MR neurography of tibial and common peroneal nerves in patients with Guillain-Barre syndrome and electrophysiological correlation

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There has been recent interest in using Diffusion-weighted imaging with background suppression (DWIBS) to evaluate peripheral nerves and corresponding lesions, but has not been applied in GBS patients. Objective To explore the value of MR neurography in evaluating tibial nerve (TN) and common peroneal nerve (CPN) in GBS patients. Methods 36 GBS patients and 36 healthy volunteers were included in this prospective study. The cross-sectional areas (CSA) and signal-to-noise ratio (SNR) values of TN and CPN on T2-weighted images were calculated. Four-grade scoring system was used to score DWIBS images of TN and CPN. The CSA and SNR values, nerve scores on DWIBS were compared. Pearson correlation tests were used to assess the correlation between the CSA and SNR values, nerve scores and electrophysiology parameters of the GBS group. Results The interobserver agreement of measurements and nerve scored values was excellent. The mean CSA and SNR values of TN and CPN were significantly larger in patients than healthy controls (P<0.05). There were statistically significant differences in nerve scores between two groups (P < 0.01). The SNR values of TN correlated negatively with motor nerve conduction velocity (MCV) and motor nerve conduction amplitude (P < 0.01). The SNR values of CPN correlated negatively with MCV (P = 0.02). The nerve scores of TN and CPN were all positively correlated with MCV and motor nerve conduction amplitude (P < 0.01). Conclusions MR neurography showed larger CSA, higher SNR values of TN and CPN and unclear nerve on DWIBS. The SNR values and nerve scores on DWIBS have correlation with electrophysiological parameters. These findings suggest that MR neurography can be useful to assess the damage of TN and CPN in GBS patients. Guillain-Barre syndrome MR neurography tibial nerve common peroneal nerves Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Guillain–Barre syndrome (GBS) is an autoimmune demyelinating neuropathy, which is the most common cause of clinical acute flaccid paralysis. The main pathological change of GBS is inflammatory demyelination of the peripheral nerves, accompanied by secondary axonal damage[ 1 , 2 ]. Limb paralysis, respiratory paralysis, or few other life-threatening symptoms can be seen in severe GBS patients. The diagnosis of GBS is mainly based on symptoms, cerebrospinal fluid analysis, and electrophysiological evaluation currently[ 1 , 3 ]. Cerebrospinal fluid (CSF)-analysis reveals cyto-albuminological dissociation. However, sometimes, especially in the early phase of disease, cerebrospinal fluid protein may be at a normal level in up to 1/3 of patients and the diagnosis can be challenging[ 3 ]. MR neurography (MRN) is an advanced and noninvasive imaging technique to visualize peripheral nerves changes[ 4 ]. MR neurography has been widely applied for the diagnosis of various peripheral neuropathies, including inflammatory neuropathies such as CIDP[ 5 ]. The studies of MR neurography in GBS were few and mainly focused on the imaging of the spinal nerve roots and cranial nerves[ 6 , 7 ], whereas few studies have evaluated the changes in the tibial nerves (TN) and common peroneal nerves (CPN). Ultrasound imaging as well as histopathological studies of peripheral nerves demonstrated that GBS also manifests with distal nerve (including tibial nerves and common peroneal nerves) enlargement in the early stage[ 8 ]. Diffusion-weighted imaging with background suppression (DWIBS) is a noninvasive magnetic resonance neurography (MRN) modality developed based on diffusion-weighted imaging (DWI). DWIBS enables a more straightforward evaluation of peripheral nerves due to its excellent nerve-peripheral soft tissue contrast, satisfactory background suppression, and three-dimensional maximum intensity projection (MIP). There has been recent interest in using DWIBS to evaluate peripheral nerves and corresponding lesions, such as brachial plexus, lumbosacral plexus, median and ulnar nerves, et al.[ 9 – 11 ]. To our knowledge, the evaluation of extremity peripheral nerve injury of GBS patients using DWIBS has not been studied previously. Therefore, in this study, we aimed to explore the value of MR neurography in evaluation of the TN and CPN in patients with GBS by quantifying cross-sectional areas (CSAs) and signal-to-noise ratio (SNR) of the TN and CPN and observing the imaging feature on DWIBS, and to analyze their correlations with electrophysiological parameters of lower extremities. Materials and Methods Subjects This research was conducted in accordance with the Declaration of Helsinki of the World Medical Association and approved by the Ethics Committee of Zibo Central Hospital. Written informed consent was obtained from all GBS patients and and volunteers prior to study participation. From June 2019 to November 2023, 49 patients with clinically suspected GBS were referred for an MR examination. Patients who satisfied the following criteria were potentially included in the study: the patient’s diagnosis was confirmed as GBS according to published criteria[ 3 ], and the time interval between electrophysiology examination and MR imaging was no more than 3 days. Therefore, 42 patients who consented to an MR examination were initially included in our study. Six of the patients were excluded after their MR examination. The exclusion criteria were as follows: patients whose MR images were with motion artifacts (n = 2); patients who underwent medication therapy between MR imaging and electrophysiology examination (n = 1); patients who had a history of multiple neuritis, chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), acute myelitis, diabetes, and other causes of polyneuropathy (n = 3). Finally, 72 lower extremities of 36 GBS patients (age range, 13–72 years; average: 43 years), including 16 women and 20 men, were analyzed in this study (Fig. 1 ). A total of 72 lower extremities of 36 sex- and age-matched healthy controls (HCs; age range, 13–70 years; average: 42 years; females: 17, males: 19) were also examined in this study. Table 1 described the demographic characteristics for all subjects. Table 1 Demographic characteristics of GBS patients and healthy controls Characteristics GBS patients Healthy controls No. of subjects 36 36 Age (mean ± standard deviation) 43 ± 14 42 ± 13 Age (range) 13–72 13–70 No. of men 20 19 No. of women 16 17 GBS, Guillain–Barre syndrome. Table 2 Imaging scores for visualization of TN and CPN on DWIBS Nerve Imaging Scores 4 3 2 1 TN 9 26 21 16 CPN 10 25 19 18 TN, tibial nerve; CPN, common peroneal nerve; GBS, Guillain-Barre syndrome. Electrophysiology examination All GBS patients underwent an electrophysiology