- Email: [email protected]
ID 102 – Moscow’s 15 years of experience in mobile neurophysiologic assessment
Abstracts / Clinical Neurophysiology 127 (2016) e18–e132
not change significantly in myopathy and healthy controls, but increase in neuropathy. doi:10.1016/j.clinph.2015.11.200
ID 424 – Laser evoked potentials habituation and central sensitization symptoms in childhood migraine—E. Vecchio a, V. Sciruicchio b, K. Ricci a, A. Montemurno a, F. Gentile b, M.G. Foschino Barbaro c, M. Simeoni b, M. Goffredo c, Marina de Tommaso a (a Basic Medical, Neuroscience and Sensory System Department, Bari Aldo Moro University, Bari, Italy, b Pediatric Neurology Division, Bari Policlinico General Hospital, Bari, Italy, c Psychological Pediatric Service, Bari Policlinico General Hospital, Bari, Italy) Objectives: Few studies dealt with central sensitization symptoms and pain processing in childhood migraine. Our aims were to examine pain sensitivity and evoked responses by CO2 laser stimuli (LEPs) including habituation in migraine children compared to controls, and to correlate LEPs features to signs of central sensitization Methods: Thirty five 8–15 years aged migraine without aura patients were evaluated during the inter-critical phase and compared to 17 controls. LEPs were analyzed and main features correlated with clinical symptoms including allodynia and pericranial tenderness. Results: Laser pain threshold was lower in migraine children and the N2P2 vertex complex amplitude was increased. Furthermore LEPs vertex waves habituation showed a clearly tendency toward progressive amplitude enhancement in migraine. Acute allodynia and inter-critical pericranial tenderness correlated with trigeminal LEPs features and in particular abnormal habituation pattern. Discussion: Abnormalities of pain processing and symptoms of central sensitization seem to characterize migraine children. Conclusions: Reduced habituation and progressive amplification of cortical responses under laser stimuli, indicate an overactive nociceptive system at the onset of migraine, which may subtend allodynia and pericranial tenderness. Key message: Future trials may aid to early individuation of clinical phenotypes with tendency to chronic form development, worthy of a timely therapeutic approach. doi:10.1016/j.clinph.2015.11.201
PS-01-04 Case reports
e61
abductor pollicis brevis muscle bilaterally. Median nerve motor conduction studies recorded from APB muscles obtained by stimulating the nerve at the wrist and elbow showed responses with very low amplitude bilaterally. Needle electromyography of bilateral abductor pollicis brevis and abductor digiti minimi muscles are found as normal. Conclusion: Ulnar to median anastomosis in the palm should be kept in mind in patient with unexpected electrophysiological results. If the hand muscles are clinically intact but electrophysiological examination shows a severe median nerve lesion, RCA should be suspected. doi:10.1016/j.clinph.2015.11.202
ID 79 – The usefulness of miotatic electronic reflex (T-reflex) in early stages of Guillain Barre syndrome. A case report— S. Alvarez-Paradelo a, A. Garcia a, M.J. Sedano b, J. Berciano b (a Service of Clinical Neurophysiology, University Hospital ‘‘Marqués de Valdecilla”, Santander, Spain, b Service of Neurology, University Hospital ‘‘Marqués de Valdecilla”, Santander, Spain) Objective: Guillain-Barré Syndrome (GBS) diagnosis in its early stages remains a clinical challenge and thus new diagnostic techniques need to be incorporated. The aim of this work is to evaluate the usefulness of miotatic electronic reflex (T-reflex) in initial phases of GBS. Methods: A 46-year-old woman was admitted with 7 days of distal paresthesias and intense interscapular pain. Serial electrodiagnostic studies (EDX) on 7th & 33rd day following clinical onset included motor and sensory nerve conduction, somatosensory evoked potentials (SEP) and T-reflex. Results: First study showed minimal abnormalities in proximal motor nerve conduction (appearance of A waves and inconsistent F waves) and abolition of Achilles T-reflex