Semin Musculoskelet Radiol 2024; 28(01): 092-102
DOI: 10.1055/s-0043-1776427
Review Article

Imaging Biomarkers of Peripheral Nerves: Focus on Magnetic Resonance Neurography and Ultrasonography

1   Department of Radiology, UT Southwestern Medical Center, Dallas, Texas
Cindy Weinschenk
1   Department of Radiology, UT Southwestern Medical Center, Dallas, Texas
Avneesh Chhabra
1   Department of Radiology, UT Southwestern Medical Center, Dallas, Texas
2   Department of Radiology & Orthopedic Surgery, UT Southwestern Medical Center, Dallas, Texas
› Author Affiliations


Peripheral neuropathy is a prevalent and debilitating condition affecting millions of individuals globally. Magnetic resonance neurography (MRN) and ultrasonography (US) are noninvasive methods offering comprehensive visualization of peripheral nerves, using anatomical and functional imaging biomarkers to ensure accurate evaluation. For optimized MRN, superior and high-resolution two-dimensional and three-dimensional imaging protocols are essential. The anatomical MRN and US imaging markers include quantitative measures of nerve and fascicular size and signal, and qualitative markers of course and morphology. Among them, quantitative markers of T2-signal intensity ratio are sensitive to nerve edema-like signal changes, and the T1-mapping technique reveals nerve and muscle tissue fatty and fibrous compositional alterations.

The functional markers are derived from physiologic properties of nerves, such as diffusion characteristics or blood flow. They include apparent diffusion coefficient from diffusion-weighted imaging and fractional anisotropy and tractography from diffusion tensor imaging to delve into peripheral nerve microstructure and integrity. Peripheral nerve perfusion using dynamic contrast-enhanced magnetic resonance imaging estimates perfusion parameters, offering insights into nerve health and neuropathies involving edema, inflammation, demyelination, and microvascular alterations in conditions like type 2 diabetes, linking nerve conduction pathophysiology to vascular permeability alterations.

Imaging biomarkers thus play a pivotal role in the diagnosis, prognosis, and monitoring of nerve pathologies, thereby ensuring comprehensive assessment and elevating patient care. These biomarkers provide valuable insights into nerve structure, function, and pathophysiology, contributing to the accurate diagnosis and management planning for peripheral neuropathy.

Financial Disclosures

Alireza Eajazi is a consultant for ICON Medical and TREACE Medical Concepts. He receives book royalties from Jaypee and Wolters, is a medical adviser for ImageBiopsy Lab, and receives research grants from ImageBiopsy Lab and Qure AI.

Publication History

Article published online:
08 February 2024

© 2024. Thieme. All rights reserved.