examination of the lower limbs, before or after the MRI examination no more than 3 days, and were assessed by a board-certified clinical neurophysiologist with 8 years of experience. Motor nerve conduction velocity (MCV) and motor nerve conduction amplitude of each subject were recorded. The normal MCV value of the TN and CPN is ≥ 41 m/s. The normal motor nerve conduction amplitude values are ≥ 4 mV in TN and ≥ 2 mV in CPN, respectively[ 2 ]. MRI examination A 3-Tesla MR-scanner (Achieva, Philips Healthcare, Best, Netherlands) equipped with dual-source parallel radiofrequency excitation and transmission technology was used for all MR examinations. The subjects were placed supine in feet-first position and unilateral imaging, using an eight-channel knee coil at the knee level. MRI sequences included axial T1-weighted imaging, axial T2-weighted spectral attenuated inversion recovery (SPAIR), and axial DWIBS. The sequence parameters were as follows: T1-weighted imaging: repetition time/echo time (TR/TE) 550/20 ms, slice thickness 3.0 mm, overlap 0 mm, the field of view (FOV) 120×120 mm 2 , number of signals acquired (NSA) 2, and acquisition time 3 min 34 sec. T2-weighted SPAIR imaging: TR/TE 3000/55 ms, slice thickness 3.0 mm, overlap 0.1 mm, FOV 120×120 mm 2 , NSA 2, and acquisition time 3 min 45 sec. DWIBS: single-shot echo-planar imaging (EPI) sequence, TR/TE 9000/86 ms, slice thickness 3.0 mm, overlap 0 mm, FOV 100×100 mm 2 , b-value 800 s/mm 2 , half-fourier factor 0.795, EPI factor 41, NSA 2, number of slices 80, image matrix 75×72, and acquisition time 3 min 54 sec. Date postprocessing For T2-weighted SPAIR, the CSA and SNR values of the TN and CPN were calculated. The three slices through the superior margin of patella, on the upper 10 mm and lower 10 mm, were chosen for the region of interest (ROI) placement. ROIs were placed manually as large as possible on the TN and CPN, encompassing the boundary of the nerves and excluding the adjacent structures. The measurements of three ROIs were recorded by two radiologists independently (SS.W with 8 years, and T.G with 9 years of experience in neuroimaging, respectively), and the average of the two radiologists’ results were used as the final CSA and SNR values. The SNR was calculated as follows: SNR = SI (nerve)/SD (noise), where SI (nerve) is the signal intensity of the TN and CPN, and SD (noise) is the standard deviation of the noise measured in an ROI drawn outside of the image. Figure 2 shows the axial T2-weighted MR images of patients with GBS and healthy controls. The raw data of DWIBS images were processed on an independent workstation (Extended MR Workspace, v. 2.6.3.2, Philips Healthcare) by two radiologists (WJ.Z with 6 years, and P.S with 5 years of experience in neuroimaging, respectively), blinded to each other and information of subjects. The postprocessing was performed using the full-volume MIP reconstruction and volume editing, which allowed removal of superimposed structures with similar hyper-intensity, such as veins and articular fluids, to display the nerves more clearly and obtain coronal 3D volume images of the TN and CPN. A four-grade scoring system was used to evaluate the coronal 3D volume DWIBS images of the TN and CPN (Fig. 3 ): 4 = nerve clearly visualized with sharp edges, good and uniform signal intensity; 3 = nerve moderately well visualized with blurred edges, medium signal intensity; 2 = nerve dissatisfiedly visualized with blurred or distorted edges, weak signal intensity; 1 = nerve poorly visualized with obviously distorted and unclear edges, significantly weak signal intensity or part of nerve not visualized. If the score was not uniform, the final score was decided by the two radiologists together. Statistical analysis Statistical analysis was performed using the software Prism Version 8 and SPSS software (v. 20, SPSS, Chicago, IL) and a value of P < 0.05 was considered statistically significant. Chi-square test was used to determine differences in gender between GBS patients and HCs. Student’s t test was used to determine differences in age, height, weight between GBS patients and HCs. The interobserver agreement of the CSA and SNR values was assessed using intraclass correlation coefficient (ICC) analysis. The ICC ranges of reliability values provided by Landis and Koch were used as the reference standard[ 12 ]. The Kappa statistic was used to assess the interobserver agreement for the scoring results of TN and CPN on DWIBS: kappa value (K)>0.80 indicating excellent, 0.60<K<0.80 indicating good, 0.40<K<0.60 indicating moderate, and K<0.40 indicating poor[ 12 ]. Independent samples t-test was performed to compare the differences of CSA and SNR values in two groups. Kruskal-Wallis test and a Dunn test was used to assess the differences in nerve scored values between GBS patients and HCs. Pearson correlation tests were used to assess the correlation between the CSA, SNR values, nerve scored values of TN and CPN and electrophysiology parameters (MCV and motor nerve conduction amplitude) of the GBS group. Results There were no significant differences in age, sex, weight, or height between the two groups. Table 1 shows the demographics of the patients and HCs. ICCs for interobserver agreement of CSA measurements were 0.865 (95% confidence interval (CI), 0.812–0.936) for TN, 0.832 (95% CI, 0.729–0.912) for CPN. ICCs for interobserver agreement of SNR values were 0.801 (95% confidence interval (CI), 0.767–0.941) for TN, 0.820 (95% CI, 0.719–0.912) for CPN, respectively. The interobserver statistic (k) for nerve scored values showed that the level of agreement was excellent, with k values between 0.81 and 1.00. The mean CSA of TN and CPN were significantly larger in patients with GBS (11.23 ± 0.99 mm 2 for TN, 4.42 ± 0.57 mm 2 for CPN) compared to healthy controls (10.78 ± 1.18 mm 2 for TN, 4.17 ± 0.64 mm 2 for CPN) (p<0.05). The mean SNR value of TN and CPN were significantly larger in patients with GBS (14.79 ± 1.79 for TN, 14.55 ± 1.71 for CPN) compared to healthy controls (14.04 ± 1.79 for TN, 13.83 ± 1.68 for CPN) (p<0.05). The statistical results are presented in Fig. 4 . DWIBS showed long trajectories of the TN and CPN in all healthy controls. The 72 TN and CPN of 36 healthy volunteers were all clearly visualized with sharp edges, good and uniform signal intensity on DWIBS, and the scores were all 4 (the diagnostic coincidence rate was 100%). Of the 72 TN and CPN in 36 GBS patients, 63 TN and 62 CPN had abnormal changes in varying degrees, including blurred or distorted contour, medium or weak signal intensity, and even part of nerve not visualized, and the scores were 1–3. There were statistically significant differences in nerve scores between patients and HCs (P < 0.01). The SNR values of TN correlated negatively with MCV and motor nerve conduction amplitude (P = 