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P21-25 Peripheral neuropathy caused by severe hypothermia: a case report
S232 are compatible with prolonged action potential and delay repolarization in traditional neurophysiological study. One of the patients suffered from severe cramp in hands especially in the winter and difficulty in writing and housework, others are no obvious problems in daily activities. The recovery cycles test on this patient showed prominently increasing in superexcitabilities and prolonged period of superexciability. Conclusion: Nerve excitability tests might contribute the direct of indirect information about ion channel function, including nerve and muscle. P21-22 Is nerve conduction study safe in patients with implanted cardioverter-defibrillator? M.A. Derejko1 , P. Derejko2 , A. Przybylski2 , M. Niewiadomska1 , M. Banach1 , M. Wieclawska1 , F. Walczak2 , M. Rakowicz1 1 Departament of Clinical Neurophysiology Insititute of Psychiatry and Neurology Warsaw, Poland, 2 Dept. of Cardiac Arrhythmias, Institute of Cardiology, Warsaw, Poland
Posters controlled by the injured nerve can be compensated. It may also result in a series of unconformity on its clinical symptoms, the lesions degree of the nerve and the electrophysiological findings. Conclusion: Thoroughly understanding the compensative effects of anastomosis is crucial importance in case the clinical diagnosis and treatment of median or ulnar nerve injury, as well as to avoid the misinterpretation of the electrodiagnostic report and confusion during the test. P21-25 Peripheral neuropathy caused by severe hypothermia: a case report S. Loseth1 , T. Torbergsen1 , A. Bagenholm2 , E. Stalberg3 1 Department of Neurology, University Hospital of North Norway, Tromso, Norway, 2 Department of Radiology, University Hospital of North Norway, Tromso, Norway, 3 Department of Clinical Neurophysiology, Uppsala University Hospital, Uppsala, Sweden
Objective: Patients with implanted cardioverter defibrillator (ICD) may suffer from disorders of the peripheral nervous system and require nerve conduction study (NCS) to establish diagnosis. ICD is increasingly used in clinical practice, but little is known about the safety of NCS in patients with ICD. Aim: To examine the influence of rate, location and intensity of electrical impulses generated during NCS on ICD function. Methods: Ten patients (9M, 1F; mean age: 56.7±9.2) chronically treated with amiodarone and statins with ICD (primary prevention two patients; secondary prevention eight patients) and symptoms sugesting neuropathy were included into the study. ICD types included: 5 Medtronic, 3 St Jude Medical and 2 Biotronik devices. Among them there were 4 single chamber, 5 dual chamber and 1 biventricular device. NCS was performed according to AAN electrodiagnostic criteria of neuropathy. Sensory nerve conduction study (SNCS) was carried out using stimulation rate of 2 Hz over the ulnar and sural nerves. Motor nerve conduction study (MNCS) was conducted in ulnar and peroneal nerves using supramaximal single pulses of 0.2 ms duration and 1 ms duration when stimulated in Erb point. Before and after NCS the ICD function was assessed. During NCS patients were monitored continuously via electrocardiogram and the device programmer. Results: In none of the patients electrical impulses generated during SNCS and MNCS affected ICD function. Electrical stimulation at left Erb point with stimulus intensity of 100 mA and 1 ms of duration was detected by ICD but did not influence its function. We diagnosed the sensory axonal polyneuropathy in one patient, carpal tunnel syndrome in two patients, ulnar neuropathy at the elbow in one patient. Conclusion: NCS even performed close to the implantation site of ICD or using stimulation rate of 2 Hz is safe in patients with ICD.
Objective: To describe neurophysiological findings at different time points over a period of ten years in a patient developing peripheral neuropathy after very deep accidental hypothermia (13.7ºC) at age 29 years. Methods: Nerve conduction studies and electromyography (EMG) were performed at the intensive care unit (1999) and at several followup studies during the first five years and then after ten years. Motor and sensory nerves in at least one leg and one arm were tested. EMG examinations assessed spontaneous activity, MUP and interference patterns in several muscles. Macro EMG was performed in 2004. Tests for small fiber function were performed in 2009 ((thermal perception thresholds, skin biopsy for quantification of intraepidermal nerve fibers (IENFs), sympathetic skin response (SSR) and RR-interval)). Results: At the first examination (day 20) no motor responses were obtained except from the tibial nerve (motor amplitude 8 mV, and conduction velocity 50 m/s). Sensory responses were absent. Amplitudes and conduction velocities then gradually improved over the first five years, but are still abnormal in most nerves. Nerve excitability was reduced. Initially EMG showed pronounced denervation activity in all tested muscles and no voluntary activity in legs and hand muscles. After one to five months reinnervation activity was found. MacroEMG (2004) showed high amplitudes indicating effective reinnervation. SSR and RR-interval were normal. Thermal perception thresholds were borderline, especially at distal sites. IENF density was also borderline (6.0 fibers/mm) Conclusions: A severe sensimotor axonal neuropathy developed during the first two weeks at the intensive care unit. This could be due to both critical illness polyneuropathy and cold injury to peripheral nerves. For some reason both tibial nerves were spared. Motor and sensory recovery took place as well as reinnervation. At ten years follow up large myelinated fibres were involved more extensively than small fibres.