bilaterally. Central and peripheral sensory nerve studies were normal. Second study (3 weeks after immunoglobulin treatment) showed disappearance of abnormalities detected in proximal motor nerve conduction and ‘‘ad integrum” recovery of Achilles T-reflex. Conclusions: T-reflex provides a complete study of the miotatic reflex including 1A sensory fibers unexplored by conventional EDX. Therefore, this test can contribute to GBS diagnosis in its early stages and, as in this case, suggests the presence of dorsal roots conduction block. Thus, it would be desirable to incorporate T-reflex in GBS studies. doi:10.1016/j.clinph.2015.11.203
ID 21 – Riche–Cannieu anastomosis: A case report—E. Gozke, R. Gurer, N. Gurbuzer, N. Dortcan (FSM Teaching and Research Hospital, Department of Neurology, Istanbul, Turkey)
Objective: Riche–Cannieu anastomosis (RCA) is a rare type of anomalous innervation. It is characterized as innervation of medial and lateral part of palm involving the deep branch of the ulnar nerve crossover to the recurrent branch of the median nerve in the hand. Methods: A 44 years old woman who has numbness and pain her hands evaluated by nerve conduction studies and needle electromyography. Results: In neurological examination, there was no wasting or weakness of the hand muscles, nor sensory impairment. Nerve conduction studies showed dual innervation (mainly ulnar nerve) of
ID 102 – Moscow’s 15 years of experience in mobile neurophysiologic assessment—I.D. Stulin b, M.V. Sinkin a, D.S. Solonskiy b, R. S. Musin b, A.V. Kasheev a, A.O. Mnushkin b, L.A. Savin b, M.A. Bolotnov c (a Neurodiagnostic, Municipal Hospital #24, Moscow, Russia, b Neurology, Moscow State University of Medicine and Dentistry, Moscow, Russia, c Neurodiagnostic, Municipal Hospital #13, Moscow, Russia) Background: One of important factor in comatose patient assessment is express neurophysiologic evaluation. Other important issue for developing countries is lack of qualified neurophysiologists and technical equipment.
e62
Abstracts / Clinical Neurophysiology 127 (2016) e18–e132
Materials: Moscow hospitals collaborated efforts to create a highly specialized mobile neurodiagnostic team (MNT) in 1995. It is staffed with six clinical neurophysiologists, one of whom is on call around the clock. In cases of deep coma patients (GCS < 5), a team member capable of performing clinical evaluations, EEG/EVP, TCD, duplex, can be dispatched to any hospital in Moscow in the equipped van, which carries a portable EEG/EVP/Myography device, ultrasound scanner. In cases of suspected brain death (BD), the MNT experts also take part in clinical consultations Results: More than 4500 critically ill patients have been examined by MNT since 1995. Most patients suffered from stroke and SAH (68%) or brain trauma (28%). Tumor and coma due to cardiac arrest (3% and 1%). MNT specialists took part in BD consultations in more than 600 cases. Conclusion: In large cities, a highly professional mobile group, able to make clinical examinations and neurophysiological assessments, can improve the quality of neurocritical care without tremendous additional material costs, can increase the accuracy of BD diagnostics by offering more specialized and specific confirmation tests. doi:10.1016/j.clinph.2015.11.204
ID 140 – Left-side asymmetry in cortical and spinal inhibitory circuits in stiff-person syndrome: A case report—V. Bocek, B. Cvickova, T. Peisker, I. Stetkarova (Department of Neurology, Charles University, Third Faculty of Medicine, Charles University in Prague and Faculty Hospital Kralovske Vinohrady, Czech Republic) Objective: Stiff-person syndrome (SPS) is an autoimmune disease characterized by progressive rigidity and generalized muscle stiffness caused by loss of GABA-ergic inhibition. Diffuse impairment of the GABA-system can be observed by neurophysiological methods. We investigated intracortical and spinal inhibition and correlate these findings with clinical status. Methods: Fifty-one years old male with a two years history of stiffness and muscle spasms was investigated in our department. Subsequently, we