0.0001 and P = 0.001 respectively). The SNR values of CPN correlated negatively with MCV (P = 0.02). No correlations were found between CSAs of TN and CPN and electrophysiological parameters and between SNR values of CPN and motor nerve conduction amplitude. The nerve scores of TN and CPN in the DWIBS sequence were all positively correlated with MCV and motor nerve conduction amplitude ( P < 0.01). The statistical results are presented in Fig. 5 . Discussion In the present study, MR neurography showed larger CSA, higher SNR values of TN and CPN and more unclear nerve on DWIBS in GBS patients. Besides, the SNR values and nerve scores on DWIBS have correlation with the corresponding electrophysiological parameters. These findings suggest that MR neurography can be useful to reflect the change of TN and CPN in GBS patients. There were few reports on the MRN of GBS patients, most of them focus on the lumbosacral plexus and cauda equina[ 6 , 7 ]. This is to our knowledge the first study to evaluate the morphologic and T2 signal intensity changes of TN and CPN in GBS patients using MRN, especially DWIBS. Given that GBS is an immune-mediated neuropathies, inflammatory oedema, demyelination and Wallerian-like degeneration are considered to be the major histopathological changes of GBS[ 13 – 15 ]. Patients in our cohort presented with larger CSA and higher T2 signal intensity of TN and CPN, which might be related to these histopathological changes. The larger CSA are consistent with previous sonographic studies[ 16 ]. Most TN and CPN of GBS patients in our study showed varying degrees of morphological abnormalities and reduced signals on DWIBS. This may be explained by extensive inflammatory cell infiltration and primary demyelination of peripheral nerves in GBS patients, which may lead to reduced diffusion restriction of water molecule in peripheral nerves[ 17 ]. In this study, the scores of 9 TN and 10 CPN of GBS patients were 4, which were similar to the healthy controls. This perhaps because these patients were in the early stages of GBS and inflammatory oedema was the main histopathological change[ 13 ], not demyelination, so the reduction of water molecule diffusion limitation in peripheral nerves was not significant. Our study showed the SNR values and nerve scores on DWIBS have correlation with the corresponding electrophysiological parameters. As the principal electrophysiological parameters, MCV and motor nerve conduction amplitude could reflect the functional changes in the peripheral nerve. In general, demyelination is manifested as a decrease in MCV, and axonal injury is associated with a reduction in motor nerve conduction amplitude[ 18 ]. The conduction velocity and the motor nerve conduction amplitude decreased with the increase of T2 signal intensity and the decrease of nerve scores in TN and CPN, reflecting the increase of T2 signal intensity and more unclear nerve may suggest an increase nerve damage. However, the CSA of nerve did not correlate well with electrophysiological parameters, which are consistent with previous sonographic studies[ 19 ]. Therefore, nerve T2 signal intensity and the nerve visualization on DWIBS seems to be the more robust biomarker, which might also be explained by the MR signal being more susceptible to inflammatory oedema. This study has some limitations. First, the sample size of this study was small. Second, no comparison study was carried out on GBS patients before and after clinical treatments. Third, the duration and classification of the disease were not considered in this study, which may affect the results of the study. Fourth, we did not evaluate the ADC values. Further research is still needed to clarify the value of MRN in assessing GBS peripheral nerve disorder. In conclusion, MR neurography showed larger CSA, higher SNR values of TN and CPN and more unclear nerve on DWIBS, which reflect the pathophysiological changes of GBS. The SNR values and nerve scores on DWIBS have correlation with the corresponding electrophysiological parameters. These findings suggest that MR neurography can be useful to assess the damage of TN and CPN in GBS patients. Declarations Acknowledgements Not applicable. Author contributions GB.W and JF.C designed the study and revised the manuscript. SS.W and T.G contributed to the data analysis and drafting of the manuscript. WJ.Z and P.S contributed to the collection of the data. All authors reviewed the final version of the manuscript. Fundings No funding was received for conducting this study. Data availability No datasets were generated or analysed during the current study. Ethics approval This study was conducted in accordance with the Declaration of Helsinki of the World Medical Association and approved by the Ethics Committee of Zibo Central Hospital (No. 201900788B0C503). Written informed consent was obtained from each GBS patient prior to study participation. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Author details 1 Department of Radiology, Zibo Central Hospital, Zibo, Shandong, China 2 Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China 3 School of Medical Imaging, Binzhou Medical University, Yantai, Shandong, China References Shahrizaila N, Lehmann HC, Kuwabara S. Guillain-Barré syndrome. 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Berciano J, Sedano MJ, Pelayo-Negro AL, García A, Orizaola P, Gallardo E, et al. Proximal nerve lesions in early Guillain-Barré syndrome: implications for pathogenesis and disease classification. J Neurol. 2017;264(2):221–36. Tan CY, Sekiguchi Y, Goh KJ, Kuwabara S, Shahrizaila N. A model to predict the probability of acute inflammatory demyelinating polyneuropathy. Clin Neurophysiol. 2020;131(1):63–9. Kerasnoudis A, Pitarokoili K, Behrendt V, Gold R, Yoon MS. Correlation of nerve ultrasound, electrophysiological and clinical findings in chronic inflammatory demyelinating polyneuropathy. J Neuroimaging. 2015;25(2):207–16. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5752299","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":401024342,"identity":"91f3bc6a-7bbb-4c57-b3ea-3ea5c6593ec2","order_by":0,"name":"Jinfeng Cao","email":"","orcid":"","institution":"Central Hospital of Zibo","correspondingAuthor":false,"prefix":"","firstName":"Jinfeng","middleName":"","lastName":"Cao","suffix":""},{"id":401024343,"identity":"9f26e839-f136-4f0f-b9af-8e262d4e4963","order_by":1,"name":"Shanshan Wang","email":"","orcid":"","institution":"Shandong Provincial Hospital Affiliated to Shandong First Medical University","correspondingAuthor":false,"prefix":"","firstName":"Shanshan","middleName":"","lastName":"Wang","suffix":""},{"id":401024344,"identity":"da8261d8-e4b6-44f2-b67c-c9232325362b","order_by":2,"name":"Tao Gong","email":"","orcid":"","institution":"Shandong Provincial Hospital Affiliated to Shandong First Medical University","correspondingAuthor":false,"prefix":"","firstName":"Tao","middleName":"","lastName":"Gong","suffix":""},{"id":401024345,"identity":"02afce91-2df5-4a66-9aff-aa6a9f8a8c9d","order_by":3,"name":"Wenjing Zheng","email":"","orcid":"","institution":"Binzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Wenjing","middleName":"","lastName":"Zheng","suffix":""},{"id":401024346,"identity":"a380a108-74e1-403a-9477-f921757a6a52","order_by":4,"name":"Peng Sun","email":"","orcid":"","institution":"Binzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Peng","middleName":"","lastName":"Sun","suffix":""},{"id":401024347,"identity":"b92c7ade-4f44-44fa-bbce-d3b635d26d2b","order_by":5,"name":"Guangbin Wang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAUlEQVRIiWNgGAWjYFACHvYfH37Y1POzNx8D89nYCWthkJzZk5Yg2XMsjYEhAaiFmQgt0jxshxMMbviYgbUwENJicH7tAWMeHuY8gxs83x58/LFNno+ZgfHDxxw8Wm68S0icY8FWLHm7d7vhjITbhm3MDMySM7fh1mJ244zBgTc8PIx9d85uk+ZJuM0I1MLGzItfi2EDD5sEY8ONnGcgLfaEtZzvMWbkYTNInHAjhw2kJZGgFvsbfGmMM3sSjIGBbCY5I+12chszYzNev0j2nz3G8OHHfzlgVD6T+GBz23Z+e/PBDx/xaGGQSMAQYmzAox4I+A/glx8Fo2AUjIJRwAAA9AZU+T1dGoQAAAAASUVORK5CYII=","orcid":"","institution":"Shandong Provincial Hospital Affiliated to Shandong First Medical University","correspondingAuthor":true,"prefix":"","firstName":"Guangbin","middleName":"","lastName":"Wang","suffix":""}],"badges":[],"createdAt":"2025-01-02 13:53:33","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5752299/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5752299/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12883-025-04618-2","type":"published","date":"2026-01-23T15:57:09+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":73783366,"identity":"431089bf-0eae-48b4-be38-a5015013b5ec","added_by":"auto","created_at":"2025-01-14 15:43:55","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":734696,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of the study GBS patients.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-5752299/v1/355e3fe017fa491ff86f0a32.png"},{"id":73782471,"identity":"e2834e52-e8e8-4ae8-bf67-568e658a5ec0","added_by":"auto","created_at":"2025-01-14 15:35:55","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":555167,"visible":true,"origin":"","legend":"\u003cp\u003eAxial T2-weighted MR images of patients with GBS (a) and healthy controls (b) show the TN and CPN.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-5752299/v1/490a8f20f5a378b9e8c90e9e.png"},{"id":73782469,"identity":"70dc3274-e59c-452e-b536-45766948c4bb","added_by":"auto","created_at":"2025-01-14 15:35:55","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":309826,"visible":true,"origin":"","legend":"\u003cp\u003eThe DWIBS images of TN and CPN with a score of 1-4. (a) DWIBS image of a healthy control, the score of TN and CPN is 4. (b-d) DWIBS images of GBS patients, the scores of TN and CPN are 3 (b), 2 (c), 1 (d), respectively.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-5752299/v1/b0bfc9f62a02e797de4fa068.png"},{"id":73782467,"identity":"6408c463-ec77-4b03-9d18-5a861d32d7c9","added_by":"auto","created_at":"2025-01-14 15:35:55","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":30118,"visible":true,"origin":"","legend":"\u003cp\u003eThe differences in CSA and SNR value of TN and CPN between DBS patients and HCs.\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-5752299/v1/f8b6a46a74393400f2f322b2.png"},{"id":73782480,"identity":"8b30efab-aac3-4e8c-8999-3bd117f43d77","added_by":"auto","created_at":"2025-01-14 15:35:55","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":146315,"visible":true,"origin":"","legend":"\u003cp\u003eScatterplots of Pearson correlation between CSA, SNR value and nerve scores of TN and CPN and electrophysiology parameters (MCV and motor nerve conduction amplitude). The red squares represent statistically significant values.\u003c/p\u003e","description":"","filename":"Figure5.png","url":"https://assets-eu.researchsquare.com/files/rs-5752299/v1/38f69a339e4ddcbde35473a1.png"},{"id":101151809,"identity":"26af11b6-ce2a-4ff8-b7ab-d6758b2b7347","added_by":"auto","created_at":"2026-01-26 16:05:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2602457,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5752299/v1/193054ff-6363-4476-8ed5-1ad5a2902c3f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"MR neurography of tibial and common peroneal nerves in patients with Guillain-Barre syndrome and electrophysiological correlation","fulltext":[{"header":"Introduction","content":"\u003cp\u003eGuillain\u0026ndash;Barre syndrome (GBS) is an autoimmune demyelinating neuropathy, which is the most common cause of clinical acute flaccid paralysis. The main pathological change of GBS is inflammatory demyelination of the peripheral nerves, accompanied by secondary axonal damage[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Limb paralysis, respiratory paralysis, or few other life-threatening symptoms can be seen in severe GBS patients. The diagnosis of GBS is mainly based on symptoms, cerebrospinal fluid analysis, and electrophysiological evaluation currently[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Cerebrospinal fluid (CSF)-analysis reveals cyto-albuminological dissociation. However, sometimes, especially in the early phase of disease, cerebrospinal fluid protein may be at a normal level in up to 1/3 of patients and the diagnosis can be challenging[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMR neurography (MRN) is an advanced and noninvasive imaging technique to visualize peripheral nerves changes[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. MR neurography has been widely applied for the diagnosis of various peripheral neuropathies, including inflammatory neuropathies such as CIDP[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The studies of MR neurography in GBS were few and mainly focused on the imaging of the spinal nerve roots and cranial nerves[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], whereas few studies have evaluated the changes in the tibial nerves (TN) and common peroneal nerves (CPN). Ultrasound imaging as well as histopathological studies of peripheral nerves demonstrated that GBS also manifests with distal nerve (including tibial nerves and common peroneal nerves) enlargement in the early stage[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDiffusion-weighted imaging with background suppression (DWIBS) is a noninvasive magnetic resonance neurography (MRN) modality developed based on diffusion-weighted imaging (DWI). DWIBS enables a more straightforward evaluation of peripheral nerves due to its excellent nerve-peripheral soft tissue contrast, satisfactory background suppression, and three-dimensional maximum intensity projection (MIP). There has been recent interest in using DWIBS to evaluate peripheral nerves and corresponding lesions, such as brachial plexus, lumbosacral plexus, median and ulnar nerves, et al.