8th Congress of Clinical Neurophysiology Society of Serbia and Montenegro with International Participation Belgrade, Serbia and Montenegro, October 13-15, 2005 President of the Society: Zarko Martinovic

Clinical Neurophysiology 117 (2006) e5–e16 www.elsevier.com/locate/clinph

Society Proceedings

8th Congress of Clinical Neurophysiology Society of Serbia and Montenegro with International Participation Belgrade, Serbia and Montenegro, October 13–15, 2005 President of the Society: Zˇarko Martinovic´ * Department of Epilepsy and Clinical Neurophysiology, Institute of Mental Health, Palmoticeva 37, 11000 Belgrade, Serbia and Montenegro

Effect of change of calcium concentration on bursting activity induced by nickel and cobalt—V. Nedeljkov, S. ˇ emerikic´ (Department of Lopicˇic´, N. Nenadovic´, D. C Pathophysiology, Medical Faculty, Belgrade, Serbia and Montenegro)

Ionic mechanism of effect of b-N-methylamino-L-alanine on Retzius nerve cells of the leech Haemopis sanguiˇ emerikic´, S. suga—S. Lopicˇic´, V. Nedeljkov, D. C Dragovic´, Medical Faculty, Belgrade, Serbia and Montenegro

Purpose: We investigated the effect of extracellular calcium concentration change on rhythmic epileptiform activity induced by nickel and cobalt on Retzius nerve cells of the leech Haemopis sanguisuga. Methods: Intracellular recordings were performed using glass tube microelectrodes filled with 3 M KCl. Rapid changes in membrane potential were followed on Hameg oscilloscope and registered on Hameg thermal printer. Slow changes were recorded on Linseis pen recorder. Nickel and cobalt were administered in dose of 3 mM. Results: Both nickel and cobalt induced rhythmic plateau depolarizations of the membrane potential accompanied with bursts of action potentials. Duration of these plateau depolarizations in standard Ringer solution with added nickel was 7.94G 0.88 s (nZ3), and with added cobalt 3.41G0.35 s (nZ3). In Ringer solution, in which calcium ions were completely omitted the frequency of action potential firing increased, while the duration of plateau depolarizations was 12.35G0.59 s (nZ3) in presence of nickel, and 4.71G0.24 s (nZ3) in presence of cobalt. Conclusions: Lack of calcium ions leads to prolonged duration of plateau depolarizations and increased rate of firing of action potentials during rhythmic epileptiform activity induced by nickel and cobalt ions on Retzius nerve cells of the leech.

Purpose: It has been established that excitatory, and potentially neurotoxic, amino acid b-N-methylamino-L-alanine (L-BMAA) depolarizes Retzius nerve cells of the leech Haemopis sanguisuga. Here, we studied effects of 10K2 M L-BMAA in sodium-free Ringer in order to reveal the ionic mechanism and sodium dependency of that depolarization. Material and methods: We used glass tube microelectrodes filled by 3 M KCl, with resistance of 15–25 MU impelled into the cell. The substance was first applied in standard Ringer solution and then, after recovery, in sodium-free Ringer where sodium ions were completely replaced by Tris(hydroxymethyl) aminomethane–Cl. Results: In standard leech Ringer solution, 10K2 M L-BMAA depolarized the cell membrane potential by 15.36G1.51 mV (nZ 3). In sodium-free Ringer, depolarization was 5.83G1.27 mV (nZ 3), yielding the difference between standard and sodium-free Ringer of 9.53G0.24 mV, which is statistically highly significant (P!0.01, Student’s t test). Conclusions: We conclude that L-BMAA produces significantly smaller effect in sodium-free medium. This indicates that L-BMAA causes membrane depolarization through sodium influx from the extracellular side.

* Tel.: C381 11 3307 588; fax: C381 11 3231 333. E-mail address: [email protected].

1388-2457/$30.00 doi:10.1016/j.clinph.2005.11.011

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Influence of the lipid calf thymic extract on neuromuscular function in mice—Zˇ. Malicˇevic´, M. Ninkovic´, I. Vasiljevic´, M. Jovanovic´, Institute for Medical Research—MMA, Belgrade Purpose: Results of numerous studies were found that thymus disturbs neuromuscular transmission through its secretory products, what is manifested by diminution of muscular function. According to these data, we proposed that lipid extract of calf thymus (LECT) could influence on function of skeletal muscle. Using repetitive nerve stimulation, we examined weather LECT influences on neuromuscular transmission in mice. Material and method: Influence of LECT on neuromuscular function was studied on adult Swiss white mice. In two experimental groups preparation was applied intraperitoneally in a both single dose of 0,1!10K3 g and 0,03!10K3 g, respectively. These doses were estimated according to the content of peptide fraction. Estimation of neuromuscular measurements was made before application of LECT and 6 h after its administration during six consecutive days. Results and Conclusion: Based on original results obtained by electromyographic registration of repetitive stimulation test in mice subjected to single or multiple treatment with LECT in a dose of 0,1/0,03!10K3 g, respectively, it could be concluded that there were no signs of diminish or damage of neuromuscular transmission, as well as function of skeletal muscles. There were no significant differences in results of repetitive stimulation test between front and hind limbs.

Blocking effects of sodium valproate in metaphit’s model of audiogenic seizures in rats— O. Stanojlovic´, D. Hrncˇic´, D. Zˇivanovic´, V. Sˇusˇic´ (Department of Physiology, School of Medicine, University of Belgrade, Belgrade, Serbia and Montenegro) Purpose: The effects of sodium valproate on behavioral and EEG characteristics of convulsions in metaphit (1-(1-(3-isothiocyanatophenyl)-cyclohexyl)-piperidine)—treated rats were studied. Material and methods: Male Wistar rats were i.p. injected with: 1. Saline; 2. metaphit (mp, 10 mg kgK1); 3. metaphit (10 mg kgK1) and 8 h later with VPA (100 mg kgK1) and four. VPA, alone (100 mg kgK1). The rats were exposed to sound stimulation (110G3 dB, 60 s) at hourly intervals and the behavior and EEG were analyzed. Incidence, intensity of seizure and duration of latency were behaviorally assessed. Result: EEG signals in metaphit rats appeared as a sleep-like pattern and spike-wave complexes with increased power spectra. The incidence and intensity of convulsions in metaphit’s group were maximal from 7 to 12 h after metaphit administration. VPA reached a peak of action immediately after the application, was reduced the incidence and intensity of convulsions and prolonged duration of latency within 4 h after the administration. Applied dose did not eliminat the metaphit-provoked EEG signs of epileptiform activity. Conclusion: Valproate reversing metaphit-induced behavioral and motor changes and expressing no effect on electrocortical activity.