performed EMG, paired TMS and cortical (CoSP) and spinal (CSP) silent periods. Results: The patient had 50 times higher serum level of anti-GAD. He suffered from severe lumbar hyperlodosis, hypertrophy of axial muscles, and slightly asymmetrical generalized stiffness more pronounced on the left extremities. EMG discovered continuous involuntary muscle activity. Intracortical short-time inhibition (ICSI) after TMS stimulation was abnormal while stimulated both hemisphere and was more pronounced from the left APB muscle. CoSP and CSP were both abnormally shortened with more shortening when recorded from the left side. Conclusion: Our findings confirmed loss of GABA-ergic inhibition in SPS. Involvement of both GABA-A and GABA-B inhibitory circuit systems are present with makeable left-side asymmetry corresponding to clinical status. Supported by PRVOUK P34, IGA-NT 13693, 12282. doi:10.1016/j.clinph.2015.11.205
ID 159 – Madelung’s disease. A case report—N. Ausín Morales a, I. Lambarri San Martín a, J. Barcena Llona b, A. Jauregui Barrutia b, A. Martínez Zuluaga a, T. Vicario Elorduy a, I. Yurrebaso Santa María a (a Department of Clinical Neurophysiology, Cruces University Hospital, Barakaldo, Basque Country, Spain, b Department of Neurology, Cruces University Hospital, Barakaldo, Basque Country, Spain) Objective: Madelung’s disease or multiple symmetric lipomatosis (MSL) is characterized by accumulation of unencapsulated fat, generally located symmetrically in the cervical region and back. Peripheral neuropathy is a common finding as well as the association with alcoholism, hepatopathy and glucose intolerance. Pathogenesis is unknown. Methods: The authors present a case of 44 year old ex-alcoholic man with a 4 year history of multiple cervical lipomas being diagnosed of MSL. He developed symmetrical pain and weakness in lower limbs. Peripheral neuropathy was suspected based on distal amyotrophy and bilateral pes cavus deformities. Distal legs were thin with inverted-champagne bottle appearance. The study was based on radiological study and electrodiagnostic examination with electroneurography, needle electromyography and somatosensory evoked potentials. Result: The electromioneurography study showed an intense sensorimotor polyneuropathy with a demyelinating and axonal component and signs of cervical polyradiculopathy. The cervical MRI showed cervical stenosis without significant cord compression. Conclusion: MSL is a rare condition associated with alcoholism and high prevalence of peripheral neuropathy. Based on the neurophysiological examination and the clinical picture our patient presents a polyneuropathy caused by the toxic effect of the alcohol and with features of the hereditary motor and sensory neuropathy. Key message: Madelung’s disease, peripheral neuropathy. doi:10.1016/j.clinph.2015.11.206
ID 199 – Demographic and electrophysiological pattern in Chronic Inflammatory Demyelinating polyradiculoneuropathy among Iranian patients referred to Iran University of Medical Sciences—Bahram Haghi Ashtiani, Babak Zamani, Maryam Saeidi, Mostafa Almasi (Neurology, Electrodiagnostic Ward, Iran University of Medical Sciences, Iran) Objectives: There are four basic electrodiagnostic parameters in Chronic Inflammatory Demyelinating polyneuropathy (CIDP): (1) reduced motor conduction velocity (NCV); (2) motor conduction block or abnormal temporal dispersion; (3) prolonged motor distal latency (DL); and (4) prolonged minimal F-wave latency or absent F waves. Methods: We retrospectively reviewed the medical records of patients with the clinical diagnosis of CIDP in IRAN university hospitals in 2014 on the basis of a progressive or relapsing polyradiculoneuropathy developing over at least 2 months. Electrophysiological studies were performed with standard surface stimulation and recording techniques. The amplitude, the area under the curve (AREA), and the duration (DUR) of the negative peak of the compound muscle action potential (CMAP) were determined as well as NCV, and DL from the Median, Ulnar, Tibial, and Peroneal nerves in both side.