[\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. To our knowledge, the evaluation of extremity peripheral nerve injury of GBS patients using DWIBS has not been studied previously.\u003c/p\u003e \u003cp\u003eTherefore, in this study, we aimed to explore the value of MR neurography in evaluation of the TN and CPN in patients with GBS by quantifying cross-sectional areas (CSAs) and signal-to-noise ratio (SNR) of the TN and CPN and observing the imaging feature on DWIBS, and to analyze their correlations with electrophysiological parameters of lower extremities.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSubjects\u003c/h2\u003e \u003cp\u003e This research was conducted in accordance with the Declaration of Helsinki of the World Medical Association and approved by the Ethics Committee of Zibo Central Hospital. Written informed consent was obtained from all GBS patients and and volunteers prior to study participation.\u003c/p\u003e \u003cp\u003eFrom June 2019 to November 2023, 49 patients with clinically suspected GBS were referred for an MR examination. Patients who satisfied the following criteria were potentially included in the study: the patient\u0026rsquo;s diagnosis was confirmed as GBS according to published criteria[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], and the time interval between electrophysiology examination and MR imaging was no more than 3 days. Therefore, 42 patients who consented to an MR examination were initially included in our study. Six of the patients were excluded after their MR examination. The exclusion criteria were as follows: patients whose MR images were with motion artifacts (n\u0026thinsp;=\u0026thinsp;2); patients who underwent medication therapy between MR imaging and electrophysiology examination (n\u0026thinsp;=\u0026thinsp;1); patients who had a history of multiple neuritis, chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), acute myelitis, diabetes, and other causes of polyneuropathy (n\u0026thinsp;=\u0026thinsp;3). Finally, 72 lower extremities of 36 GBS patients (age range, 13\u0026ndash;72 years; average: 43 years), including 16 women and 20 men, were analyzed in this study (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). A total of 72 lower extremities of 36 sex- and age-matched healthy controls (HCs; age range, 13\u0026ndash;70 years; average: 42 years; females: 17, males: 19) were also examined in this study. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003e described the demographic characteristics for all subjects.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic characteristics of GBS patients and healthy controls\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGBS patients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHealthy controls\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo. of subjects\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43\u0026thinsp;\u0026plusmn;\u0026thinsp;14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42\u0026thinsp;\u0026plusmn;\u0026thinsp;13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u0026ndash;72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u0026ndash;70\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo. of men\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo. of women\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eGBS, Guillain\u0026ndash;Barre syndrome.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eImaging scores for visualization of TN and CPN on DWIBS\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNerve\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003eImaging Scores\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCPN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eTN, tibial nerve; CPN, common peroneal nerve; GBS, Guillain-Barre syndrome.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eElectrophysiology examination\u003c/h3\u003e\n\u003cp\u003eAll GBS patients underwent an electrophysiology examination of the lower limbs, before or after the MRI examination no more than 3 days, and were assessed by a board-certified clinical neurophysiologist with 8 years of experience. Motor nerve conduction velocity (MCV) and motor nerve conduction amplitude of each subject were recorded. The normal MCV value of the TN and CPN is \u0026ge;\u0026thinsp;41 m/s. The normal motor nerve conduction amplitude values are \u0026ge;\u0026thinsp;4 mV in TN and \u0026ge;\u0026thinsp;2 mV in CPN, respectively[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eMRI examination\u003c/h3\u003e\n\u003cp\u003eA 3-Tesla MR-scanner (Achieva, Philips Healthcare, Best, Netherlands) equipped with dual-source parallel radiofrequency excitation and transmission technology was used for all MR examinations. The subjects were placed supine in feet-first position and unilateral imaging, using an eight-channel knee coil at the knee level.\u003c/p\u003e \u003cp\u003eMRI sequences included axial T1-weighted imaging, axial T2-weighted spectral attenuated inversion recovery (SPAIR), and axial DWIBS. The sequence parameters were as follows: T1-weighted imaging: repetition time/echo time (TR/TE) 550/20 ms, slice thickness 3.0 mm, overlap 0 mm, the field of view (FOV) 120\u0026times;120 mm\u003csup\u003e2\u003c/sup\u003e, number of signals acquired (NSA) 2, and acquisition time 3 min 34 sec. T2-weighted SPAIR imaging: TR/TE 3000/55 ms, slice thickness 3.0 mm, overlap 0.1 mm, FOV 120\u0026times;120 mm\u003csup\u003e2\u003c/sup\u003e, NSA 2, and acquisition time 3 min 45 sec. DWIBS: single-shot echo-planar imaging (EPI) sequence, TR/TE 9000/86 ms, slice thickness 3.0 mm, overlap 0 mm, FOV 100\u0026times;100 mm\u003csup\u003e2\u003c/sup\u003e, b-value 800 s/mm\u003csup\u003e2\u003c/sup\u003e, half-fourier factor 0.795, EPI factor 41, NSA 2, number of slices 80, image matrix 75\u0026times;72, and acquisition time 3 min 54 sec.\u003c/p\u003e\n\u003ch3\u003eDate postprocessing\u003c/h3\u003e\n\u003cp\u003eFor T2-weighted SPAIR, the CSA and SNR values of the TN and CPN were calculated. The three slices through the superior margin of patella, on the upper 10 mm and lower 10 mm, were chosen for the region of interest (ROI) placement. ROIs were placed manually as large as possible on the TN and CPN, encompassing the boundary of the nerves and excluding the adjacent structures. The measurements of three ROIs were recorded by two radiologists independently (SS.W with 8 years, and T.G with 9 years of experience in neuroimaging, respectively), and the average of the two radiologists\u0026rsquo; results were used as the final CSA and SNR values. The SNR was calculated as follows: SNR\u0026thinsp;=\u0026thinsp;SI (nerve)/SD (noise), where SI (nerve) is the signal intensity of the TN and CPN, and SD (noise) is the standard deviation of the noise measured in an ROI drawn outside of the image. Figure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the axial T2-weighted MR images of patients with GBS and healthy controls.