Delta sleep-inducing peptide and analogues alleviate severity of metaphit seizures— O. Stanojlovic´, D. Zˇivanovic´, V. Sˇusˇic´ and D. Hrncˇic´(Department of Physiology, School of Medicine, University of Belgrade, Serbia and Montenegro) Purpose: We investigated the potential of DSIP and its analogue DSIPK12 (in position 2 of DSIP molecule substituted by b-alanine) and tetrapeptide analogue, to antagonize metaphit (1(1(3-isothiocyanatophenyl)-cyclohexyl(piperidine) induced generalized, reflex audiogenic seizures in adult male Wistar albino rats. Material and methods: Five groups of adult male Wistar rats were intraperitoneally treated with: 1. saline; 2. metaphit; 3. DSIP; 4. metaphitCDSIP; 5. metaphitCDSIP(1-4) and 6. metaphitC DSIPK12. To examine blocking effects of DSIP and its analogues on fully developed metaphit seizures, the last two groups were injected after 8th audiogenic testing. The rats were stimulated using electric bell (100G3 dB and frequency 5–8 kHz, 60 s) 1 h after metaphit and afterwards at hourly intervals during the experiment. For EEG recordings and power spectra three goldplated screws were implanted into the skull. Results: In metaphit-treated animals, EEGs appeared as polyspikes and spike-wave complexes while the power spectra were increasing. The incidence and severity of metaphit-induced audiogenic seizures reached peak value 7–12 h after the injection. Both DSIP and DSIP analogues significantly increased power spectra of delta waves and decreased incidence of seizures, mean seizure grade and tonic component of metaphit-induced convulsions. Conclusion: Taken together, these results suggest that DSIP and its analogues should be considered as potential antiepileptics.

Early wakefulness after sleep is different from true wakefulness— T. Bojic, V. Asti, T. Cianci, V. Ferrari, Franzini C, Lenzi P, Silvani A, Zoccoli G (Department of Human and General Physiology, University of Bologna, Bologna, Italy) Aim: It was investigated weather early wakefulness after awakening from quiet sleep (QS) differs from early wakefulness after active sleep (AS) and weather both differ from normal wakefulness (W). Material and method: Two Sprague–Dawley rats were implanted with EEG, ECG and EMG electrodes and a catheter in the abdominal aorta for mean arterial pressure (MAP) and heart period (HP) recording. Acoustic stimulation was delivered during W, QS or AS. During a first 30 s interval immediately preceding acoustic stimulation and a second interval ranging from 20 to 50 s after stimulation, MAP and HP were measured, baroreceptive indexes and MAP and HP spectral components were calculated. EEG spectral components, as well as EMG root mean square, were calculated within each interval. Results: Data were collected from 92 awakenings (34 from QS and 58 from AS). Discriminant analysis was performed on W, QS and AS groups in interval I and two discriminant functions were obtained. Discriminant scores were then calculated in W, QS and AS groups within interval II and compared by t test. Significant

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differences (P!0.01) were found between all the considered states. Conclusion: Early wakefulness after QS is different from early wakefulness after AS and both differ from normal wakefulness. This suggests that early wakefulness quality depends on weather awakening occurs from QS or AS.

A pilot study on the relation between post-movement beta event-related synchronization and recovery from ˇ ovicˇkovic´-Sˇternic´, M. stroke— C. Eder, D. Sokic´, N. C Mijajlovic´, M. Savic´, T. Sinkjaer, D.B. Popovic´ (Aalborg University, Denmark and Neurology Institute, Belgrade, Serbia and Montenegro) Purpose: Our study follows the great interest in correlating neurophysiological changes and recovery of motor function. We investigated the dependence of inter-hemispheric PMBS asymmetries on the side of movement in eight post-stroke hemiparetic subjects. Materials and methods: Four subjects were affected on the left side and four on the right side. The movement task was to repeatedly move the hand on a drawing board towards a predetermined target position. Significant reactive beta bands over bipolar central channels were obtained by spectrograms and the lateralization of the filtered PMBS time course was quantified by a signed symmetry index. Results and conclusion: The left- and right-paretic group was distinguished by their symmetry index, but only when their normal hand moved (PZ0.04). A re-test on three recovered subjects suggests a trend of changes in the PMBS lateralization towards the side contralateral to the moving hand, which follows a ’normalization’ of somatotopic movement organization. The presented technique might be an option in evaluation of therapy-induced changes in cortical movement organization. A further study on the relation between PMBS symmetry and recovery of motor functions is planned for a larger population.

Interictal slow activity in focal epilepsies of adulthood— ˇ . Martinovic´ M. Milovanovic´, D. Denic´, N. Buder, Z (Institute of Mental Health, Belgrade, Serbia and Montenegro) Purpose: To determine the significance of interictal slow activity in focal (partial) epilepsies in a sample of adult patients. Method: All consecutive patients with proven focal epilepsy examined during the year 2002 were followed-up for a period of thirty months. The group of patients with interictal slow electroencephalographic (EEG) activity was compared on a number of variables with controls without this finding. The level of statistical significance was set at 0.05. Results: According to demographic characteristics, group of 45 patients with interictal slow activity (mean age 42.0 years, 44.4% males) was comparable with control group of 47 patients (mean age 39.9, 46.8% males). Compared to control group, the group with interictal slow activity showed significantly more common symptomatic etiology, mesiotemporal location of epileptogenic lesion, definite cognitive deficits, and pharmacoresistance. Control

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group showed significantly more common idiopathic etiology, lower number of generalized tonic-clonic seizures and a better seizure control. Temporal interictal rhythmic delta activity (TIRDA) was recorded only in patients with epileptogenic lesion involving mesiotemporal location. Conclusion: focal epilepsies with interictal slow activity contain a cluster of clinical characteristics associated with an unfavourable prognosis of epilepsy. TIRDA has both prognostic and localizatory value.

Effects of antiepileptic drugs on cognitive dysfunctions related to epileptiform EEG discharges in children— Jovic N (Clinic of Paediatric Neurology and Psychiatry, Belgrade, Serbia and Montenegro) Majority of available antiepileptic drugs (AEDs) do not have deleterious effects on cognitive and behavioral development, despite of individual risk for neuro-behevioral toxicity. Cognitive and behavioral profiles of new AEDs remain to be defined. Cognitive impact of both ictal and interictal EEG epileptiform discharges (subtle seizures) is well documented. Relationship between frequent discharges and impairment of language, attention, high information processing and academic underachievement is recognized in some epileptic encephalopathies. Frequent epileptiform abnormalities and overnight bioelectrical status in children with Landau-Kleffner syndrome cause functional ablation of cortical language areas leading to auditory agnosia and speech impairment. Syndrome of electrical status during slow wave sleep is characterized by cognitive deterioration. EEG paroxysmal activity was recorded in almost 30% of children with developmental language disorders. Vigorous early pharmacological intervention (corticosteroids, ethosuximide, lamotrigine, topiramate) is advocated to prevent detrimental development of epileptic encephalopaties dues to (sub)continuous epileptic activity. For many of these conditions there are no established treatment guidelines and AED adjustment is empirical. St Piers Lingfield study showed that lamotrigine improved academic performance and suppressed frequent subtle seizures. Use of lamotrigine resulted in normalization/marked reduction of spikewaves events in 38% of our patients with frequent epileptiform discharges.

Photosensitivity and photosensitive epilepsies—Martiˇ (Institute of Merntal Health, Belgrade, Serbia novic´ Z and Montenegro) Photosensitivity evoked by intermittent light stimulation (ILS) and striped patterns was studied in man and animal models for nearly six decades. Nowadays, a clear distinction is made between laboratory photosensitivity apparent as electroencefalographic (EEG) photoparoxysmal response (PR) and EEG-clinical phenomena of photogenic or visual induced seizures. According to the classification of the International league of Epilepsy, photogenic or visual induced seizures are most commonly of generalized, and rarely of focal type. However, recent studies demonstrate that photosensitivity in man is initiated in parieto-occipital cortex and the ILS evoked epileptogenesis would be a model of reflex partial epilepsy with secondary generalization.

