title: Hirayama's disease: an Italian single center experience and review of the literature.
abstract: BACKGROUND
  Hirayama's disease (HD), is a benign, self-limited, motor neuron disease, characterized by asymmetric weakness and atrophy of one or both distal upper extremities. In the present study we report the clinical, electrophysiological and MRI features of a group of Italian patients, with review of the literature. Moreover we propose an optimized MRI protocol for patients with suspected or diagnosed HD in order to make an early diagnosis and a standardized follow up.
  
  
  METHODS
  Eight patients with clinical suspicion of Hirayama disease underwent evaluation between January 2007 and November 2013. All patients underwent standard nerve conduction studies (NCS), electromyography (EMG) and motor/sensory evoked potentials (MEP/SEP). Cervical spine MRI studies were conducted with a 1.5 Tesla MRI scanner in neutral and flexion position, including sagittal T1-weighted sequences and sagittal and axial T2-weighted sequences. The following diagnostic features were evaluated: abnormal cervical curvature, localized cervical cord atrophy in the lower tract (C4-C7), presence of cord flattening (CF), intramedullary signal hyperintensity on T2 weighted sequences, anterior shifting of the posterior wall of the cervical dural sac (ASD) and presence of flow voids (EFV) in the posterior epidural space during flexion.
  
  
  RESULTS
  All patients complained of weakness in hand muscles as initial symptoms, associated with hand tremor in three of them and abnormal sweating of the hand palm in two of them. No sensory deficits and weakness at lower limbs were reported by any patients. Distal deep tendon reflexes at upper limbs were absent in all patients with the absence of the right tricipital reflex in one of them. Deep tendon reflexes at lower limbs were normal and no signs of pyramidal tract involvement were present. The clinical involvement at onset was unilateral in six patients (three left-sided and three right-sided) and bilateral asymmetric in two of them, with the right side more affected. With the progression of the disease all patients but one experienced weakness and wasting of hand muscles and forearm bilaterally, but still asymmetric. The duration of the progression phase of the disease ranged from eight months to three years. In all patients, NCS and EMG findings were consistent with a spinal metameric disorder involving the C7-T1 myotomes bilaterally; sensory conduction and electrophysiologic features at lower limbs were normal. MEP and SEP were normal and we did not observe the disappearance of the spinal potential during the neck flexion in any of the patients. MRI is the best diagnostic tool in the diagnosis of HD; it can confirm clinical diagnosis and exclude other conditions responsible for the neurological deficits leading to a correct patient management and therapy, limiting arm impairment. On MRI all patients had loss of the normal cervical lordosis (100%). Five patients had loss of attachment of posterior dural sac and anterior dural shift on flexion MRI with presence of flow voids from venous plexus congestion (62.5%); three patients had no anterior dislocation of the dural sac and no epidural vein congestion. Two patients showed localized cord atrophy, one at C5-C6 and the other at C6-C7 level (25%). Three patients had T2 intramedullary hyperintensities (37.5%) and cord flattening (CF) was present in 5 patients of 8 (62.5%).
  
  
  CONCLUSIONS
  HD is a rare entity and a self-limited condition, but it has to be early differentiated from other diseases that may determine myelopathy and amyotrophy to establish a correct therapy and limit arm impairment. MRI is very important to confirm the clinical suspect of HD and a standardized MRI protocol using axial and sagittal images in both neutral and flexing position is needed, in order to diagnose and follow up affected patients.
authors.affiliation: Department of Imaging and Radiation Therapy, Azienda Socio-Sanitaria Territoriale di Lecco, A.Manzoni Hospital-Lecco, Italy.
authors.forename: Valerio
authors.initials: V
authors.lastname: Vitale
authors.affiliation: Department of Advanced Biomedical Sciences, Division of Neuroradiology, University Hospital Federico II, Naples, Italy.
authors.forename: Ferdinando
authors.initials: F
authors.lastname: Caranci
authors.affiliation: Departments of Neurosciences, Reproductive Sciences, and Odontostomatology, University Hospital Federico II, Naples, Italy.
authors.forename: Chiara
authors.initials: C
authors.lastname: Pisciotta
authors.affiliation: Departments of Neurosciences, Reproductive Sciences, and Odontostomatology, University Hospital Federico II, Naples, Italy.
authors.forename: Fiore
authors.initials: F
authors.lastname: Manganelli
authors.affiliation: Department of Advanced Biomedical Sciences, Division of Neuroradiology, University Hospital Federico II, Naples, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Briganti
authors.affiliation: Departments of Neurosciences, Reproductive Sciences, and Odontostomatology, University Hospital Federico II, Naples, Italy.
authors.forename: Lucio
authors.initials: L
authors.lastname: Santoro
authors.affiliation: Department of Advanced Biomedical Sciences, Division of Neuroradiology, University Hospital Federico II, Naples, Italy.
authors.forename: Arturo
authors.initials: A
authors.lastname: Brunetti
keywords: Hirayama’s disease (HD); Magnetic resonance imaging (MRI); atrophy; spinal cord