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Principle of Neuroelectrodiagnosis

Angkana Nudsasarn , MD , FRCP(T) Northern Neuroscience Center

Clinical neurophysiology Nerve conduction studies and electromyography! Evoked potentials! Electroencephalography! Transcranial magnetic stimulations

Resting Membrane Potential

Extracellular

uid

Axon hillock

Saltatory conduction
Myelin sheath Node of Ranvier

Myelinated axon

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Intracellular + + + Extracellular

uid + uid +

Direction of action potential propagation

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Orthodromic

Antidromic

Motor neuron

Orthodromic

Sensory neuron
Antidromic

Objective of NCS

Confirm clinical diagnosis Localization Pathology ( e.g. axonal vs demyelination Disease state Prognosis

Nerve conduction study


Common nerve
Upper extremity
Median Ulnar Radial

Lower extremity
Peroneal! Tibial! Sural

Nerve conduction study


What to test?
Motor Distal latency Amplitude Velocity Late response - F wave - H reflex

What to test?
Sensory Distal latency Amplitude! Velocity

What to test?
Autonomic function test
Sympathetic skin response(SSR) The quantitative sudomotor axon reflex test (QSART)"! Thermoregulatory sweat test(TST)

Distal stimulation

Kimura, Electrodiagnosis in Diseases of Nerve and Muscle: Principles and

Proximal stimulation

What to measure ?

Distal latency
measure the fastest conduction fiber A
C D E

A
A B
C

D E

Latency abnormality
C A C B

B A

A
C

Amplitude
We measure the sum of number of conducted fiber

D E

Amplitude = A+B+C+D+E

Amplitude abnormality
Fiber A D C are sick Only B and C can conduct

Amplitude = B plus C A B C D E

Conduction block

Criteria of conduction block


Definite ! >50% drop in amplitude , <15% prolong duration!
!

>50% drop in amplitude and area!


!

>20% drop in amplitude and area over a short segment

Temporal dispersion

Temporal dispersion

Demyelination : disease of myelin


:The fastest conduction fiber A & B are sick because no myelin
A C B

A
C

Distal latency & Demyelination


A B C

Delayed DL C

A B Amplitude : Not much change

A B

DE

Demyelination
Delayed distal latency B A C A C B Amplitude : Not much change

A
C

Axonal degeneration
Only fiber B & C are well

Amplitude is small
A B

Amplitude Vs Axonal degeneration


Only fiber B & C are well
C C

B A

Distal latency not change much D E

Axonal degeneration
Amplitude : change > 70 %
B A C C

Latency change < 30%

Axonal degeneration

A woman with acute left foot drop

A A

BK AK
Left peroneal Right peroneal

A woman with acute left foot drop

This 50 y.o. woman has had nocturnal numbness in both hands for 2 months
.

Physical examination revealed no definite weakness nor numbness in both hands

Tienels sign was negative but Phalans test was positive

Right median motor

Comparison of Left and Right median motor NCV

Median motor NCVs

Left

Right

1.56 2.5

2.5

2.4 3.9 3.8

Right median sensory NCV

F wave

H reflex

F wave

A Mallik, Conduction studies:Essential and pitfall in practice

Ulnar nerve

Tibial nerve

Usefulness of F wave
Testing of proximal segments ! Testing long lengths of nerves ! A sensitive indicator of proximal portion! Determine the site of conduction slowing

Case example
A 27 years old woman
!

Acute progressive sharp soothing pain over distal limbs for 2 weeks
!

Physical examination
Motor gr v DTR gr 0

Left

Right

Median

Ulnar

Tibial

Left

Right

Peroneal

CSF shown albuminocytologic dissociation

AIDP

H reflex

Sensory nerve conduction study


Median orthodromic sensory study

Objective of NCS
Confirm clinical diagnosis! Localization! Pathology ( e.g. axonal vs demyelination)! Disease state ! Prognosis

Typical nerve conduction study abnormalities in axon loss or demyelination


Axonopathy Demyelination

! ! ! ! !

dL amplitude

! ! ! ! !

Normal or slightly prolonged Small

! !

Prolonged Normal (reduced if conduction block or temporal desperion)

CB/Temporal

Present

SNAP and localization related to dorsal root ganglion

Pattern of abnormality

Repetitive nerve stimulation test


Evaluate patients with suspected neuromuscular junction disorders!

Normal NMJ

Action Potential

Ca2+ Ca2+ Ca2+

Presynaptic

Acetylcholine receptor

Postsynaptic

Action Potential

Ca2+
Presynaptic
Acetylcholine

Acetylcholine receptor

Postsynaptic

Action Potential

Ca2+
Presynaptic

Immediate pool
Acetylcholine

Acetylcholine receptor

Postsynaptic

Low rate stimulation

Low rate stimulation


< 5 HZ

The depletion of available quanta of Ach becomes more important.