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Pharmacotherapy of photosensitive seizures and epilepsies was thoroughly investigated. In clinical practice, valproate is the drug of choice for all photosensitive seizures in photosensitive epilepsies. Levetiracetam is the most effective of new antiepileptic drugs. Benzodiazepines are second choice agents. Drugs effective in treatment of partial epilepsies (carbamazepine, phenytoin, gabapentin) are of no value in long-term prophylaxis of photosensitive epilepsies. Optical filters are currently investigated as a nonpharmacological method of photogenic or visual induced seizures and epilepsies.

Photosensitivity in Childhood Absence Epilepsy—M. Jovanovic, B. Jocic-Jakubi, D. Stankovic-Jankovic (The Clinic for Mental Health and Neuropsychiatry of the Development Age, Nis, Serbia and Montenegro) Introduction: Photoparoxysmal responses can be defined as epileptiform EEG responses to intermittent photic stimulation (IPS) or various visual patterns. Photoparoxysmal EEG responses may be a coincidental finding but they are often related to the type of the epilepsy. According to some recent papers, photoparoxysmal responses can be found in about 15% of children suffering from absence seizures. For this reason, it was interesting to analyze the presence of the photoparoxysmal reaction in our sample of children with absence seizures. Method: The study was done in 27 children with clinical and EEG diagnosed absences, age range 5–14 years. IPS was used with flicker frequency of 3, 10, 15, 20, 25, 30 Hz. Results: Photoparoxysmal responses without the clinical manifestation of the seizures have been recorded in eight children (29,63%) out of 27. The therapy with valproate and/or ethosuximide that has been associated with plasma concentrations in therapeutic range, photoparoxysmal response, was not elicited in any of our patients. Conclusion: Photoparoxysmal responses in our sample of children with absence epilepsy were found in 29.63% of children, most often with flicker frequency of 15 and 20 Hz.

Electroencephalographic patterns in children with fragile X syndrome—T. Redzek Mudrinic, M. Knezevic Pogancev (Children and Youth Health Care Institute, Novi Sad, Serbia and Montenegro) Introduction: Fragile X syndrome, present in approximately 1: 2000 females and 1:1000–1:10,000 males, accounts for 2–6%of cases of males with mental retardation. Various authors reported a 25–65% incidence of seizures (complex partial seizures or generalized tonic clonic seizures) or epileptiform electroencephalographic (EEG) patterns. The EEG studies show characteristic focal spikes during sleep similar to those seen in benign rolandic epilepsy. Purpose: To present EEG patterns in children with fragile X syndrome. Material and methods: This study was conducted in the Children and Youth Health Care Institute, during a 10 year period (1993–2003). We present data from six boys with fragile X syndrome diagnosed by the peripheral blood karyotype.

Results: The mean age of the first visit due to hyperactivity and developmental delay (IQ!66) was 4 years and 10 months. Only one boy initially had afebrile secondary generalized seizures. Four children had epileptiform EEG patterns—focal with tendency of bilateral spreading anterior centrotemporal maximum and the other had isolated temporal spikes. Conclusions: We confirm the connection and higher incidence of epilepsy and epileptiform EEG patterns in children with fragile X syndrome.

EEG lateralization in temporal lobe epilepsy in relation with psychiatric disorders and neuroimaging—N. Buder ˇ . Martinovic´a,b (aInstitute of Mental Na, S. Malobabic´b, Z Health, Belgrade, Serbia and Montenegro, bMedical Faculty, Belgrade, Serbia and Montenegro) Purpose: To examine the lateralization of EEG changes in patients with temporal lobe epilepsy (TLE) in relation with psychiatric disorders and neuroimaging findings. Material and methods: We have analyzed and compared clinical, EEG and neuroimaging findings of 80 TLE patients with the like findings obtained from a subgroup of 24 patients suffering from extra-temporal focal epilepsy and psychiatric disorders. Results: In respect of the demographic and clinical characteristics there was rather evenness within both the group and the subgroup. Pathological EEG findings—group 73(91,25%), subgroup 24(100%). Lateralization of EEG changes—group: left 5(68, 7%), right 15(18,75%), generalized 3(3,75%), subgroup: left 17(21,25%), right 6(7,5%), generalized 1(1,25%). Pathological neuroimaging findings—group: 45(56,25%), subgroup: 19(79,2%) . In subgroup with pathological neuroimaging findings, the changes in EEG were as follows: left 14(58,3%), right 3(12,5%), generalized 2(8,3%). Conclusions: The ratio of left/right EEG lateralization is 3,7 to 1 in TLE suffering patients; in patients with TLE and psychiatric disorders 2,8 to 1; in patients with TLE, psychiatric disorders and pathological neuroimaging findings 4,6 to 1. The percentage of pathological neuroimaging findings in patients with TLE and psychiatric disorders is greater than in patients with TLE and this difference bears importance when statistics are concerned.

The relation of clozapine dosage with induction of epileptic seizures and Epileptiform abnormalities—D. Stankovic-Jankovic, B.Jocic-Jakubi,M. Jovanovic (Clinic for Mental Health, Nis, Serbia and Montenegro) Method: We have retrospectively analyzed EEG recordings of 61 patients (31 women and 30 men), age range 20–47, treated with clozapine in daily dose range from 100–300 mg. EEG before clozapine was normal. Results: Epileptiform abnormalities were recorded in interictal EEG of 12 (19,67%) patients. Generalised paroxysmal epileptiform discharges was found in eight patients (spike-wave, polyspike-wave complexes), and focal paroxysmal epileptiform discharges of temporo-central location (two left and two right) were found in four patients. The largest number of patients (six) was taking high doses of clozapine (about 300 mg), five patients

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200 mg and only one 100 mg. Myoclonic jerks occurred in one patient taking a 300 mg dose; they were accompanied with bilateral irregular spike-waves, also recorded in interictal period). Conclusions: Clozapine is the antipsychotic medication, which increases the risk of epileptic attacks and epileptiform EEG abnormalities. A high clozapine dose and a rapid achievement of therapeutic dosage increase the liability to clozapine induced epileptiform discharges and seizures. These problems can be avoided by a slow introduction of medication and the use of a small total therapeutic dose of clozapine.

Video and EEG in the differential diagnosis of the paroxysmal changes of behavior and motor activity— Tomovic´ M, Rajsˇic´ N, Sˇundric´ Z, Lekovic´ V. (Department of neurology, MMA, Belgrade) Purpose: The most important and decisive step in the beginning of the corresponding therapy are the distinguishing epileptic seizures from behavior changes in others neuropsychiatric disorders. Material and methods: In the Clinic of neurology in Military medical academy, the video system has been used since the end of 2002 that enables analysis and proper classification of seizures with simultaneous long term EEG. Some abrupt changes of the behavior, prolonged rhythmic movements of legs and pelvis, coital movements, starring, unresponsiveness to the external events and unusual behavior that is different to accepted form of seizures were considered as pseudo epileptic. Results: A total of 380 patients directed to loss of consciousness, epilepsy, behavioral changes and movements were investigated. There were clear epileptic seizures in 37 (66%) and pseudoepileptic in 19 subjects, three of those have had also epilepsy. PE seizures might be as well dramatic as epileptic, often endure longer, have a serial tendency, and do not have postictal neurological signs. Conclusions: Video estimation is much more helpful in hypermotor seizures, whereas there is much more benefit from the EEG when subjects have hypomotor or no motor activity.

