Special Ar ticle Original Research

zcan et al. Doppler Ultrasound of the Radial and Ulnar Arteries Special Article Original Research

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Dynamic Doppler Evaluation of the Radial and Ulnar Arteries in Patients With Carpal Tunnel Syndrome
Hatice Nursun zcan1,2 Murat Kara3 Frat zcan 4 Sevin Bostano lu2 Mehmet Alp Karademir 2 Glten Erkin 3 Levent zakar 5
zcan HN, Kara M, zcan F, et al.

Keywords: carpal tunnel syndrome, Doppler ultrasound, hemodynamics, Phalen position, radial artery, reverse Phalen position, ulnar artery DOI:10.2214/AJR.11.6559 Received January 24, 2011; accepted after revision April 7, 2011.
1 Department of Radiology, Etimesgut State Hospital, Yenimahalle, Ankara, Turkey. Address correspondence to H. N. zcan (drhnozcan@yahoo.com) at Faklteler Mah Dirim sok 22/3 Cebeci, Ankara, Turkey. 2 Department of Radiology, Numune Training and Research Hospital, Ankara, Turkey. 3 Department of Physical Medicine and Rehabilitation, Ankara Physical Medicine and Rehabilitation Training and Research Hospital, Ankara, Turkey. 4

OBJECTIVE. The objective of our study was to evaluate the blood flow characteristics of the radial and ulnar arteries of the hands of patients with carpal tunnel syndrome (CTS) either in the neutral position or in provocative positions using color Doppler imaging. SUBJECTS AND METHODS. Subjects with relevant complaints of CTS and positive Tinel sign and/or Phalen maneuver were recruited. Nerve conduction studies were performed to confirm the diagnosis of CTS. Forty-four hands of 22 patients with CTS (bilateral involvement) and 24 hands of 12 healthy volunteers were included in the study. Pulsed and color Doppler evaluations with the hands in the neutral, Phalen, and reverse Phalen positions were performed of the radial and ulnar arteries using a 5-13MHZ linear-array transducer (Logiq 9). RESULTS. All of the CTS patients and control subjects were women; their mean ages were 50.77 7.69 (SD) and 46.42 4.32 years, respectively. When hands were evaluated in the neutral position, the flow volume, peak systolic velocity, end-diastolic velocity, and diameter values of both the radial and ulnar arteries were significantly greater in patients with CTS than in control subjects (all p < 0.05). When compared with the measurements obtained with hands at the neutral position, the decreases in the amount of blood flow during the Phalen and reverse Phalen maneuvers were significantly greater in the CTS group than the control group. The amount of blood flow decrease was not correlated with the disease duration. CONCLUSION. Blood flow in the hands of CTS patients differs from that of healthy individuals both at rest and during certain hand movements. Future studies, also with simultaneous monitoring of sympathetic innervation, could be beneficial to confirm the association between blood flow and the sympathetic nerves of the hand. arpal tunnel syndrome (CTS) is the most common peripheral entrapment neuropathy; it occurs because of compression of the median nerve at the wrist level. The scenario is that of pain and paresthesia of the first three or four fingers in the involved hand [1]. The diagnosis is mainly clinical; however, either electrophysiologic or imaging techniques can be used to confirm the diagnosis or to uncover possible underlying causes [2]. In this regard, MRI [38] and high-resolution sonography [913] have emerged as feasible and noninvasive tools for the morphologic evaluation of the median nerve at the carpal tunnel. Studies have also focused on the vascular mechanisms concerning the entrapment syndrome, but investigators have mainly reported on the abnormal vascularization or the presence of a persistent median artery using MRI or Doppler sonography [1419]. To date, only one study has mentioned enhanced

Department of Cardiology, Yksek htisas Training and Research Hospital, Ankara, Turkey.