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe raw data of DWIBS images were processed on an independent workstation (Extended MR Workspace, v. 2.6.3.2, Philips Healthcare) by two radiologists (WJ.Z with 6 years, and P.S with 5 years of experience in neuroimaging, respectively), blinded to each other and information of subjects. The postprocessing was performed using the full-volume MIP reconstruction and volume editing, which allowed removal of superimposed structures with similar hyper-intensity, such as veins and articular fluids, to display the nerves more clearly and obtain coronal 3D volume images of the TN and CPN.\u003c/p\u003e \u003cp\u003eA four-grade scoring system was used to evaluate the coronal 3D volume DWIBS images of the TN and CPN (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e): 4\u0026thinsp;=\u0026thinsp;nerve clearly visualized with sharp edges, good and uniform signal intensity; 3\u0026thinsp;=\u0026thinsp;nerve moderately well visualized with blurred edges, medium signal intensity; 2\u0026thinsp;=\u0026thinsp;nerve dissatisfiedly visualized with blurred or distorted edges, weak signal intensity; 1\u0026thinsp;=\u0026thinsp;nerve poorly visualized with obviously distorted and unclear edges, significantly weak signal intensity or part of nerve not visualized. If the score was not uniform, the final score was decided by the two radiologists together.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was performed using the software Prism Version 8 and SPSS software (v. 20, SPSS, Chicago, IL) and a value of P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. Chi-square test was used to determine differences in gender between GBS patients and HCs. Student\u0026rsquo;s t test was used to determine differences in age, height, weight between GBS patients and HCs.\u003c/p\u003e \u003cp\u003eThe interobserver agreement of the CSA and SNR values was assessed using intraclass correlation coefficient (ICC) analysis. The ICC ranges of reliability values provided by Landis and Koch were used as the reference standard[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The Kappa statistic was used to assess the interobserver agreement for the scoring results of TN and CPN on DWIBS: kappa value (K)\u0026gt;0.80 indicating excellent, 0.60\u0026lt;K\u0026lt;0.80 indicating good, 0.40\u0026lt;K\u0026lt;0.60 indicating moderate, and K\u0026lt;0.40 indicating poor[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIndependent samples t-test was performed to compare the differences of CSA and SNR values in two groups. Kruskal-Wallis test and a Dunn test was used to assess the differences in nerve scored values between GBS patients and HCs. Pearson correlation tests were used to assess the correlation between the CSA, SNR values, nerve scored values of TN and CPN and electrophysiology parameters (MCV and motor nerve conduction amplitude) of the GBS group.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThere were no significant differences in age, sex, weight, or height between the two groups. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the demographics of the patients and HCs. ICCs for interobserver agreement of CSA measurements were 0.865 (95% confidence interval (CI), 0.812\u0026ndash;0.936) for TN, 0.832 (95% CI, 0.729\u0026ndash;0.912) for CPN. ICCs for interobserver agreement of SNR values were 0.801 (95% confidence interval (CI), 0.767\u0026ndash;0.941) for TN, 0.820 (95% CI, 0.719\u0026ndash;0.912) for CPN, respectively. The interobserver statistic (k) for nerve scored values showed that the level of agreement was excellent, with k values between 0.81 and 1.00.\u003c/p\u003e \u003cp\u003eThe mean CSA of TN and CPN were significantly larger in patients with GBS (11.23\u0026thinsp;\u0026plusmn;\u0026thinsp;0.99 mm\u003csup\u003e2\u003c/sup\u003e for TN, 4.42\u0026thinsp;\u0026plusmn;\u0026thinsp;0.57 mm\u003csup\u003e2\u003c/sup\u003e for CPN) compared to healthy controls (10.78\u0026thinsp;\u0026plusmn;\u0026thinsp;1.18 mm\u003csup\u003e2\u003c/sup\u003e for TN, 4.17\u0026thinsp;\u0026plusmn;\u0026thinsp;0.64 mm\u003csup\u003e2\u003c/sup\u003e for CPN) (p\u0026lt;0.05). The mean SNR value of TN and CPN were significantly larger in patients with GBS (14.79\u0026thinsp;\u0026plusmn;\u0026thinsp;1.79 for TN, 14.55\u0026thinsp;\u0026plusmn;\u0026thinsp;1.71 for CPN) compared to healthy controls (14.04\u0026thinsp;\u0026plusmn;\u0026thinsp;1.79 for TN, 13.83\u0026thinsp;\u0026plusmn;\u0026thinsp;1.68 for CPN) (p\u0026lt;0.05). The statistical results are presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eDWIBS showed long trajectories of the TN and CPN in all healthy controls. The 72 TN and CPN of 36 healthy volunteers were all clearly visualized with sharp edges, good and uniform signal intensity on DWIBS, and the scores were all 4 (the diagnostic coincidence rate was 100%). Of the 72 TN and CPN in 36 GBS patients, 63 TN and 62 CPN had abnormal changes in varying degrees, including blurred or distorted contour, medium or weak signal intensity, and even part of nerve not visualized, and the scores were 1\u0026ndash;3. There were statistically significant differences in nerve scores between patients and HCs (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e \u003cp\u003eThe SNR values of TN correlated negatively with MCV and motor nerve conduction amplitude (P\u0026thinsp;=\u0026thinsp;0.0001 and P\u0026thinsp;=\u0026thinsp;0.001 respectively). The SNR values of CPN correlated negatively with MCV (P\u0026thinsp;=\u0026thinsp;0.02). No correlations were found between CSAs of TN and CPN and electrophysiological parameters and between SNR values of CPN and motor nerve conduction amplitude. The nerve scores of TN and CPN in the DWIBS sequence were all positively correlated with MCV and motor nerve conduction amplitude (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). The statistical results are presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn the present study, MR neurography showed larger CSA, higher SNR values of TN and CPN and more unclear nerve on DWIBS in GBS patients. Besides, the SNR values and nerve scores on DWIBS have correlation with the corresponding electrophysiological parameters. These findings suggest that MR neurography can be useful to reflect the change of TN and CPN in GBS patients.\u003c/p\u003e \u003cp\u003eThere were few reports on the MRN of GBS patients, most of them focus on the lumbosacral plexus and cauda equina[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This is to our knowledge the first study to evaluate the morphologic and T2 signal intensity changes of TN and CPN in GBS patients using MRN, especially DWIBS.