Comparison of absolute intensities and amplitudes of EEG rhythms during different phases of task processing in five hearing impaired children—Radicˇevic´ Z., Radicˇevic´ V., Sovilj M. (The Institute for Experimental Phonetics and Speech Pathology, Belgrade, Serbia) Purpose: Establishing the signs of processing the preparation of the speech statement in the maps of power and amplitude of EEG rhythms in hearing impaired children. Material and methods: Five hearing impaired children with developed conventional speech with use of amplificator are recorded during the task of thinking out the speech statement after viewing story in pictures. EEG is recorded in resting state on 12 channels in bipolar outputs and longitudinal montage. All five frequency bands are analyzed. Results: Four children showed: significant increase of powers in theta and delta rhythm in task compared to the state of rest, twice higher concentration of their main powers in theta delta rhythm,

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left-sided presentation of the concentration in delta band, bilateral with left predominance in theta rhythm, and prefrontal or frontal narrower location of both rhythms. Conclusions: Hearing impaired children aged 8–10 processed modally specific preparation in theta rhythm or theta/alpha rhythm bihemispherically in frontopolar and frontal regions responsible for language processing.

Clinical—electroencephalography correlation in children with Rasmussen syndrome—Ruzˇica Kravljanaca, N. Jovicb, B. Marjanovica, M. Djurica, D. Zamurovica (aInstitute for mother and child health of Serbia, bClinic for neurology and psychiatry for children and youth, Belgrade) Purpose: To determine the correlation between clinical and electroencephalographic (EEG) features in children with Rasmussen syndrome (RS). Methods: The investigation included 10 children with RS, aged 4–13 years (mean 6.7C3.1) at the onset of the disease. The clinical and the EEG follow-up period lasted from 6 months to 21 years. Results: The disease was divided into three clinical phases. First phase—different types of seizures were dominant and the EEG showed abnormal background activity (BA) in two patients while epileptic discharges (ED) were evident in seven patients. Second phase—all patients had epilepsia partial continua and neurological deficits. At the end of the follow up period—all patients had abnormal, mostly asymmetrical BA and ED. In the beginning of the disease and at the end of the follow up period (P! 0.05), there was important statistical difference between the frequency of pathological BA and ED. There was no important statistical difference between the frequency and the type of the ED in periods of aggravation of the disease before or after the specific types of treatment. Conclusion: The clinical evaluation of the disease was correlated with EEG from the onset period to the second phase but not with further progression of RS.

Psychological, sleep and autonomic nervous system disturbances as comorbidities in epilepsy—G.KitevaTrencevska (Clinic of Neurology, Skopje, R. Macedonia) Purpose: We evaluated the psychological, sleep and autonomic nervous system disturbances (ANSD) in different epilepsies. Material and methods: A group of 50 patients with psychological disturbances (PD), aged 33 years sd 13 was compared with 40 patients without PD, aged 34 years sd 15. Non-REM sleep EEG after sleep deprivation was analyzed in 52 newly diagnosed idiopathic generalized epilepsy (IGE) patients, aged 24 years SD 9. Results: Regarding PD, there was not a significant difference between the groups, considering seizure/syndrome type, duration, EEG, therapy, except for seizure frequency, P!0,05. Seizure control was important for preventing PD. AED treatment with valproat was indicated in the case of IGE with ANSD. We found brief awakenings in 14 of 46 and shifts from deep towards

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superficial non REM sleep in six of 46 patients after interictal SWD, thus presenting sleep fragmentation and increase of superficial non-REM sleep with consequential daytime sleepiness, fatigue, headache, impaired cognitive functioning. Conclusion: Somatoneurological and psychological comorbidities, being sometimes more prominent than the epilepsy, should be recognized and properly treated to improve the quality of life in people with epilepsy.

Evolution of clinical and EEG features of amygdaloid and hippocampal epilepsy—D. Guberinic´, R. Guberinic´ (General Hospital, Pancˇevo, Serbia and Montenegro) Purpose: Analysis of ictal clinical behavioural manifestations and corresponding EEG recordings of amygdalo-hippocampal epilepsy of right temporal lobe origin. Material and method: Medical history, neurologic examinations and EEG recordings. Results: During the 2 years’ evaluation, clinical features were continously changed over and over. Ictal manifestations were abdominal aura, followed by altered consciousness and verbal automatisms, generalised clonic seizures and head/body turning. The patient became depressive and had disturbances of cognitive functions. Rhythm of alpha frequency predominated in the background EEG activity. Pathological EEG patterns were variable, like localized low-voltage rhythmic activity, rhythm of beta frequency from right fronto-temporal region, then bilateral 1– 2 Hz sharp and slow wave activity over the centro-parietotemporal regions, 2.5–4.5 Hz generalised paroxysms of sharp and slow wave complexes, and focal 1–2 Hz spike-wave paroxysms from the right fronto–central region. Conclusions: Our patient has probably amygdalo-hippocampal epilepsy of cryptogenic etiology. Clinical manifestations were not allways supported by the correspondent EEG and because of that we could not find a distinct epilptogenic focus. Our results confirm the complexity of detecting epileptogenic focus in the case of amygdalo-hippocampal epilepsy.

Efficiency and tolerability of lamotrigine in different types of epilepsy—Zˇ. Radic´, V. Andrejic´, CC Dr ‘Dragisˇa Misˇovic´‘, Belgrade, Serbia and Montenegro Rationale: The efficiency and good torerability of lamotrigine in treating different types of epileptic seizures and refractery epileptic syndromes are clinically established. Thus, lamotrigine could be a good candidate to control epileptic attacks with less side efects in comparison to other antiepileptic drugs. Results: We have analysed the efficacy and tolerability of lamotrigine in patients with idiopathic (60%) and symptomatic epilepsy (40%) as well. Our group of in and out patients (nZ15) comprised 10 females and five males, age range from 21 to 57 years. Seizure types were either grand—mal in 53,3% or several types of epilepsy in 46,7%. Majority of patients were on monotherapy (60%) but in 40% of patients lamotrigine was induced as a second antiepileptic drug. The patients were treated with lamotrigine in doses 250–450 mg per day. Seizure control with lamotrigine was achieved in 13,3% of cases and a significant

seizure reduction in 66,7%. In some patients (20%) lamotrigine was not effective. There were no side effects. Conclusion: Lamotrigine is efficacious antiepileptic drug in wide spectar with good tolerability.