P21-24 A study of the effects for the anomalous innervation on the diagnosis upon the median or ulnar nerve injury
P21-26 Distal conduction disturbance after post exercise in anti-MAG neuropathy
M. Li1 , G. Li1 , M. Lin1 Department of Special Examination, Foshan Hospital of TCM (Traditional Chinese Medicine), Guangdong, China
H. Tsukamoto1 , Y. Hatanaka1 , E. Ito2 , K. Hokkoku1 , M. Sonoo1 , T. Shimizu1 1 Department of Neurology, Teikyo University School of Medicine, Tokyo, Japan, 2 Department of Neurology, Tokyo Wemen’s Medical University Medical Center East, Japan
1
Objective: To study the effects on the diagnosis of median or ulnar nerve injury for presence of the anomalous anastomosis between median and ulnar nerve in the forearm and the palm of the hand, including the anatomosis from median nerve in the forearm to the ulnar nerve (Martin-Gruber anastomosis, MGA), the anatomosis from ulnar nerve in the forearm (reversed Martin-Gruber anastomosis, RMGA), and the anatomosis from median nerve in the palm of the hand to the ulnar nerve (Riche-Cannieu anastomosis, RCA). Methods: Base on the results of two thousands electrophysiological examination reports of median or ulnar nerve lesion from 2002 to 2008, 160 cases of anastomosis have been found. (102 male, 58 female, age from 16 to 63, mean age 38.3) of median or ulnar nerve injury with the presence of anomalous anastomosis were assigned to three groups: 65 cases of ulnar nerve lesion with MGA, 8 cases of median nerve lesion with RMGA, 87 cases of median nerve lesion with RCA. They were analysed on fields of anatomical foundation, clinical symptoms, electrophysiological data and diagnosis. Results: The compensative effect of anastomosis in all of these 160 cases (100%) have been observed by the function of the muscle which was
Purpose: Conduction disturbances after post exercise are known well in CIDP or MMN, such as the activity dependent conduction block. However there are no studies about anti-MAG neuropathy demonstrated demyelination in distal peripheral nerves. In this study, We aimed to investigate whether distal conduction disturbance is produced after post exercise in anti-MAG neuropathy. Methods: The nerve conduction studies in median and ulnar nerve were performed on five healthy control subjects and four patients with antiMAG neuropathy. We examined repetitive nerve stimulation (RNS), and recorded CMAP more than 1 minute each 6 seconds after a maximal contraction for 60 seconds. We evaluated the distal latency (DL), negative peak latency (nPL), amplitude (AMP) and duration (DUR) Results: We demonstrated 3 median nerves and 2 ulnar nerves in antiMAG neuropathy patients, whereas examined both nerves in all controls. The RNS were revealed no decrement among all patients and controls. In the post exercise recordings, delay of DL and depression of AMP were observed 3 nerves, prolongation of DUR were revealed in 4 nerves. Delay
Posters controlled by the injured nerve can be compensated. It may also result in a series of unconformity on its clinical symptoms, the lesions degree of the nerve and the electrophysiological findings. Conclusion: Thoroughly understanding the compensative effects of anastomosis is crucial importance in case the clinical diagnosis and treatment of median or ulnar nerve injury, as well as to avoid the misinterpretation of the electrodiagnostic report and confusion during the test. P21-25 Peripheral neuropathy caused by severe hypothermia: a case report S. Loseth1 , T. Torbergsen1 , A. Bagenholm2 , E. Stalberg3 1 Department of Neurology, University Hospital of North Norway, Tromso, Norway, 2 Department of Radiology, University Hospital of North Norway, Tromso, Norway, 3 Department of Clinical Neurophysiology, Uppsala University Hospital, Uppsala, Sweden
Objective: Patients with implanted cardioverter defibrillator (ICD) may suffer from disorders of the peripheral nervous system and require nerve conduction study (NCS) to establish diagnosis. ICD is increasingly used in clinical practice, but little is known about the safety of NCS in patients with ICD. Aim: To examine the influence of rate, location and intensity of electrical impulses generated during NCS on ICD function. Methods: Ten patients (9M, 1F; mean age: 56.7±9.2) chronically treated with amiodarone and statins with ICD (primary prevention two patients; secondary prevention eight patients) and symptoms sugesting neuropathy were included into the study. ICD types included: 5 Medtronic, 3 St Jude Medical and 2 Biotronik devices. Among them there were 4 single chamber, 5 dual chamber and 1 biventricular device. NCS was performed according to AAN electrodiagnostic criteria of neuropathy. Sensory nerve conduction study (SNCS) was carried out using stimulation rate of 2 Hz over the ulnar and sural nerves. Motor nerve conduction study (MNCS) was conducted in ulnar and peroneal nerves using supramaximal single pulses of 0.2 ms duration and 1 ms duration when stimulated in Erb point. Before and after NCS the ICD function was assessed. During NCS patients were monitored continuously via electrocardiogram and the device programmer. Results: In none of the patients electrical impulses generated during SNCS and MNCS affected ICD function. Electrical stimulation at left Erb point with stimulus intensity of 100 mA and 1 ms of duration was detected by ICD but did not influence its function. We diagnosed the sensory axonal polyneuropathy in one patient, carpal tunnel syndrome in two patients, ulnar neuropathy at the elbow in one patient. Conclusion: NCS even performed close to the implantation site of ICD or using stimulation rate of 2 Hz is safe in patients with ICD.