5 Department of Physical Medicine and Rehabilitation, Hacettepe University Medical School, Ankara, Turkey.

blood flow to the hand after carpal release surgery [20]. However, to our knowledge, dynamic Doppler ultrasound assessment of the hand arteries in patients with CTS has not been studied in the radiology literature. Accordingly, the aim of our study was to use color Doppler imaging to evaluate the blood flow characteristics and parameters in the arteries of the hand in either the neutral position or provocative positions of patients with CTS and compare the results with the results of healthy subjects. We reasoned that we could show a possible association between CTS and blood supply to the hand. Subjects and Methods Patients
Subjects with relevant complaints of CTS (i.e., nocturnal hand discomfort and paresthesia in the distribution of the median nerve) and positive Tinel sign and/or Phalen maneuver were recruited. Nerve conduction studies were performed

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zcan et al.
to confirm the diagnosis of CTS according to the established criteria and recommendations of the American Academy of Neurology [21]. CTS was diagnosed in subjects who had decreased sensory conduction velocities (< 40 ms) or prolonged distal motor latencies (> 3.8 ms) of the median nerve at the wrist level without any abnormalities of the ulnar nerve. This study was approved by the local ethics committee of our hospital. Furthermore, the examination was explained to the patients and control subjects and written informed consent was obtained. The following individuals were excluded from the study: patients with a history of an orthopedic or neurologic disease that may involve the median nerve; patients with thyroid disease, diabetes mellitus, or hypertension; patients with a history of hand surgery or of trauma to the hand or wrist; and pregnant women. Overall, 44 hands of 22 CTS patients (bilateral involvement) and 24 hands of 12 healthy volunteers were included in the study. transducer was placed parallel to the long axis of the radial and ulnar arteries; the diameter of the vessels was measured from wall to wall by placing a cursor in the arterial wall. Color Doppler imaging was used on the radial and ulnar arteries to guide placement of the spectral Doppler gate and to estimate the beam-to-vessel angle. The Doppler angle was maintained between 30 and 60 during the examinations. The color parameter settings included a low wall filter (2246) and a low-velocity scale (pulse repetition frequency, 100 or 400 Hz). Color gain was adjusted dynamically, usually to a value of 4060 dB, to maximize visualization of the arteries while avoiding artificial color noise. We used the smallest spectral gate and adjusted the frequency of the pulse repetition for spectral waveform measurements; hence, the height of the Doppler waveform was maximized and accurate measurements were obtained (Fig. 1). The peak systolic and end-diastolic flow velocities were measured for the ulnar and radial arteries. The resistive index (RI) is defined as the difference between the peak systolic and end-diastolic flow velocities divided by the peak systolic velocity. Flow volume is calculated by artery diameter measurement using the area below the spectral waveform. The RI and flow volume were measured for each waveform, and then the average value of three measurements from each artery was obtained.

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Color Doppler Evaluations

Pulsed and color Doppler sonography was performed using a 5-13MHZ linear-array transducer (Logiq 9, GE Healthcare). Two physiciansa physiatrist manipulating the hand of the patient and a radiologist performing the sonographic measurementsevaluated the radial and ulnar arteries bilaterally. Subjects were seated in a stable position across from a physician who was seated at the same level. The wrist and hand of the subject were placed in a semisolid rubber support to achieve stabilization. The mean examination time was 2030 minutes. Doppler evaluations for the radial and ulnar arteries were performed with the patients hand at three different positions at the level of the styloid process: neutral, Phalen, and reverse Phalen. The

Statistical Analysis
Statistical analysis was performed using statistics software (SPSS, version 13.0, SPSS). The Kolmogrov-Smirnov test was used for testing the normal distribution of each parameter. The mean values of the two groups were compared with the Student t test. The Pearson rank test was used for correlation analysis. Statical significance was set at p < 0.05.