Efficacy of lamotrigine therapy of pharmacoresistant epilepsy related to EEG and neuroimaging—N. Buder, R. Velicˇkovic´, Zˇ. Martinovic´ (Institute of Mental Health, Belgrade, Serbia and Montenegro) Purpose: To assess the efficacy of lamotrigine therapy of patients with pharmacoresistant epilepsy (PRE) in relation to pathological EEG lateralization and abnormal neuroimaging findings. Methods: We have analyzed a group of 22 patients with PRE, evaluated the clinical response on the scale from 0 (inefficacy) to three (seizure-free) and correlated EEG lateralization with neuroimaging findings. Results: A group of 22 patients (12 males), mean age 32 years, was treated with lamotrigine in the average dosage of 174 mg per day, for an average duration of 3 years. The distribution according to the pathological EEG lateralization was even. The average score of therapy efficacy was highest (2.31) in patients with pathological EEG findings in right cerebral hemisphere, and lower in those with pathological EEG findings in left cerebral hemisphere (1.58) or with generalized changes (1.37). The average score of therapy efficacy in patients with abnormal neuroimaging findings was 2.05 being higher (2.17) in case of localized changes than in patients with normal findings (1.83). Conclusion: The differences have not reached statistical significance due to a small sample studied, but the trend of results indicates keeping further track of investigated parameters.

The characteristic of EEG findings and level of neuroticism at patients with symptomatic headaches—S. Tomasˇevic´, D. Filipovic´, N. Naumovic´ (Clinic for medical rehabilitation, Novi Sad, Serbia and Montenegro) Purpose: The patients with degenerative disease of neck part of spinal have polymorph painful and painless symptomatology. Electroencephalogram is functional diagnostic method applied at patients with symptomatic headaches. The aim of the work was identifying characteristic EEG at patients with cervical cephalic syndrome. Material and methods: The study included 33 patients with cervical cephalic syndrome average age at 43.90 years. The patients were multidisciplinary examined and treated at Medical Rehabilitation Clinic, Clinical Center Novi Sad. For all patients, X-ray examination of cervical spine and EEG examination were performed. Results: The most common pathological finding was degenerative changes of cervical spine. 39.39% of patients had normal electroencephalogram, and 36.36% EEG indicated physical tension. 24.24% of patients had non-specific finding. Neuroticism has been diagnosed by test of General Neuroticism and it is present 23 in 80,77% patients with neck pain.

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Conclusions: The results of the research indicate a large amount of neurological disorders and implicate the great need for routine usage of CIN4 test. Psychogenic factor often complicate diagnosis, so the team approach is necessary in diagnostics and treatment of patients with symptomatic headaches.

Epidemiological analysis of epilepsy—Radic´ Zˇ., Andrejic´ V. (CC Dr ‘Dragisˇa Misˇsˇovic´‘, Belgrade, Serbia and Montenegro) Background: Etiologic aspect in epidemiology of epilepsy is important with the aim of better understanding, control and treating of epilepsy. Methods: We have analysed in and out patients with diagnosis of epilepsy during the last 5 years (2000–2005). Results: We have identified a group of 62 patients aged from 21 to70 years, 28 female and 34 males). In our group, 25, 8% had idiopathic and 74,2% symptomatic epilepsy. Among the patients younger than 30, idiopathic epilepsy was found in 38, 3% of them. Posttraumatic epilepsy (PTE) was in 53,8%, infectious diseases of central nervous system (CNS) took part in 7,8% of the patients. In the group of patients aged between 30 and 50, idiopathic epilepsy was in 36,3% cases and symptomatic epilepsy in 63,7%—cerebrovascular diseases 27, 4%, brain tumors 4,6%, PTE 13,7%, infectious diseases of CNS 9%, alcoholism 9%. Among the population between 50 and 65 symptomatic epilepsy was the most common (86,4%)— cerebrovascular diseases 41%, brain tumors 13,7%, PTE 22, 7%, alcoholism 9%. Patients older than 65 had symptomatic epilepsy caused by previous cerebrovascular desease (CVD). Conclusions: Symptomatic epilepsy is the most common with adult people; main etiologic factor for symptomatic epilepsy is CVD.

Magnetic resonance angiography—Tatjana Stosˇic´Opinc´al (Magnetic resonance Centre, Medical University School, Belgrade, Serbia and Montenegro) Conventional angiography is the standard of reference in the diagnosis of neurovascular pathology but has a relatively high complication rate. The use of MRA permits noninvasive evaluation of patients with cerebrovascular disease. We review the current approach to inntracranial and extracranial magnetic resonance angiography (MRA) and its clinical utility and limitations. MRA offers good spatial resolution, it is a reliable diagnostic and followup modality and its findings are often complementing with other diagnostic modalities. In some cases, MRA can even replace conventional angiography in the diagnostic evaluation of carotid oclusive diseases, unruptured aneurysms, dissections, stroke, penetrating trauma to the neck, and dural venous sinus occlusive disease. As a screening procedure, MRA is not yet ideal because of the higher cost compared with ultrasound and the MR units availability.

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Establishing the borders of amygdale and hippocampus using MRI—K. Davidovic´, J. Nikolajevic´, T. Stosˇic´Opinc´al, M. Jovancˇevic´, S. Malobabic´, L. Pusˇkasˇ (Medical Faculty, Belgrade; Centre for magnetic resonance of railway workers, Belgrade, Serbia and Montenegro) Purpose: A lot of disease and disorders (such as Alzheimer disease and epilepsy) are followed by changing of volume of amygdale and hippocampus. We want to show how the borders of these structures are established and in which way our findings differ from the three most used protocols (Szabo, 2001; Rosso, 2004; Mc Carley, 2002). Materials and methods: We examined 10 healthy volunteers on MRI (right-handed, six females and four males, aged between 20 and 25, rotation angle 218), using coronary continual slices (without gap, 1,5 mm thick, in 3D T1 sequence) on MRI Philips 3T machine. Results: Front border of amygdale is within the slice where the optical chiasm and both optical tracts are visible and the back border of amygdale is within the slice where corpora mammillares disappear. Front border of hippocampus is the appearing of mammillary bodies and the back border is the appearing of cerebral aqueduct Sylvie. Conclusions: Every laboratory has its own parameters of volume measuring, so it is almost impossible to compare the data among different scientists.

Emerging role for MRI in assessing fetal CNS abnormalities—N. Cerovac (Medical Faculty, Belgrade, Serbia and Montenegro) Purpose: Fetal magnetic resonance imaging (MRI) is still in its infancy, but it is now the technique of choice when ultrasonography (US) detects fetal CNS abnormalities and further elucidation is required. MRI has transformed the practice of obstetrics and created the discipline of anatomic prenatal diagnosis. Here, we studied the role of MRI after careful US examination in detecting abnormalities of the fetal brain that may alter the diagnosis of fetal prognosis. Material and methods: MRI was done in 25 fetuses with abnormal central nervous system findings by ultrasound. Median gestational age of fetuses during MRI assessment was 25.9 gestational weeks. Imaging was classified as: normal and abnormal. Results: MRI images were normal in seven cases and abnormal in 18 cases. Analyzing abnormal US and MRI images, ventriculomegaly was found in 10 cases, but MR was superior to US in detecting porencephalic cyst (two of them) and brain atrophy (1). Similarly, MRI was superior to US in detecting agenesis of corpus callosum (two cases), arachnoid cyst (1), tuberous sclerosis (2) and parenchymal lesions (3). Conclusion: As technology continues to improve and even more clinical experience is gained the future role for fetal MRI will certainly increase.