\u003c/p\u003e \u003cp\u003eGiven that GBS is an immune-mediated neuropathies, inflammatory oedema, demyelination and Wallerian-like degeneration are considered to be the major histopathological changes of GBS[\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Patients in our cohort presented with larger CSA and higher T2 signal intensity of TN and CPN, which might be related to these histopathological changes. The larger CSA are consistent with previous sonographic studies[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Most TN and CPN of GBS patients in our study showed varying degrees of morphological abnormalities and reduced signals on DWIBS. This may be explained by extensive inflammatory cell infiltration and primary demyelination of peripheral nerves in GBS patients, which may lead to reduced diffusion restriction of water molecule in peripheral nerves[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In this study, the scores of 9 TN and 10 CPN of GBS patients were 4, which were similar to the healthy controls. This perhaps because these patients were in the early stages of GBS and inflammatory oedema was the main histopathological change[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], not demyelination, so the reduction of water molecule diffusion limitation in peripheral nerves was not significant.\u003c/p\u003e \u003cp\u003eOur study showed the SNR values and nerve scores on DWIBS have correlation with the corresponding electrophysiological parameters. As the principal electrophysiological parameters, MCV and motor nerve conduction amplitude could reflect the functional changes in the peripheral nerve. In general, demyelination is manifested as a decrease in MCV, and axonal injury is associated with a reduction in motor nerve conduction amplitude[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The conduction velocity and the motor nerve conduction amplitude decreased with the increase of T2 signal intensity and the decrease of nerve scores in TN and CPN, reflecting the increase of T2 signal intensity and more unclear nerve may suggest an increase nerve damage. However, the CSA of nerve did not correlate well with electrophysiological parameters, which are consistent with previous sonographic studies[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Therefore, nerve T2 signal intensity and the nerve visualization on DWIBS seems to be the more robust biomarker, which might also be explained by the MR signal being more susceptible to inflammatory oedema.\u003c/p\u003e \u003cp\u003eThis study has some limitations. First, the sample size of this study was small. Second, no comparison study was carried out on GBS patients before and after clinical treatments. Third, the duration and classification of the disease were not considered in this study, which may affect the results of the study. Fourth, we did not evaluate the ADC values. Further research is still needed to clarify the value of MRN in assessing GBS peripheral nerve disorder.\u003c/p\u003e \u003cp\u003eIn conclusion, MR neurography showed larger CSA, higher SNR values of TN and CPN and more unclear nerve on DWIBS, which reflect the pathophysiological changes of GBS. The SNR values and nerve scores on DWIBS have correlation with the corresponding electrophysiological parameters. These findings suggest that MR neurography can be useful to assess the damage of TN and CPN in GBS patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGB.W and JF.C designed the study and revised the manuscript. SS.W and T.G contributed to the data analysis and drafting of the manuscript. WJ.Z and P.S contributed to the collection of the data. All authors reviewed the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFundings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for conducting this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo datasets were generated or analysed during the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the Declaration of Helsinki of the World Medical Association and approved by the Ethics Committee of\u0026nbsp;Zibo Central Hospital (No. 201900788B0C503). Written informed consent was obtained from each GBS patient prior to study participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eDepartment of Radiology, Zibo Central Hospital, Zibo, Shandong, China\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u003c/sup\u003eDepartment of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e3\u003c/sup\u003eSchool of Medical Imaging, Binzhou Medical University, Yantai, Shandong, China\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eShahrizaila N, Lehmann HC, Kuwabara S. Guillain-Barr\u0026eacute; syndrome. Lancet. 2021;397(10280):1214\u0026ndash;28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan Doorn PA, Van den Bergh PYK, Hadden RDM, Avau B, Vankrunkelsven P, Attarian S, et al. European Academy of Neurology/Peripheral Nerve Society Guideline on diagnosis and treatment of Guillain-Barr\u0026eacute; syndrome. J Peripher Nerv Syst. 2023;28(4):535\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFokke C, van den Berg B, Drenthen J, Walgaard C, van Doorn PA, Jacobs BC. Diagnosis of Guillain-Barr\u0026eacute; syndrome and validation of Brighton criteria. Brain. 2014;137(Pt 1):33\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKronlage M, Baumer P, Pitarokoili K, Schwarz D, Schwehr V, Godel T, et al. Large coverage MR neurography in CIDP: diagnostic accuracy and electrophysiological correlation. J Neurol. 2017;264(7):1434\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWu F, Wang W, Zhao Y, Liu B, Wang Y, Yang Y, et al. MR neurography of lumbosacral nerve roots: Diagnostic value in chronic inflammatory demyelinating polyradiculoneuropathy and correlation with electrophysiological parameters. Eur J Radiol. 2020;124:108816.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlthubaiti F, Guiomard C, Rivier F, Meyer P, Leboucq N. Prognostic value of contrast-enhanced MRI in Guillain-Barr\u0026eacute; syndrome in children. Arch Pediatr. 2022;29(3):230\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerciano J. Thickening and contrast enhancement of spinal roots on MR imaging in Guillain-Barre syndrome: thoughts on pathologic background. AJNR Am J Neuroradiol. 2011;32(9):E179.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrimm A, Decard BF, Axer H. Ultrasonography of the peripheral nervous system in the early stage of Guillain-Barr\u0026eacute; syndrome. J Peripher Nerv Syst. 2014;19(3):234\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang L, Xiao T, Yu Q, Li Y, Shen F, Li W. Clinical Value and Diagnostic Accuracy of 3.0T Multi-Parameter Magnetic Resonance Imaging in Traumatic Brachial Plexus Injury. Med Sci Monit. 