not change significantly in myopathy and healthy controls, but increase in neuropathy. doi:10.1016/j.clinph.2015.11.200
ID 424 – Laser evoked potentials habituation and central sensitization symptoms in childhood migraine—E. Vecchio a, V. Sciruicchio b, K. Ricci a, A. Montemurno a, F. Gentile b, M.G. Foschino Barbaro c, M. Simeoni b, M. Goffredo c, Marina de Tommaso a (a Basic Medical, Neuroscience and Sensory System Department, Bari Aldo Moro University, Bari, Italy, b Pediatric Neurology Division, Bari Policlinico General Hospital, Bari, Italy, c Psychological Pediatric Service, Bari Policlinico General Hospital, Bari, Italy) Objectives: Few studies dealt with central sensitization symptoms and pain processing in childhood migraine. Our aims were to examine pain sensitivity and evoked responses by CO2 laser stimuli (LEPs) including habituation in migraine children compared to controls, and to correlate LEPs features to signs of central sensitization Methods: Thirty five 8–15 years aged migraine without aura patients were evaluated during the inter-critical phase and compared to 17 controls. LEPs were analyzed and main features correlated with clinical symptoms including allodynia and pericranial tenderness. Results: Laser pain threshold was lower in migraine children and the N2P2 vertex complex amplitude was increased. Furthermore LEPs vertex waves habituation showed a clearly tendency toward progressive amplitude enhancement in migraine. Acute allodynia and inter-critical pericranial tenderness correlated with trigeminal LEPs features and in particular abnormal habituation pattern. Discussion: Abnormalities of pain processing and symptoms of central sensitization seem to characterize migraine children. Conclusions: Reduced habituation and progressive amplification of cortical responses under laser stimuli, indicate an overactive nociceptive system at the onset of migraine, which may subtend allodynia and pericranial tenderness. Key message: Future trials may aid to early individuation of clinical phenotypes with tendency to chronic form development, worthy of a timely therapeutic approach. doi:10.1016/j.clinph.2015.11.201
PS-01-04 Case reports
e61
abductor pollicis brevis muscle bilaterally. Median nerve motor conduction studies recorded from APB muscles obtained by stimulating the nerve at the wrist and elbow showed responses with very low amplitude bilaterally. Needle electromyography of bilateral abductor pollicis brevis and abductor digiti minimi muscles are found as normal. Conclusion: Ulnar to median anastomosis in the palm should be kept in mind in patient with unexpected electrophysiological results. If the hand muscles are clinically intact but electrophysiological examination shows a severe median nerve lesion, RCA should be suspected. doi:10.1016/j.clinph.2015.11.202
ID 79 – The usefulness of miotatic electronic reflex (T-reflex) in early stages of Guillain Barre syndrome. A case report— S. Alvarez-Paradelo a, A. Garcia a, M.J. Sedano b, J. Berciano b (a Service of Clinical Neurophysiology, University Hospital ‘‘Marqués de Valdecilla”, Santander, Spain, b Service of Neurology, University Hospital ‘‘Marqués de Valdecilla”, Santander, Spain) Objective: Guillain-Barré Syndrome (GBS) diagnosis in its early stages remains a clinical challenge and thus new diagnostic techniques need to be incorporated. The aim of this work is to evaluate the usefulness of miotatic electronic reflex (T-reflex) in initial phases of GBS. Methods: A 46-year-old woman was admitted with 7 days of distal paresthesias and intense interscapular pain. Serial electrodiagnostic studies (EDX) on 7th & 33rd day following clinical onset included motor and sensory nerve conduction, somatosensory evoked potentials (SEP) and T-reflex. Results: First study showed minimal abnormalities in proximal motor nerve conduction (appearance of A waves and inconsistent F waves) and abolition of Achilles T-reflex bilaterally. Central and peripheral sensory nerve studies were normal. Second study (3 weeks after immunoglobulin treatment) showed disappearance of abnormalities detected in proximal motor nerve conduction and ‘‘ad integrum” recovery of Achilles T-reflex. Conclusions: T-reflex provides a complete study of the miotatic reflex including 1A sensory fibers unexplored by conventional EDX. Therefore, this test can contribute to GBS diagnosis in its early stages and, as in this case, suggests the presence of dorsal roots conduction block. Thus, it would be desirable to incorporate T-reflex in GBS studies. doi:10.1016/j.clinph.2015.11.203