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Auditory evoked potentials and brain-stem vascular lesions—O. Sinanovic´ O, B. Raicˇevic´ (University Clinical Center Tuzla, Tuzla, Bosnia and Herzegovina)

TMS contributions to ‘plastic brain’ investigation—TV. Ilic (Clinic of Neurology, Military Medical Academy, Belgrade)

Purpose: The aim of this study was to analyze abnormality of auditory evoked potentials (AEPs) in patients with brain-stem vascular lesions. Subjects and methods: The study included 45 patients with stroke (29 males or 64.44% and 16 females or 35.56%) with mean age of 59.3C/K15.22 years (range 37–80 years). Computer tomography (CT) was done in all patients. EPs were done using disc electrodes placed over the scalp according to International 10– 20 electrodes placement; Auditory stimulus ‘click’ type was used. Results: CT scan showed: ischemic lesion in the brain-stem in 39 (86.66%), hemorrhage in one (2.22%), and in five patients (11.12%) CT findings were normal. AEPs abnormalities were found in 41 (91.12%) patients, and only in four (8.88%) cases finding was normal. The most frequent abnormalities were: reduction of wave V amplitudes and bad morphology of I–V waves (21 or 46.66%), followed by prolongation of wave V latency (18 or 40.0%), absence of wave V (13 or 28.88%), and complete absence of AEPs (7 or 15.55%). Conclusion: Different abnormalities of auditory evoked potentials in brain-stem vascular lesions are common findings in routine clinical neurophysiology testing, and very useful for diagnostics and evaluation of stroke patients.

Over the past decade, animal studies bring to us substantial evidence that the adult cerebral cortex is capable of significant functional plasticity. Neuroimaging and other noninvasive mapping studies in humans address many questions in aim to better understand neural basis of such form of adaptive reorganization. Non-invasive, safe and painless technique of transcranial magnetic stimulation (TMS) is particularly well suited to transfer certain experimental concepts, based on analogies, from the level of cellular physiology to the regional level. The reorganization of cortex following partial sensory deafferentation offers compelling evidence for cortical plasticity. Experimental manipulation based on acute ischemic handdeafferentation-model shows an expansion of representational maps of muscles proximal to the nerve block into the cortical regions that previously controlled the deafferented muscles. It was presumed that this experimental manipulation and the subsequent reduction of intracortical inhibition might unmask existing excitatory horizontal cortical connections. The acquisition of skilled motor behavior represents one of the most powerful stimuli by that reorganizational changes can be driven. Considering the mechanisms of learning-induced cortical plasticity in primary motor cortex, recent experiments demonstrated that a relationship between motor learning and subsequent induction of long-term plasticity—like exists in humans.

Visual evoked potentials in poorly controlled patients with insulin depended diabetes mellitus—Matanovic D, Popovic S (Clinical Center Serbia, Belgrade, Serbia and Montenegro) Purpose: To determine whether acute poorly metabolic control has influence on visual evoked potentials in patients without signs of diabetic retinopathy. Material and methods: We evaluated 61 patients (age 30,4G 8,3 years) with disease duration 5,96G2,88 years, in poor metabolic control (glycemia 9,45G4,95 mmol/l, Hb A1c 10, 65G2,60%) hospitalized on Institute of Endocrinology. Visual evoked potentials (VEP) recorded under basal conditions (monocular and binocular stimulation) showed that P100 latency was significantly increased in these patients (P!0.01), compared to the same patients in the stable metabolic control. Results: The P100 latency was 109,42G15,47 ms in left eye; 108,10G13,61 ms in right eye; and 107, 81G14,95 ms in binocular stimulation. N75-P100 amplitude was similar as in previous diagnostic. Conclusion: The VEP results suggest an early involvement of the nervous conduction in the optic nerve. However, the acute poorly metabolic control had influence on visual evoked potentials recordings in patients with IDDM and without signs of diabetic retinopathy.

Restless legs syndrome (RLS)—S. Kostic, J. Potic, T. Smiljkovic, J. Martinovic, B. Potic, J Malovic, M. Kostic (Clinical Hospital Zvezdara, Belgrade, Serbia and Montenegro) Introduction: RLS is a sensomotor disorder, characterized by an urge to move the extremities, mostly the legs. Methods: We analyzed a group of patients, which considered the criteria of the International RLS Study Group. All of patients had neurological, electromyoneurographic examinations and biochemical analyses of blood. They were tested with Johns Hopkins’s Restless Legs Severity Scale and with RLS Quality of Life Questionnaire. Results: Among 65 patients, the average age of 46.2 years, three (4.66%) patients had primary type of RLS and the other 62 (95.34%) patients had secondary type of RLS. Secondary RLS occurs in patients with chronic uraemia: 22 (33%), diabetes mellitus: 17 (26%), group of patients which were treated with neuroleptic and/or antidepressant drugs: 12 (18%), group of patients with anaemia: four (6%), two patients with thyroidal dysfunctions, one patient with colon irritabile. Clinical and EMNG examinations showed that 34 patients (52,3%) had signs of polyneuropathy. The iron deficiency and serum ferritin concentrates were lower in 30 (46.15%) of patients.

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Conclusions: The most important connections were between the recognition the polyneuropathy, the iron and ferritin blood deficiency and signs of RLS. While RLS remains a subjective disorder, neurophysiologic measures have been important, especially for assessment.

Stimulation single fibre EMG (SFEMG) in the diagnosis of myasthenia gravis—J. Trontelj (Institute of Clinical Neurophysiology, Ljubljana, Slovenia) Purpose: Jitter measurement from single muscle fibres in situ as used in the diagnosis of myasthenia gravis is described. Methods: The original SFEMG technique was modified so that the individual muscle fibres from which recordings are made are activated with axonal microstimulation (rectangular pulses of 0.01–0.04 ms, 1.0–10 mA, 0.5–50 Hz), applied intra- or extramuscularly. Certain pitfalls, in particular threshold stimulation, have to be carefully avoided. The latency variation of consecutive responses (jitter) is a measure of safety margin of neuromuscular transmission. Normal upper value (expressed as mean of consecutive latency differences, MCD, for a sample of 30 motor end plates) ranges between 20 and 26 ms for different muscles, and does not increase with advanced age. Results: In a series of 52 consecutive myasthenic patients, which included 11 with ocular form, diagnostic sensitivity of the technique was 98% when only one muscle was examined. Conclusions: SFEMG with axonal microstimulation is a highly sensitive technique for diagnosing disorders of neuromuscular transmission. When patients with proper clinical symptoms and signs are included, also specificity is similarly high.

Clinical neurophysiological tests in assessment of lower sacral segments—Vodusˇek D.B. (Division of Neurology, University Medical Centre, Ljubljana, Slovenia) Purpose: Clinical neurophysiologal methods have been introduced to test motor and sensory parts of the somatic and autonomic nervous system involved in control of sacral functions, pelvic floor muscles and sensory innervation of perineum and pelvic organs. The aim of the presentation is to review available tests. Method: A literature review including research of the Ljubljana laboratory is provided. Results: The whole gamut of EMG, conduction, and autonomic tests is applicable for use in sacral dysfunction. Clinical application has revealed a new syndrome of myogenic urethral sphincter hyperactivity (Fowler syndrome), neurogenic contribution to ‘genuine’ stress urinary and anal incontinence, and, particularly, lesions due to trauma and dysraphism. Conclusion: Kinesiological sphincter EMG recording (to document activity patterns) and concentric needle EMG with sacral reflex recording (to diagnose lesions within the peripheral lower sacral reflex arc) is recommended in selected patients. Clinical neurophysiological tests remain interesting for research in patients with neurogenic uroanogenital dysfunction.