2018;24:7199\u0026ndash;205.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eM\u0026uuml;rtz P, Kaschner M, Lakghomi A, Gieseke J, Willinek WA, Schild HH, et al. Diffusion-weighted MR neurography of the brachial and lumbosacral plexus: 3.0 T versus 1.5 T imaging. Eur J Radiol. 2015;84(4):696\u0026ndash;702.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBao H, Wang S, Wang G, Yang L, Hasan MU, Yao B, et al. Diffusion-weighted MR neurography of median and ulnar nerves in the wrist and palm. Eur Radiol. 2017;27(6):2359\u0026ndash;66.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShankar V, Bangdiwala SI. Observer agreement paradoxes in 2x2 tables: comparison of agreement measures. BMC Med Res Methodol. 2014;14:100.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerciano J. Inflammatory oedema of nerve trunks may be pathogenic in very early Guillain-Barr\u0026eacute; syndrome. Acta Neurol Belg. 2020;120(5):1061\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerciano J. Axonal degeneration in Guillain-Barr\u0026eacute; syndrome: a reappraisal. J Neurol. 2021;268(10):3728\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVucic S, Cairns KD, Black KR, Chong PS, Cros D. Neurophysiologic findings in early acute inflammatory demyelinating polyradiculoneuropathy. Clin Neurophysiol. 2004;115(10):2329\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrimm A, D\u0026eacute;card BF, Schramm A, Pr\u0026ouml;bstel AK, Rasenack M, Axer H, et al. Ultrasound and electrophysiologic findings in patients with Guillain-Barr\u0026eacute; syndrome at disease onset and over a period of six months. Clin Neurophysiol. 2016;127(2):1657\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerciano J, Sedano MJ, Pelayo-Negro AL, Garc\u0026iacute;a A, Orizaola P, Gallardo E, et al. Proximal nerve lesions in early Guillain-Barr\u0026eacute; syndrome: implications for pathogenesis and disease classification. J Neurol. 2017;264(2):221\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTan CY, Sekiguchi Y, Goh KJ, Kuwabara S, Shahrizaila N. A model to predict the probability of acute inflammatory demyelinating polyneuropathy. Clin Neurophysiol. 2020;131(1):63\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKerasnoudis A, Pitarokoili K, Behrendt V, Gold R, Yoon MS. Correlation of nerve ultrasound, electrophysiological and clinical findings in chronic inflammatory demyelinating polyneuropathy. J Neuroimaging. 2015;25(2):207\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Guillain-Barre syndrome, MR neurography, tibial nerve, common peroneal nerves","lastPublishedDoi":"10.21203/rs.3.rs-5752299/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5752299/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe early and accurate evaluation of peripheral nerve injury in Guillain\u0026ndash;Barre syndrome (GBS) patients is of great significance for clinical diagnosis and treatment. There has been recent interest in using Diffusion-weighted imaging with background suppression (DWIBS) to evaluate peripheral nerves and corresponding lesions, but has not been applied in GBS patients.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo explore the value of MR neurography in evaluating tibial nerve (TN) and common peroneal nerve (CPN) in GBS patients.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e36 GBS patients and 36 healthy volunteers were included in this prospective study. The cross-sectional areas (CSA) and signal-to-noise ratio (SNR) values of TN and CPN on T2-weighted images were calculated. Four-grade scoring system was used to score DWIBS images of TN and CPN. The CSA and SNR values, nerve scores on DWIBS were compared. Pearson correlation tests were used to assess the correlation between the CSA and SNR values, nerve scores and electrophysiology parameters of the GBS group.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe interobserver agreement of measurements and nerve scored values was excellent. The mean CSA and SNR values of TN and CPN were significantly larger in patients than healthy controls (P\u0026lt;0.05). There were statistically significant differences in nerve scores between two groups (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01). The SNR values of TN correlated negatively with motor nerve conduction velocity (MCV) and motor nerve conduction amplitude (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01). The SNR values of CPN correlated negatively with MCV (P\u0026thinsp;=\u0026thinsp;0.02). The nerve scores of TN and CPN were all positively correlated with MCV and motor nerve conduction amplitude (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eMR neurography showed larger CSA, higher SNR values of TN and CPN and unclear nerve on DWIBS. The SNR values and nerve scores on DWIBS have correlation with electrophysiological parameters. These findings suggest that MR neurography can be useful to assess the damage of TN and CPN in GBS patients.\u003c/p\u003e","manuscriptTitle":"MR neurography of tibial and common peroneal nerves in patients with Guillain-Barre syndrome and electrophysiological correlation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-14 15:35:50","doi":"10.21203/rs.3.rs-5752299/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-04-07T18:33:02+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-03-19T11:45:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"300864070478901433554165981104569208723","date":"2025-03-05T22:15:42+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-02-24T12:39:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"275011206763044587105436006259064001333","date":"2025-02-18T13:36:39+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-02-17T09:19:20+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-01-09T22:23:42+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-01-09T15:22:22+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-01-09T15:20:34+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Neurology","date":"2025-01-02T13:48:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"467f9732-be16-4eea-8f37-21b4d3629e20","owner":[],"postedDate":"January 14th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-26T16:02:17+00:00","versionOfRecord":{"articleIdentity":"rs-5752299","link":"https://doi.org/10.1186/s12883-025-04618-2","journal":{"identity":"bmc-neurology","isVorOnly":false,"title":"BMC Neurology"},"publishedOn":"2026-01-23 15:57:09","publishedOnDateReadable":"January 23rd, 2026"},"versionCreatedAt":"2025-01-14 15:35:50","video":"","vorDoi":"10.1186/s12883-025-04618-2","vorDoiUrl":"https://doi.org/10.1186/s12883-025-04618-2","workflowStages":[]},"version":"v1","identity":"rs-5752299","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5752299","identity":"rs-5752299","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}