Results All CTS patients (44 hands; mean disease duration, 17.82 12.65 [SD] months) and all control subjects (24 hands) were women; their mean ages were 50.77 7.69 and 46.42 4.32 years, respectively. Because the measurements pertaining to the right and left hands of all the patients and subjects were statistically similar, we compared the measurements of the patients and control subjects rather than performing analyses by hand. The results of Doppler evaluations performed with the subjects hands in the neutral position are given in Table 1 and Figure 2. When compared with the measurements of the control group, flow volume, peak systolic velocity, end-diastolic velocity, and diameter values of both the radial and ulnar arteries were significantly greater in the CTS patients (all p < 0.05). Although the RI for both arteries was smaller in the patients with CTS, only measurements with respect to the radial artery reached statistical significance (p = 0.01). The measurements obtained while hands were in the reverse Phalen position are summarized in Table 1. The flow velocity, diameter, and peak systolic velocity values for the radial artery and the diameter and end-diastolic velocity for the ulnar artery were significantly greater in patients with CTS than in control subjects (all p < 0.05). The RI of the radial artery was smaller in CTS patients than in control subjects (p = 0.01). The measurements obtained with hands in the Phalen position are given in Table 1. The diameter and end-diastolic velocity values of the ulnar artery were greater in CTS patients than in the control subjects (p < 0.05). The RI of the ulnar artery was smaller in CTS patients than in the control subjects and the RI of the radial artery was greater in CTS patients. When compared with the measurements obtained with the hands in the neutral position, the decreases in the amount of blood flow were significantly greater in the CTS group than in the control group during the Phalen (p < 0.001 for the radial artery and p < 0.001 for the ulnar artery) and reverse Phalen (p < 0.001 only for ulnar artery) maneuvers; however, the decreases in the amount of blood flow were not correlated with the disease duration. Discussion The radial and ulnar arteries form a dual blood supply network in the hand. The deep palmar archderived from the radial arterysupplies the first two digits, and the su-

Fig. 1 Doppler spectral gate of radial artery of 45-year-old woman with carpal tunnel syndrome. Hand was in neutral position for imaging.

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Doppler Ultrasound of the Radial and Ulnar Arteries TABLE 1: Doppler Sonography Assessments of Flow Volume, Diameter, Peak Systolic Velocity, End-Diastolic Velocity, and Resistive Index of Radial and Ulnar Arteries at Neutral and Provocative Positions
Radial Artery Position of Hand During Imaging Downloaded from www.ajronline.org by 182.181.230.133 on 09/01/13 from IP address 182.181.230.133. Copyright ARRS. For personal use only; all rights reserved Neutral position Flow volume (mL/s) Diameter (mm) Peak systolic velocity (cm/s) End-diastolic velocity (cm/s) Resistive index Phalen position Flow volume (mL/s) Diameter (mm) Peak systolic velocity (cm/s) End-diastolic velocity (cm/s) Resistive index Reverse Phalen position Flow volume (mL/s) Diameter (mm) Peak systolic velocity (cm/s) End-diastolic velocity (cm/s) Resistive index 62.95 36.80 2.63 0.39 54.22 25.55 6.62 7.86 0.90 0.09 39.80 22.20 2.43 0.18 41.86 16.75 6.78 4.21 0.84 0.06 0.002 0.01 0.02 0.92 0.01 17.87 13.77 2.52 0.37 28.21 17.14 1.63 2.03 0.94 0.06 19.80 10.63 2.25 0.28 31.74 14.36 3.83 6.11 0.91 0.04 0.52 0.001 0.37 0.03 0.03 43.20 29.31 2.62 0.39 40.80 16.67 4.66 6.34 0.91 0.11 48.74 21.51 2.43 0.18 45.36 16.45 8.54 5.06 0.81 0.09 0.37 0.08 0.283 0.08 0.01 33.56 20.96 2.52 0.37 38.65 16.73 2.36 3.03 0.93 0.75 31.46 17.96 2.25 0.28 37.43 14.68 6.41 5.79 0.84 0.10 0.66 0.01 0.75 < 0.001 < 0.001 95.43 44.55 2.620 0.39 58.66 6.22 18.63 8.58 0.69 0.09 61.28 24.29 2.43 0.18 52.44 9.5 13.43 6.13 0.74 0.09 < 0.001 0.01 0.05 0.01 0.03 108.73 60.86 2.54 0.37 68.36 17.26 22.12 10.52 0.67 0.1 60.80 25.84 2.25 0.28 54.55 10.45 16.30 8.60 0.71 0.13 < 0.001 0.001 < 0.001 0.02 0.23 Patient Group Control Group p Patient Group Ulnar Artery Control Group p

