive types of tissue water in nerve from the point of view of MR imaging. [1]A.G. Filler et al Neurol Clin 2004

Methodology Patients and controls T2w SPAIR (0.6x0.6x3mm), 3Tesla 4 type II diabetic patients with polyneuropathy (DPN) 2 type II diabetic patients (nDPN) without neuropathy 4 healthy control (HC) subjects. T2w SPAIR (0.6x0.6x3mm), 3Tesla Presence of neuropathy was determined based on the clinical examination Neuropathy impairment score Neuropathy symptom score and nerve conduction studies T2w spectral selection attenuated inversion recovery (SPAIR) images (0.6x0.6x3mm) were acquired to measure the extent of the focal nerve lesions at 3 Tesla. The MR scans consisted of 30 axial slices of the sciatic nerve in mid-thigh level. Two male subjects were scanned including a type 2 diabetic patient with polyneuropathy (DPN) and a type 2 diabetic patient (DM2) without neuropathy. Presence of neuropathy was determined based on clinical examinations; Neuropathy impairment score (NIS) Neuropathy symptom score (NSS) and Nerve conduction velocity tests. BM surface coil Bone fix points greater trocanter of femur to patella

MR Neurography T2w MR imaging of the hyperintense low-protein endoneurial fluid Suppression of fat signal around nerves and from within nerves Image resolution < 0.6x0.6mm High quality surface coils Detecting DPN has been performed with the STIR (Short Tau Inversion Recovery) sequence. However, STIR introduces intrinsic limitations such as reduced signal to noise ratio (SNR) and scan time efficiency, additionally STIR may inadvertently suppress tissues of interest that have short longitudinal relaxation times. Alleviating this problem, STIR inversion pulses can be designed to spectrally select only the fat magnetization. However, such modification will inevitably render the technique sensitive to B0 magnetic field inhomogeneity [8]. Altering the spin magnetization modulation of the RF pulses in the STIR sequence into other modalities could make the detection of nerve lesions more specific, of which SPAIR (Spectral Selection Attenuated Inversion Recovery) is a prominent pulse sequence [11]. SPAIR provide a method to increase the flip angle generating more signal and higher SNR in a more homogeneous fat suppression. [1] M. Pham et al. Diabetes Care 2011

Results A B Lav effekt med zoom..! T2w SPAIR MRI A) Diabetic patient with severe neuropathy B) Diabetic patient without neuropathy

Results +Neuropathy -Neuropathy Controls p-value N 4 2 - Male sex (%) 4(100%) 1(50%) 3(75%) 0.37 Age (yrs) 64(17) 69(6) 59(21) 0.24 BMI (kg/m2) 26.50(5) 23(2) 23(7) 0.12 Nerve SI 0.19(0.13) 0.21(0.03) 0.14(0.07) 0.21 Muscle SI 0.25(0.09) 0.20(0.13) 0.15(0.01) Vessel SI 0.69(0.15) 0.64(0.32) 0.68(0.12) 0.71 Volume (cm3) 5.91(3.91) 3.15(0.91) 3.58(1.27) 0.03 [p,h] = ranksum(dpn(:,1),ndpn(:,1),'alpha',0.05,'tail','both','method','exact')  Der er ikke forskel på DPN og nDPN p = 0.1333 h = 0   [p,h] = ranksum(dpn(:,1),hc(:,1),'alpha',0.05,'tail','both','method','exact')  Der er forskel på DPN og HC p = 0.0286 h = 1 Kruskal–Wallis one-way analysis of variance

Konklusion MR-scanning viste en signifikant øgning I volumen af nervus ischiadicus hos patienter med diabetisk nervesygdom MR-scanning af hele nervesystemet er mulig (total nerve lesion load) MR-scanning kan anvendes til dybtliggende nervestrukturer

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