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  • References

  • 1 Gilron I, Baron R, Jensen T. Neuropathic pain: principles of diagnosis and treatment. Mayo Clin Proc 2015; 90 (04) 532-545
  • 2 Gregg EW, Sorlie P, Paulose-Ram R. et al; 1999-2000 national health and nutrition examination survey. Prevalence of lower-extremity disease in the US adult population >=40 years of age with and without diabetes: 1999-2000 National Health and Nutrition Examination Survey. Diabetes Care 2004; 27 (07) 1591-1597
  • 3 Filler AG, Howe FA, Hayes CE. et al. Magnetic resonance neurography. Lancet 1993; 341 (8846) 659-661
  • 4 Chhabra A, Andreisek G, Soldatos T. et al. MR neurography: past, present, and future. AJR Am J Roentgenol 2011; 197 (03) 583-591
  • 5 Vaeggemose M, Pham M, Ringgaard S. et al. Magnetic resonance neurography visualizes abnormalities in sciatic and tibial nerves in patients with type 1 diabetes and neuropathy. Diabetes 2017; 66 (07) 1779-1788
  • 6 Chhabra A, Chalian M, Soldatos T. et al. 3-T high-resolution MR neurography of sciatic neuropathy. AJR Am J Roentgenol 2012; 198 (04) W357-W364
  • 7 Chen J, Qin Z, Zeng X. et al. Applicative value of T2 mapping in evaluating lumbosacral nerve root injury induced by lumbosacral disc herniation. Acta Radiol 2023; 64 (04) 1526-1532
  • 8 Dessouky R, Xi Y, Zuniga J, Chhabra A. Role of MR neurography for the diagnosis of peripheral trigeminal nerve injuries in patients with prior molar tooth extraction. AJNR Am J Neuroradiol 2018; 39 (01) 162-169
  • 9 Bäumer P, Dombert T, Staub F. et al. Ulnar neuropathy at the elbow: MR neurography—nerve T2 signal increase and caliber. Radiology 2011; 260 (01) 199-206
  • 10 Sollmann N, Weidlich D, Cervantes B. et al. High isotropic resolution T2 mapping of the lumbosacral plexus with T2-prepared 3D turbo spin echo. Clin Neuroradiol 2019; 29 (02) 223-230
  • 11 Larmour S, Chow K, Kellman P, Thompson RB. Characterization of T1 bias in skeletal muscle from fat in MOLLI and SASHA pulse sequences: quantitative fat-fraction imaging with T1 mapping. Magn Reson Med 2017; 77 (01) 237-249
  • 12 Marty B, Coppa B, Carlier PG. Monitoring skeletal muscle chronic fatty degenerations with fast T1-mapping. Eur Radiol 2018; 28 (11) 4662-4668
  • 13 Puntmann VO, Peker E, Chandrashekhar Y, Nagel E. T1 mapping in characterizing myocardial disease: a comprehensive review. Circ Res 2016; 119 (02) 277-299
  • 14 Yang Y, Qiu L, Gu X. et al. Monitoring rotator cuff muscle fatty infiltration progression by magnetic resonance imaging T1 mapping: correlation with direct evaluation findings in rats. Am J Sports Med 2022; 50 (04) 1078-1087
  • 15 Eppenberger P, Andreisek G, Chhabra A. Magnetic resonance neurography: diffusion tensor imaging and future directions. Neuroimaging Clin N Am 2014; 24 (01) 245-256
  • 16 Chhabra A, Zhao L, Carrino JA. et al. MR neurography: advances. Radiol Res Pract 2013; 2013: 809568
  • 17 Mazal AT, Ashikyan O, Cheng J, Le LQ, Chhabra A. Diffusion-weighted imaging and diffusion tensor imaging as adjuncts to conventional MRI for the diagnosis and management of peripheral nerve sheath tumors: current perspectives and future directions. Eur Radiol 2019; 29 (08) 4123-4132
  • 18 Chhabra A, Flammang A, Padua Jr A, Carrino JA, Andreisek G. Magnetic resonance neurography: technical considerations. Neuroimaging Clin N Am 2014; 24 (01) 67-78
  • 19 Chhabra A, Soldatos T, Subhawong TK. et al. The application of three-dimensional diffusion-weighted PSIF technique in peripheral nerve imaging of the distal extremities. J Magn Reson Imaging 2011; 34 (04) 962-967
