Jpn J Rehabil Med 2015 ; : MRI Two Cases of Shoulder-Hand Syndrome after Stroke : Clinical Symptoms and MRI Findings Hiroko YAMANA

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1 Jpn J Rehabil Med 2015 ; : MRI Two Cases of Shoulder-Hand Syndrome after Stroke : Clinical Symptoms and MRI Findings Hiroko YAMANAKA, 1 Hidekata YAMANAKA, 1 Masayuki WAKITA, 2, 3 Yoshiya HASHIGUCHI, 2 Junji KASUYA 2 Abstract : In two cases of poststroke shoulder-hand syndrome, the patients complained of hemi-paretic shoulder pain. Both cases showed characteristic findings on magnetic resonance imaging MRI of the paretic shoulder. Case 1 underwent MRI before the syndrome occurred, while Case 2 underwent MRI after the syndrome occurred. In both cases, chemical saturation T 2- weighted images revealed high intensity signals mainly anterior to the scapula, but also surrounding the articular capsule of the shoulder joint. Also, the subscapular muscle and subscapular bursa appeared damaged, and bloody fluid extended into the connective tissue. In Case 2, chemical saturation T 2-weighted images revealed high intensity signals in the axillary fat. The paretic hands of both patients showed conscious and objective allodynia, edema, and decreased range of finger flexion and carpal extension. Observed symptoms were consistent with a diagnosis of complex regional pain syndrome CRPS. Adherence of the posterior brachial plexus to the subscapular muscle may result in positional relationship changes and tears to the cords when the paretic shoulder is moved. The resultant small fiber neuropathy may result in edema by conduction block. Furthermore, aseptic synovitis from neurogenic inflammation may also occur. In Case 1, the arthritis of the shoulder appeared before the neuropathy. This indicates that damage to the subscapular bursa rather than neuropathy may be the underlying cause of the arthritis. Jpn J Rehabil Med. Key words : shoulder-hand syndrome subscapular muscle subscapular bursamri magnetic resonance imaging of the shoulder aseptic synovitis IASP shoulder-hand syndrome SHSRSD 4 Reflex Sympathetic Dystrophy 1 Complex regional pain syndrome type 1 CRPS I 5 CRPS I Oaklander 9 CRPS I small Department of Neurology, Atsuchi Rehabilitation Hospital Department of Neurology, Atsuchi Neurosurgical Hospital yamanaka-hiroko@umin.ac.jp 126 Jpn J Rehabil Med VOL. 52 NO

2 2 fiber neuropathy CRPS CRPS 10 SHS CRPS RSD Wrist-hand syndrome 4 SHS 2 magnetic resonance imaging MRISHS 1 1 SHS Brunnstrom Stage BRS 4 MRI 6.4 SHS 49 BRS 8 SHS PIP Proximal interphalangeal jointmp Metacarpophalangeal joint PIP MP DIP Distal interphalangeal BRS BRS 6 SHS 12.9 MRI 20.9 MP PIP DIP MRI 59 BRS mm cm 70 MP 90 MP 45 PIP SHS SHS range of motion MP metacarpophalangeal PIP proximal interphalangeal BRS Brunnstrom stage SHS shoulder-hand syndrome. BRS BRS Jpn J Rehabil Med VOL. 52 NO

1 MRI A T13.0 T TR 800 ms TE 9.60 msb T23.

0 T T1 T2 12 T2SHS T2 B B T2 1C 2C 1D 2D

3 1 MRI A T13.0 T TR 800 ms TE 9.60 msb T23.0 T TR 4400 ms TE ms C T2 3.0 T TR 4400 ms TE ms D T2 3.0 T TR 4400 ms TE ms E FC D C D 20.7 BRS ADL SHS MRI GE SIGNA EXCITE HD 3.0 T T1 T2 12 T2SHS T2 B B T2 1C 2C 1D 2D 2 T2 2B 2A BSHS 3 T2 2F G 1 1E 2 2E SHS MRI T2 128 Jpn J Rehabil Med VOL. 52 NO

4 2 2 3 MRI A 2 T13.0 T TR 800 ms TE 9.05 msb 2 T23.0 T TR 4400 ms TE ms C 2 T2 3.0 T TR 4400 ms TE ms D 2 T2 3.0 T TR 4400 ms TE ms E 2 F 3 T23.0 T TR 4400 ms TE msg 3 T2 3.0 T TR 4400 ms TE ms 12 RSD 4 12 SHS score 2 SHS 2 SHS 1 MRI 2 T2 SHS 2 small-fiber neuropathy 3 SHS Braus Jpn J Rehabil Med VOL. 52 NO

5 2 Manual Muscle Testing 2 SHS 2 13 SHS Substance P Calcitonin gene-related peptide IL Falsetti Wrist-hand syndrome RSD 20 mm 130 Jpn J Rehabil Med VOL. 52 NO

6 2 RSD 17 SHS PIP MP PIP MP DIP MP MP PIP PIP MP PIP mm SHS 2 2 SHS 1 : ; : Braus DF, Krauss JK, Strobel J : The shoulder-hand syndrome after stroke : a prospective clinical trial. Ann Neurol 1994 ; : Geurts AC, Visschers BA, van Limbeek J, Ribbers GM : Systematic review of aetiology and treatment of poststroke hand oedema and shoulder-hand syndrome. Scand J Rehabil Med 2000 ; : Greyson ND, Tepperman PS : Three-phase bone studies in hemiplegia with reflex sympathetic dystrophy and the effect of disuse. J Nucl Med 1984 ; : Merskey H, Bogduk N eds : Task force on taxonomy. in Classification of Chronic Pain : Descriptions of Pain Terms, 2nd Ed. IASP Press, Seattle, 1994 ; pp Wasner G, Heckmann K, Maier C, Baron R : Vascular abnormalities in acute reflex sympathetic dystrophy CRPS I. Complete inhibition of sympathetic nerve activity with recovery. Arch Neurol 1999 ; : Guo TZ, Wei T, Shi X, Li WW, Hou S, Wang L, Tsujikawa K, Rice KC, Cheng K, Clark DJ, Kingery WS : Neuropeptide deficient mice have attenuated nociceptive, vascular, and inflammatory changes in a tibia fracture model of complex regional pain syndrome. Mol Pain 2012 ; : 85 8 Daemen MA, Kurvers HA, Kitslaar PJ, Slaaf DW, Bullens PH, Van den Wildenberg FA : Neurogenic inflammation in an animal model of neuropathic pain. Neurol Res 1998 ; : Oaklander AL, Rissmiller JG, Gelman LB, Zheng L, Chang Y, Gott R : Evidence of focal small-fiber axonal degeneration in complex regional pain syndrome-1 reflex sympathetic dystrophy. Pain 2006 ; : : CRPS Mucha C : Einfluß von CO 2 -Bädern im frühfunktionellen Therapiekonzept der Algodystrophie. Phys Rehab Kur Med 1992 ; : ,, : MRI- 1.,, 2004 ; p 4, pp 11.13, p 34 13,,, : 1.,, 2005 ; p 35, p 43 14, : 2 1.,, 2005 ; p 9 15 Eng DL, Kocsis JD : Activity-dependent changes in extracellular potassium and excitability in turtle olfactory nerve. J Neurophysiol 1987 ; : , : ; : Falsetti P, Acciai C, Carpinteri F, Palilla R, Lenzi L : Bedside ultrasonography of musculoskeletal complications in brain injured patients. J Ultrasound 2010 ; : : 4.,, 2006 ; pp 98.99, p 104, p 156, pp , pp Jpn J Rehabil Med VOL. 52 NO

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