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Familiar Friedreich’s ataxia—electroneurography profile—G. Vlahovica, S. Todorovic´b, V. Milic´-Rasˇic´b, D. Zamurovic´a (Mother and Child Health Care Institute, Belgrade, Serbia and Montenegro, Clinic for Child Neurology and Psychiatry, Belgrade, Serbia and Montenegro) Purpose: Friedreich’s ataxia (FRDA) is an autosomal-recessive neurodegenerative disorders caused by expansion of a GAA triplet located within the first intron of the frataxin gene on chromosome 9q13. One of the clinical manifestations of FRDA is axonal sensory neuropathy caused by the loss of large myelinated fibers in peripheral nerves. Material and methods: During the 10 years period we treated 15 patients whose diagnosis was confirmed by genetic analysis. Electroneurography (ENG) was performed in all patients. Results: Three patients were cousins (brother 19 years and twin sisters 17 year-old), which allowed us to investigate clinical and neurophysiological expression of the FRDA within the family. All of them had clinical signs of neuropathy. The brother (wheelchaired) had the most severe disease. Sensory conduction studies showed uniformly absent or decreased SNAP with normal SCV. Motor conduction studies showed variability: brother had axonal neuropathy of lower limbs, twins had good amplitude of CMAP and slowed MCV below 35 m/s. Conclusion: All of findings were consist with the axonal sensory neuropathy. There was diversity of disease progression and ENG (motor) findings within the family. We plan to correlate clinical and neurophysiological findings and number of trinucleotide repeats.

The correlation of tibial nerve sensory conduction velocities values, somatosensory evoked potentials latencies values and values of thresholds determined by tactile circumferential discriminator in diabetics—Peric´ Z., Antic´ S., Stojanovic´ I. (Medical Faculty and Clinical Centre, Nis, Serbia and Montenegro) Purpose: The relationship between sensory conduction velocities (SCV) values of tibial nerve (TN), latencies of somatosensory evoked potentials (SEPs) values and two point’s threshold discrimination (TPTD) values is not precisely defined in diabetics. Material and methods: We examined 60 diabetics, average age 45,67G8,13 years. TPTD was determined in modified way by tactile circumferential discriminator. SCV (by antidromic technique) and SEPs were determined after electrical stimulation of TN at ankle. We analyzed central conduction time (CCT) and spinal conduction time (SCT) values. Linear correlation study was performed. Results: In 60% (36/60) diabetics, the reduced values of SCV TN were determined. Pathological values of N37 and P40 latencies were registered in 23,33% (14/60) analyzed patients and prolonged CCT and SCT in 8,33% (5/60) diabetics. Pathological values of TPTD were registered in 51,67% (31/60) diabetics. We registered the statistical significant negative correlation (P!0,05) between the values of TPTD and SCV TN, but not between TPTD and SEPs latencies values (PO0,05). Conclusions: The results indicate that the determination of TPTD is useful for the detection of neuropathy, but it is less sensitive

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than SCV TN for early diagnosis of diabetic neuropathy. TPTD is not correlated with central SEPs abnormalities in diabetics.

Electrophysiological evaluation of axonopathies—Peric´ Z. (Medical Faculty and Clinical Centre, Nis, Serbia and Montenegro) We analyzed methods and described characteristics of electrophysiological parameters and clinical manifestations in evaluating axonopathies. We presented the function examination of motor and/or sensory and/or autonomic axons of peripheral nerves various diameters, especially in ‘small fibre’ and ‘large fibre’ neuropathies, on the basis of data from literature and our own experience. Neuropathy in amyloidosis, Tangier and Fabry disease, some cases at diabetes mellitus, lupus erythematosus, HIV infection and also some toxic, sensory and autonomic hereditary neuropathy form ‘small fibre’ neuropathy (SFN) group with burning pain in legs. In this patients the results of conventional electroneurographic (ENG) studies are within normal range and special ENG techniques have to be applied. Sympathetic skin response and quantitative autonomic tests can detect autonomic axons dysfunction with good sensitivity and specificity, but great variability. Quantitative sensory tests that determinate the thresholds of different sensory modalities are very useful in cases with SFN, but some inorganic factors and simulation can have some influence on the results. In this case, the examination of epidermal nerve fibres density after skin biopsy of distal leg region can confirm the diagnosis of SFN.

Diagnostic importance of the F ratio in patients with radiculopathies—B. Cvetkovic´ (Military Hospital, Nis, Serbia and Montenegro) Introduction: F wave is a late answer of muscles. Latency, amplitude, duration and shape have been conventionally tested. Kimura’s formula makes it possible to define the quotient of the latence of F response based on Fo and M response. Thus, the structural state of peripheral motor neuron has been examined more precisely. F ratio directly compares the conduction time from the stimulus site with the latency M response. Aim: To examine diagnostic sensitivity of F ratio in patients with radiculopathies. Material and method: We have analysed 25 patients with radiculopathy and 25 neurologically healthy persons aged 20–50 years. Beside electromyography evaluation, motor nerve conduction we were determining minimal latency of F wave in peroneus and tibial nerve after series of 10 stimuli. We used Kimura’s formula FkZ(FKMK1)/2M to calculate F ratio. The statistically significant differences between registered parameters in the group of patients with radiculopathies and the control group was determined by student t test. Results: F ratio showed significant difference (P%0,01) between the control group and the group of patients with radiculopathies. Conclusion: The results lead to conclusion that defining of F ratio is a sensitive method in diagnosing patients with radiculopathies.

Lesions of peroneal nerve in children and adolescents as a sign of hereditary neuropathy with liability to pressure palsies—J. Mladenovc´, V. Milic´ Rasˇic´, M. Keckarevc´, V. Dobricˇic´, M. Sˇalic´ (Clinic for Neurology and Psychiatry for Children and Adolescents, Belgrade, Serbia and Montenegro) Objective: To determine proportion of cases with hereditary neuropathy with liability to pressure palsies in patients with acute lesion of peroneal nerve, registered at our Clinic. Materials and Method: Within EMNG Protocols of the Clinic, we analysed extent of mononeuropathy of peroneal nerve isolated between November 1994 and December 2004. Within this group, EMNG test was carried out on Premier apparatus (Medelec) Protocol of 1987. Results: 34 patients aged up to19 years underwent the EMNG examination. Test of polysegmental peroneal nerve conduction with complete ENG study of sensitive and motor conduction velocities on extremities and needle EMG in relevant muscles were performed. Subclinical polyneuropathy was registered in four patients from three families. All of them had demyelinating type of polyneuropathy. One patient had relapse of mononeuropathic palsy and the others had members of their families with the same entity. In two patients from two families were performed molecular genetic analyses and confirmed deletion of PMP22 gene in chromosome 17p11.2-12. Conclusion: HNPP was present in six percent of the analysed patients with acute unilateral peroneal paralysis. This suggests the need of extensive EMNG examination of each child with clinical finding of isolated peroneal mononeuropathy of unknown etiology.