  • 20 Wang X, Harrison C, Mariappan YK. et al. MR neurography of brachial plexus at 3.0 T with robust fat and blood suppression. Radiology 2017; 283 (02) 538-546
  • 21 Wang X, Greer JS, Dimitrov IE, Pezeshk P, Chhabra A, Madhuranthakam AJ. Frequency offset corrected inversion pulse for B0 and B1 insensitive fat suppression at 3T: application to MR neurography of brachial plexus. J Magn Reson Imaging 2018; 48 (04) 1104-1111
  • 22 Bendszus M, Wessig C, Solymosi L, Reiners K, Koltzenburg M. MRI of peripheral nerve degeneration and regeneration: correlation with electrophysiology and histology. Exp Neurol 2004; 188 (01) 171-177
  • 23 Li X, Shen J, Chen J, Wang X, Liu Q, Liang B. Magnetic resonance imaging evaluation of acute crush injury of rabbit sciatic nerve: correlation with histology. Can Assoc Radiol J 2008; 59 (03) 123-130
  • 24 Shen J, Zhou CP, Zhong XM. et al. MR neurography: T1 and T2 measurements in acute peripheral nerve traction injury in rabbits. Radiology 2010; 254 (03) 729-738
  • 25 Vrenken H, Geurts JJG, Knol DL. et al. Whole-brain T1 mapping in multiple sclerosis: global changes of normal-appearing gray and white matter. Radiology 2006; 240 (03) 811-820
  • 26 Wang Y, Chen Y, Wu D. et al. STrategically Acquired Gradient Echo (STAGE) imaging, part II: correcting for RF inhomogeneities in estimating T1 and proton density. Magn Reson Imaging 2018; 46: 140-150
  • 27 Yarnykh VL. Actual flip-angle imaging in the pulsed steady state: a method for rapid three-dimensional mapping of the transmitted radiofrequency field. Magn Reson Med 2007; 57 (01) 192-200
  • 28 Morrell GR. A phase-sensitive method of flip angle mapping. Magn Reson Med 2008; 60 (04) 889-894
  • 29 Ratner S, Khwaja R, Zhang L. et al. Sciatic neurosteatosis: relationship with age, gender, obesity and height. Eur Radiol 2018; 28 (04) 1673-1680
  • 30 Hiwatashi A, Togao O, Yamashita K. et al. Lumbar plexus in patients with chronic inflammatory demyelinating polyradiculoneuropathy: evaluation with simultaneous T2 mapping and neurography method with SHINKEI. Br J Radiol 2018; 91 (1092) 20180501
  • 31 Ahlawat S, Chhabra A, Blakely J. Magnetic resonance neurography of peripheral nerve tumors and tumorlike conditions. Neuroimaging Clin N Am 2014; 24 (01) 171-192
  • 32 Wilson TJ, Howe BM, Stewart SA, Spinner RJ, Amrami KK. Clinicoradiological features of intraneural perineuriomas obviate the need for tissue diagnosis. J Neurosurg 2018; 129 (04) 1034-1040
  • 33 Ahlawat S, Fayad LM, Khan MS. et al; Whole Body MRI Committee for the REiNS International Collaboration, REiNS International Collaboration Members 2016. Current whole-body MRI applications in the neurofibromatoses: NF1, NF2, and schwannomatosis. Neurology 2016; 87 (7, Suppl 1): S31-S39
  • 34 Wu C, Wang G, Zhao Y. et al. Assessment of tibial and common peroneal nerves in diabetic peripheral neuropathy by diffusion tensor imaging: a case control study. Eur Radiol 2017; 27 (08) 3523-3531
  • 35 Amaya J, Lue B, Silva FD, Raspovic K, Xi Y, Chhabra A. Diffusion-weighted MR imaging and utility of ADC measurements in characterizing nerve and muscle changes in diabetic patients on ankle DWI studies: a cross-sectional study. Eur Radiol 2023; 33 (07) 4855-4863
  • 36 Bao H, Wang S, Wang G. et al. Diffusion-weighted MR neurography of median and ulnar nerves in the wrist and palm. Eur Radiol 2017; 27 (06) 2359-2366
  • 37 Chhabra A, Carrino JA, Farahani SJ. et al. Whole-body MR neurography: prospective feasibility study in polyneuropathy and Charcot-Marie-Tooth disease. J Magn Reson Imaging 2016; 44 (06) 1513-1521
  • 38 Sigmund EE, Cho GY, Kim S. et al. Intravoxel incoherent motion imaging of tumor microenvironment in locally advanced breast cancer. Magn Reson Med 2011; 65 (05) 1437-1447