NoteBoldface indicates statistical significance.

perficial palmar archderived from the ulnar arterysupplies the ulnar third, fourth, and fifth fingers [22]. The hands vasomotor activity is regulated by the sympathetic nervous system predominantly carried by the median nerve [23]. Patients with CTS have symptoms attributable to damage of large (sensorimotor) and small (sudo- and vasomotor) myelinated nerve fibers [24]. Because the sympa280 240 200 160 120 80 40 0

thetic fibers are very thin and unmyelinated and are located in the periphery of the median nerve trunk [25], they become vulnerable to damage in CTS especially in the very early phase. Accordingly, when these fibers are disturbed, changes in vasomotor activity can readily be expected in the corresponding area. Likewise, nocturnal pain, swelling, and relief by rapid wrist flexion and extension ensue at least in part because of vasomotor dys-

Patient Group

Control Group

Patient Group

Control Group

Radial Artery

Ulnar Artery

Fig. 2 Box-andwhisker plot shows flow volumes in radial and ulnar arteries with hand in neutral position of patients with carpal tunnel syndrome and control subjects. Asterisk indicates that difference in flow volumes between groups is significant (p < 0.001). Whiskers show minimum and maximum values for flow velocity. Black = values between first and second quarter, gray = values between second and third quarter.

function. Other common features of vasomotor dysfunction in the hand are color change, coldness, and hyperesthesia [24]. Our findings have revealed that blood flow in the radial and ulnar arteries while hands are in a neutral position is increased in CTS patients as compared with healthy individuals. In more than 55% of CTS patients [26, 27], sympathoparalytic vasodilation ensues in the early phase, followed by a vasoconstrictive phasepresumably caused by postdenervation hypersensitivity of the blood vessels to circulating catecholamines thereafter [2830]. Another potential mechanism may be related to antidromic overactivation of C fibers that, in turn, causes release of a potent vasodilator, substance P. The third mechanism concerning the increased blood flow could be associated with the regional inflammatory response also causing vasoactive substance release [31]. Our results have also shown that radial and ulnar artery blood flows were similar for the patient and control groups at the Phalen maneuver and that radial artery blood flow was higher during the reverse Phalen maneuver in CTS patients than in control subjects. Perhaps more importantly, the decreases in the amount of radial and ulnar artery blood flows were greater in the CTS group during both maneuvers. Herein, aside from the

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Artery Flow Volume (mL/s)

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zcan et al. mechanical compression of the arteries, we suggest that sympathetically mediated vasoconstriction of the cutaneous vascular bed in the hands of CTS patients might have indirectly caused the decreased blood flow in the proximal arteries. However, it is well known that noxious stimuli can elicit vigorous vasoconstriction in the distal circulation [32, 33]. Moreover, altered function of the pain regulation and reflex responses mediated via the CNS and the cardiovascular system (i.e., increased vagal tone and decreased -2 sympathetic activity due to compression of the median nerve during the maneuvers) may also explain the exaggerated blood flow decrease in CTS patients. In light of our first and preliminary findings, we conclude that blood flow in the hands of CTS patients both at rest and during certain hand movements differ from that in the hands of healthy individuals. We believe that these changes do contribute to the eventual clinical findings (i.e., nocturnal pain, swelling, color change, and coldness) of those patients. Future studies also with simultaneous monitoring of the sympathetic nerves of the hands could be beneficial to confirm the association between blood flow and sympathetic innervation. Last, considering the increased use of B-mode ultrasound in the diagnosis of CTS in the recent literature, we suggest that additional color Doppler imaging of the hand arteries could also be a supplementary technique for better understanding the symptoms of patients with CTS. References
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