Neurophysiological testing in congenital myasthenic syndromes—V. Milic Rasica, S Todorovica, H. Lochmullerb (Clinic for Child Neurology and Psychiatry, Belgrade, Serbia and Montenegro, Friedrich-Baur Institut, Munchen, Germany) Purpose: To analyse repetitive stimulation test (RST) in patients with genetically confirmed congenital myasthenic syndromes (CMS). Material and methods: Twelve patients from eight families were diagnosed in Belgrade as CMS. Molecular genetic study was done in Munich. RST with low frequency stimulation (2–3 Hz) was performed on one or two nerve-muscle system. RST after maximal contraction (10 s and 1 min) was not done regularly in all patients. Results: Postsynaptic CMS was diagnosed in the most of the patients: homozygous 31267delG mutation in CHRNE gene in eight patients; homozygous N88K and R164C in RAPSN gene in three patients. Synaptic, two heterozygous mutations in COLQ gene (109delC and Q442del): one patient. Decrement of CMAP (O10%) was detected in 9/12 patients and was independent of the molecular defect site (synaptic or postsynaptic) or type of mutation. Conclusion: RST was not enough for differentiating type of neuro-muscular disorders in our patients. Absence of decrement was not excluding criteria for CMS. RST only in combination with phenotype, tensilon/neostigmine test, anti AchR-antibody test, ENMG, molecular genetic test were enough for diagnosis of CMS.

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Retrospective view to refferals in EMG diagnostics in Macedonia—M. Marku, D. Nikodijevic-Kedeva, E. Cvetkovska, A. Taravari (Neurology Clinic, University Hospital, Skopje, Macedonia)

Repetitive stimulation test in children with neuromuscular transmission disorder—S. Savic´, V. Milic´ Rasˇic´, S. Todorovic´ (Clinic of Neuropsychiatry for Children, Belgrade, Serbia and Montenegro)

Purpose: Clinical neurophysiology departments have observed a number of examinees referred to electromyography (EMG) laboratory without symptoms or signs of the peripheral nervous system disorder or with the wrong and inadequate referral diagnosis. The aim of the present study was to check the appropriateness of referrals to EMG, look for reasons for these problems and suggest possible improvement. Methods: Four hundred and one patients in the first 4 month of 2004 where analyzed. Data on examinees, referral doctors, diagnoses, clinical symptoms and signs, and electrodiagnostic findings were evaluated using statistical parameters. Results: Neurological diagnosis was provided in most of the referrals. Referral diagnosis was not noted in 18 patients (3,66%) while 38 patients (7,73%). with a diagnosis showed normal result: Half of the patients (49, 69%) had radicular and compressive neuropathies (CTS). Another half included: myopathies, myasthenia gravis, polyradiculopathies and other mononeuropathies (facialis, ulnaris). The patients are recruited to our laboratory from neurologists and other specialists (in orthopedics, ear, nose and throat surgeons, neurosurgeons, pediatricians). Conclusions: Difficulties often occur because (1) the first contact with a specialist is EMG evaluation, (2) large turnover of patients per day, (3) patient without working diagnosis. Eventual identified solutions will be subject of further work.

Purpose: To establish the diagnostic value of repetitive stimulation test (RST) in children with neuromuscular transmission disorder. Material and methods: RST was studied in children diagnosed as juvenile and congenital myasthenia gravis (JMG, CMG) based on clinical symptoms and signs, pharmacological, neurophysiological, serological and molecular-genetic analysis. The test was performed on one or more systems (nerve-muscle) and decremental response at lower rates of stimulation greater then 10% was considered as significant. Results: Test was positive in six of nine patients with CMG (66, 6%) and in 17 of 22 patients with JMG (77,2%). There were no significant differences considering the type of disease (genetic vs. autoimmune). Only one patient diagnosed as synaptic CMG (AChE deficiency) did not have specific repetitive CMAP to single nerve stimuli. Conclusions: RST was specific, but less sensitive in children with neuromuscular transmission disorder compared to adults (up to 95% positive results on RST). It cannot be used to distinguish autoimmune from genetic MG. Using lower number of systems (nerve-muscle) is probably one of the main reasons for lower sensitivity on RST in children.

Suprascapular nerve lesion in volleyball players—case report—A. Delic, J. Samu, R. Milanovic (Department of Neurology, City Hospital of Sombor, Serbia and Montenegro) We tested eletromyographically two 20-year-old volleyball players from Apatin volleyball team with painless right infraspinatus hypotrophy. Neurological examination disclosed infraspinatus hypotrophy and weakness of external rotation of the arm at the shoulder. Electromyographically, there were fibrillation potentials and positive sharp waves at rest, reduced interference pattern on voluntary activity and prolongation of motor terminal latency in the nerve conduction measurements. Normal electromyographic finding and normal motor terminal latency were found in supraspinatus and in all other tested shoulder muscles on both sides, too. Suprasccapular nerve can be damaged at the supraspinal and spinoglenoid notch. Electromyographic data showed a lesion in spinoglenoid notch in both of tested patients. Suprascapular nerve neuropathy is not common and nerve can be damaged by fractures, callus, stab wounds, shoulder dislocation, or can be a part of a brachial plexitis (Parsonage–Turner syndrome), and mononeuritis multiplex in infectious mononucleosis. It is sometimes related to severe exercise in high-level volleyball or basketball players. We suggest that in both patients right muscle is involved, which is due to excessive engagement of right arm in the act of serving. Physical therapy is method of choice, but in more severe cases neurosurgical operation is indicated.

Developmental dysphasia—speech-language and intellectual potentials—N. Cabarkapa, S. Punisic, M. Subotic (Institute for Experimental Phonetics and Speech Pathology, Belgrade, Serbia and Montenegro) Purpose: To establish the relation of intellectual and speechlanguage abilities in children with developmental dysphasia. Methodology: Sample consisted of 43 children with developmental dysphasia (E group) and 53 children with normal speechlanguage development (C group). Test Material: Wechsler Intelligence Scale for Children— WISC, test for examination of speech development—definition test. Results: WISC results indicated: (1) (a) non-verbal (manipulative) intellectual abilities of dysphasic children are normally developed i.e. the level of their development corresponds to the average level of children with normal speech-language development; (b) verbal intellectual abilities of dysphasic children are significantly less developed in comparison to the children from the control group; (c) children with developmental dysphasia had significantly lower overall achievement in the intelligence test. (2) Children with developmental dysphasia also showed significantly lower achievement in the definition test when compared to children with normal speech-language development. Conclusions: Children with developmental dysphasia had a better achievement on manipulative than on verbal part of the test of intelligence, and they had a lower achievement in comparison with children from control group generally. Their language abilities were also lower than in control group.

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Emotional disorders and stroke—S. Tomasˇevic´, D. Filipovic´, N. Naumovic´ (Clinic for medical rehabilitation, Novi Sad, Serbia and Montenegro) Purpose: The emotional distress present in patients after the stroke may compromise rehabilitation process. The aim of this paper was to determine the existence of emotional distress of patients after the stroke. Material and methods: The study included 60 patients after suffered ischemic stroke. The motor and cognitive rehabilitation

was evaluated using Barthel index, mini mental test and test of reaction time. Concerning affective disorders, the patients were grouped in four categories. Results: Emotional disorders after the stroke are very common (depression 40%, emotional lability 27%, indifference reaction 6%) and mostly present in women. The presence of emotional disorder does not differ significantly comparing the lateralization of lesion. The intensity of disorder rises with its severity. Conclusion: The great frequency of emotional disorders after the stroke emphasizes the importance of their detection.