Objective: To describe neurophysiological findings at different time points over a period of ten years in a patient developing peripheral neuropathy after very deep accidental hypothermia (13.7ºC) at age 29 years. Methods: Nerve conduction studies and electromyography (EMG) were performed at the intensive care unit (1999) and at several followup studies during the first five years and then after ten years. Motor and sensory nerves in at least one leg and one arm were tested. EMG examinations assessed spontaneous activity, MUP and interference patterns in several muscles. Macro EMG was performed in 2004. Tests for small fiber function were performed in 2009 ((thermal perception thresholds, skin biopsy for quantification of intraepidermal nerve fibers (IENFs), sympathetic skin response (SSR) and RR-interval)). Results: At the first examination (day 20) no motor responses were obtained except from the tibial nerve (motor amplitude 8 mV, and conduction velocity 50 m/s). Sensory responses were absent. Amplitudes and conduction velocities then gradually improved over the first five years, but are still abnormal in most nerves. Nerve excitability was reduced. Initially EMG showed pronounced denervation activity in all tested muscles and no voluntary activity in legs and hand muscles. After one to five months reinnervation activity was found. MacroEMG (2004) showed high amplitudes indicating effective reinnervation. SSR and RR-interval were normal. Thermal perception thresholds were borderline, especially at distal sites. IENF density was also borderline (6.0 fibers/mm) Conclusions: A severe sensimotor axonal neuropathy developed during the first two weeks at the intensive care unit. This could be due to both critical illness polyneuropathy and cold injury to peripheral nerves. For some reason both tibial nerves were spared. Motor and sensory recovery took place as well as reinnervation. At ten years follow up large myelinated fibres were involved more extensively than small fibres.
P21-24 A study of the effects for the anomalous innervation on the diagnosis upon the median or ulnar nerve injury
P21-26 Distal conduction disturbance after post exercise in anti-MAG neuropathy
M. Li1 , G. Li1 , M. Lin1 Department of Special Examination, Foshan Hospital of TCM (Traditional Chinese Medicine), Guangdong, China
H. Tsukamoto1 , Y. Hatanaka1 , E. Ito2 , K. Hokkoku1 , M. Sonoo1 , T. Shimizu1 1 Department of Neurology, Teikyo University School of Medicine, Tokyo, Japan, 2 Department of Neurology, Tokyo Wemen’s Medical University Medical Center East, Japan
1
Objective: To study the effects on the diagnosis of median or ulnar nerve injury for presence of the anomalous anastomosis between median and ulnar nerve in the forearm and the palm of the hand, including the anatomosis from median nerve in the forearm to the ulnar nerve (Martin-Gruber anastomosis, MGA), the anatomosis from ulnar nerve in the forearm (reversed Martin-Gruber anastomosis, RMGA), and the anatomosis from median nerve in the palm of the hand to the ulnar nerve (Riche-Cannieu anastomosis, RCA). Methods: Base on the results of two thousands electrophysiological examination reports of median or ulnar nerve lesion from 2002 to 2008, 160 cases of anastomosis have been found. (102 male, 58 female, age from 16 to 63, mean age 38.3) of median or ulnar nerve injury with the presence of anomalous anastomosis were assigned to three groups: 65 cases of ulnar nerve lesion with MGA, 8 cases of median nerve lesion with RMGA, 87 cases of median nerve lesion with RCA. They were analysed on fields of anatomical foundation, clinical symptoms, electrophysiological data and diagnosis. Results: The compensative effect of anastomosis in all of these 160 cases (100%) have been observed by the function of the muscle which was
Purpose: Conduction disturbances after post exercise are known well in CIDP or MMN, such as the activity dependent conduction block. However there are no studies about anti-MAG neuropathy demonstrated demyelination in distal peripheral nerves. In this study, We aimed to investigate whether distal conduction disturbance is produced after post exercise in anti-MAG neuropathy. Methods: The nerve conduction studies in median and ulnar nerve were performed on five healthy control subjects and four patients with antiMAG neuropathy. We examined repetitive nerve stimulation (RNS), and recorded CMAP more than 1 minute each 6 seconds after a maximal contraction for 60 seconds. We evaluated the distal latency (DL), negative peak latency (nPL), amplitude (AMP) and duration (DUR) Results: We demonstrated 3 median nerves and 2 ulnar nerves in antiMAG neuropathy patients, whereas examined both nerves in all controls. The RNS were revealed no decrement among all patients and controls. In the post exercise recordings, delay of DL and depression of AMP were observed 3 nerves, prolongation of DUR were revealed in 4 nerves. Delay