ID 21 – Riche–Cannieu anastomosis: A case report—E. Gozke, R. Gurer, N. Gurbuzer, N. Dortcan (FSM Teaching and Research Hospital, Department of Neurology, Istanbul, Turkey)
Objective: Riche–Cannieu anastomosis (RCA) is a rare type of anomalous innervation. It is characterized as innervation of medial and lateral part of palm involving the deep branch of the ulnar nerve crossover to the recurrent branch of the median nerve in the hand. Methods: A 44 years old woman who has numbness and pain her hands evaluated by nerve conduction studies and needle electromyography. Results: In neurological examination, there was no wasting or weakness of the hand muscles, nor sensory impairment. Nerve conduction studies showed dual innervation (mainly ulnar nerve) of
ID 102 – Moscow’s 15 years of experience in mobile neurophysiologic assessment—I.D. Stulin b, M.V. Sinkin a, D.S. Solonskiy b, R. S. Musin b, A.V. Kasheev a, A.O. Mnushkin b, L.A. Savin b, M.A. Bolotnov c (a Neurodiagnostic, Municipal Hospital #24, Moscow, Russia, b Neurology, Moscow State University of Medicine and Dentistry, Moscow, Russia, c Neurodiagnostic, Municipal Hospital #13, Moscow, Russia) Background: One of important factor in comatose patient assessment is express neurophysiologic evaluation. Other important issue for developing countries is lack of qualified neurophysiologists and technical equipment.
e62
Abstracts / Clinical Neurophysiology 127 (2016) e18–e132
Materials: Moscow hospitals collaborated efforts to create a highly specialized mobile neurodiagnostic team (MNT) in 1995. It is staffed with six clinical neurophysiologists, one of whom is on call around the clock. In cases of deep coma patients (GCS < 5), a team member capable of performing clinical evaluations, EEG/EVP, TCD, duplex, can be dispatched to any hospital in Moscow in the equipped van, which carries a portable EEG/EVP/Myography device, ultrasound scanner. In cases of suspected brain death (BD), the MNT experts also take part in clinical consultations Results: More than 4500 critically ill patients have been examined by MNT since 1995. Most patients suffered from stroke and SAH (68%) or brain trauma (28%). Tumor and coma due to cardiac arrest (3% and 1%). MNT specialists took part in BD consultations in more than 600 cases. Conclusion: In large cities, a highly professional mobile group, able to make clinical examinations and neurophysiological assessments, can improve the quality of neurocritical care without tremendous additional material costs, can increase the accuracy of BD diagnostics by offering more specialized and specific confirmation tests. doi:10.1016/j.clinph.2015.11.204
ID 140 – Left-side asymmetry in cortical and spinal inhibitory circuits in stiff-person syndrome: A case report—V. Bocek, B. Cvickova, T. Peisker, I. Stetkarova (Department of Neurology, Charles University, Third Faculty of Medicine, Charles University in Prague and Faculty Hospital Kralovske Vinohrady, Czech Republic) Objective: Stiff-person syndrome (SPS) is an autoimmune disease characterized by progressive rigidity and generalized muscle stiffness caused by loss of GABA-ergic inhibition. Diffuse impairment of the GABA-system can be observed by neurophysiological methods. We investigated intracortical and spinal inhibition and correlate these findings with clinical status. Methods: Fifty-one years old male with a two years history of stiffness and muscle spasms was investigated in our department. Subsequently, we performed EMG, paired TMS and cortical (CoSP) and spinal (CSP) silent periods. Results: The patient had 50 times higher serum level of anti-GAD. He suffered from severe lumbar hyperlodosis, hypertrophy of axial muscles, and slightly asymmetrical generalized stiffness more pronounced on the left extremities. EMG discovered continuous involuntary muscle activity. Intracortical short-time inhibition (ICSI) after TMS stimulation was abnormal while stimulated both hemisphere and was more pronounced from the left APB muscle. CoSP and CSP were both abnormally shortened with more shortening when recorded from the left side. Conclusion: Our findings confirmed loss of GABA-ergic inhibition in SPS. Involvement of both GABA-A and GABA-B inhibitory circuit systems are present with makeable left-side asymmetry corresponding to clinical status. Supported by PRVOUK P34, IGA-NT 13693, 12282. doi:10.1016/j.clinph.2015.11.205
ID 159 – Madelung’s disease. A case report—N. Ausín Morales a, I. Lambarri San Martín a, J. Barcena Llona b, A. Jauregui Barrutia b, A. Martínez Zuluaga a, T. Vicario Elorduy a, I. Yurrebaso Santa María a (a Department of Clinical Neurophysiology, Cruces University Hospital, Barakaldo, Basque Country, Spain, b Department of Neurology, Cruces University Hospital, Barakaldo, Basque Country, Spain) Objective: Madelung’s disease or multiple symmetric lipomatosis (MSL) is characterized by accumulation of unencapsulated fat, generally located symmetrically in the cervical region and back. Peripheral neuropathy is a common finding as well as the association with alcoholism, hepatopathy and glucose intolerance. Pathogenesis is unknown. Methods: The authors present a case of 44 year old ex-alcoholic man with a 4 year history of multiple cervical lipomas being diagnosed of MSL. He developed symmetrical pain and weakness in lower limbs. Peripheral neuropathy was suspected based on distal amyotrophy and bilateral pes cavus deformities. Distal legs were thin with inverted-champagne bottle appearance. The study was based on radiological study and electrodiagnostic examination with electroneurography, needle electromyography and somatosensory evoked potentials. Result: The electromioneurography study showed an intense sensorimotor polyneuropathy with a demyelinating and axonal component and signs of cervical polyradiculopathy. The cervical MRI showed cervical stenosis without significant cord compression. Conclusion: MSL is a rare condition associated with alcoholism and high prevalence of peripheral neuropathy. Based on the neurophysiological examination and the clinical picture our patient presents a polyneuropathy caused by the toxic effect of the alcohol and with features of the hereditary motor and sensory neuropathy. Key message: Madelung’s disease, peripheral neuropathy. doi:10.1016/j.clinph.2015.11.206
ID 199 – Demographic and electrophysiological pattern in Chronic Inflammatory Demyelinating polyradiculoneuropathy among Iranian patients referred to Iran University of Medical Sciences—Bahram Haghi Ashtiani, Babak Zamani, Maryam Saeidi, Mostafa Almasi (Neurology, Electrodiagnostic Ward, Iran University of Medical Sciences, Iran) Objectives: There are four basic electrodiagnostic parameters in Chronic Inflammatory Demyelinating polyneuropathy (CIDP): (1) reduced motor conduction velocity (NCV); (2) motor conduction block or abnormal temporal dispersion; (3) prolonged motor distal latency (DL); and (4) prolonged minimal F-wave latency or absent F waves. Methods: We retrospectively reviewed the medical records of patients with the clinical diagnosis of CIDP in IRAN university hospitals in 2014 on the basis of a progressive or relapsing polyradiculoneuropathy developing over at least 2 months. Electrophysiological studies were performed with standard surface stimulation and recording techniques. The amplitude, the area under the curve (AREA), and the duration (DUR) of the negative peak of the compound muscle action potential (CMAP) were determined as well as NCV, and DL from the Median, Ulnar, Tibial, and Peroneal nerves in both side.