  • 39 Zhang Z, Song L, Meng Q. et al. Morphological analysis in patients with sciatica: a magnetic resonance imaging study using three-dimensional high-resolution diffusion-weighted magnetic resonance neurography techniques. Spine 2009; 34 (07) E245-E250
  • 40 Bäumer P, Pham M, Ruetters M. et al. Peripheral neuropathy: detection with diffusion-tensor imaging. Radiology 2014; 273 (01) 185-193
  • 41 Mori S, Zhang J. Principles of diffusion tensor imaging and its applications to basic neuroscience research. Neuron 2006; 51 (05) 527-539
  • 42 Basser PJ, Mattiello J, LeBihan D. MR diffusion tensor spectroscopy and imaging. Biophys J 1994; 66 (01) 259-267
  • 43 Chhabra A, Thakkar RS, Andreisek G. et al. Anatomic MR imaging and functional diffusion tensor imaging of peripheral nerve tumors and tumorlike conditions. AJNR Am J Neuroradiol 2013; 34 (04) 802-807
  • 44 Hlis R, Poh F, Xi Y, Chhabra A. Diffusion tensor imaging of diabetic amyotrophy. Skeletal Radiol 2019; 48 (11) 1705-1713
  • 45 Wadhwa V, Hamid AS, Kumar Y, Scott KM, Chhabra A. Pudendal nerve and branch neuropathy: magnetic resonance neurography evaluation. Acta Radiol 2017; 58 (06) 726-733
  • 46 Keller S, Chhabra A, Ahmed S. et al. Improvement of reliability of diffusion tensor metrics in thigh skeletal muscles. Eur J Radiol 2018; 102: 55-60
  • 47 Guggenberger R, Nanz D, Bussmann L. et al. Diffusion tensor imaging of the median nerve at 3.0 T using different MR scanners: agreement of FA and ADC measurements. Eur J Radiol 2013; 82 (10) e590-e596
  • 48 Griffiths TT, Flather R, Teh I. et al. Diffusion tensor imaging in cubital tunnel syndrome. Sci Rep 2021; 11 (01) 14982
  • 49 Stein D, Neufeld A, Pasternak O. et al. Diffusion tensor imaging of the median nerve in healthy and carpal tunnel syndrome subjects. J Magn Reson Imaging 2009; 29 (03) 657-662
  • 50 Froeling M, Oudeman J, Strijkers GJ. et al. Muscle changes detected with diffusion-tensor imaging after long-distance running. Radiology 2015; 274 (02) 548-562
  • 51 Tuch DS. Q-ball imaging. Magn Reson Med 2004; 52 (06) 1358-1372
  • 52 Tuch DS, Reese TG, Wiegell MR, Wedeen VJ. Diffusion MRI of complex neural architecture. Neuron 2003; 40 (05) 885-895
  • 53 Bäumer P, Reimann M, Decker C. et al. Peripheral nerve perfusion by dynamic contrast-enhanced magnetic resonance imaging: demonstration of feasibility. Invest Radiol 2014; 49 (08) 518-523
  • 54 Jende JME, Mooshage C, Kender Z. et al. Sciatic nerve microvascular permeability in type 2 diabetes decreased in patients with neuropathy. Ann Clin Transl Neurol 2022; 9 (06) 830-840
  • 55 Chhabra A, Deshmukh SD, Lutz AM. et al. Neuropathy Score Reporting and Data System: a reporting guideline for MRI of peripheral neuropathy with a multicenter validation study. AJR Am J Roentgenol 2022; 219 (02) 279-291
  • 56 Chhabra A, Deshmukh SD, Lutz AM. et al. Neuropathy Score Reporting and Data System (NS-RADS): MRI reporting guideline of peripheral neuropathy explained and reviewed. Skeletal Radiol 2022; 51 (10) 1909-1922
  • 57 Holzgrefe RE, Wagner ER, Singer AD, Daly CA. Imaging of the peripheral nerve: concepts and future direction of magnetic resonance neurography and ultrasound. J Hand Surg Am 2019; 44 (12) 1066-1079
  • 58 Klauser AS, Halpern EJ, De Zordo T. et al. Carpal tunnel syndrome assessment with US: value of additional cross-sectional area measurements of the median nerve in patients versus healthy volunteers. Radiology 2009; 250 (01) 171-177
  • 59 Choi SJ, Ahn JH, Ryu DS. et al. Ultrasonography for nerve compression syndromes of the upper extremity. Ultrasonography 2015; 34 (04) 275-291