Low rate stimulation

normalNMJ

Stimulate only immediate Ach Storage

End Plate Potential

Low rate stimulation

M gravis
Stimulate only immediate Ach Storage

End Plate Potential

Low rate stimulation

Immediate storage depleted quickly

End Plate Potential

botulism

Katirji, B., 2007. Electromyography in Clinical Pract

Repetitive nerve stimulation test

Repetitive N stimulation test

RNS interpretation guide


At low rate : Initial CAMP Compare 1st and 4th potential Decremental or incremetal At high rate look at the pattern

High rate stimulation

High rate stimulation

> 10 Hz

Increased of Ach Quanta release by Ca++ becomes more important

High rate stimulation

> 10 Hz

Increased of Ach Quanta release by Ca++ becomes more important

Giant CMAP

High rate stimulation


> 10 Hz

normalNMJ

Ach quanta released by Ca++ becomes more important

High rate stimulation


> 10 Hz

M gravis

Ach quanta released by Ca++ becomes more important

High rate stimulation


> 10 Hz

botulism

Ach quanta Released by Ca++ which was previously blocked by toxin becomes more important

Repetitive Nerve Stimulation


At frequency of 30 cps
!

M.gravis shows decrementing response


!

Eaton lambert syndrome shows incremental response

Slow RNS and Rapid RNS


Slow RNS : 3-4 Hz stimulation! Rapid RNS : 20-50 Hz stimulation

Decrement in CMAP amplitude and/or area at low stimulation rates indicates a drop in the safety factor (amplitude of EPP above the threshold for action potential )for transmission both pre- or post-synaptic cause

high frequency stimulation natural facilitation is! enhanced by pre-synaptic Ca++ influx

Needle EMG
Recording of electrical activity in muscle!
Spontaneous activity Voluntary activity Amplitudes Frequencies Patterns of electrical activity Audio and visual information

Needle EMG
Distinguish myopathic from neurogenic muscle weakness! Provide supportive evidence of pathology of peripheral neuropathy( demyelination or axonal degeneration)! Differentiate focal nerve, plexus, or radicular pathology! Obligatory investigation in motor neuron disease

Normal Insertional and Spontaneous Activity

"End-plate noise (solid arrows) :seashell held to the ear! ! End-plate spikes (dashed arrow) :"sputtering fat in a frying pan

Abnormal insertional activity


Rain on tin roof, tick-tock of clock

A. Fibrillation potential!
! !

Dull pops, Rain on tin roof, tick-tock of clock

B. Positive sharp wave!


! !

Drive bomber

C. Myotonic discharge

Abnormal insertional activity


Marching soldiers

! ! !

D. Myokimic ! discharge!
Machine

! ! !

E. Complex ! repetitive ! discharge

A summary of characteristic findings on needle electromyography

A summary of characteristic findings on needle electromyography

A summary of characteristic findings on needle electromyography

Positive sharp wave and Fibrillation


Muscle denervation Ant. horn cell Root Plexus Nerve Necrotizing myopathy Muscular dystrophy

A man with chronic progressive generalized muscle atrophy ,fasciculation and hyperreflexia

Dermatomyositis

NCS : WNL
!

EMG At rest :positive sharp wave and fibrillation +2 MUP : small polyphasic

Blink reflexes

Evaluation Involvement of trigeminal or facial nerve Variety of demyelinating polyneuropathies Central lesion of brainstem

Sensory evoked potential


Demonstrate abnormal sensory system conduction when the visual evoked history and/or neurological potentials (VEPs) examination is equivocal! Reveal subclinical involvement of short latency a sensory system ! somatosensory evoked Help define the anatomic potentials(SSEPs) distribution and give some insight into pathophysiology of a disease! brainstem auditory Monitor changes in a patients evoked potentials neurological status
(BSAEPs)

Visual evoked potentials (VEPs)


VEP wave form are extracted from the EEG by signal averaging!
!

Any abnormality that affects the visual pathways or visual cortex in the brain can affect the VEP!
!

Investigation of demyelinating disease, optic neuritis, and other optic neuropathies

PATTERN REVERSAL VEP

104

Left eye

Patient with right optic neuritis, illustrating delay of the P100 component from the right eye

Right eye

A man with history of demyelinating injury of his left optic radiation

Aminoffs Electrodiagnpsis in clinical practice

Brainstem Auditory Evoked Potentials (BAEPs)


A test of auditory brainstem function in response to auditory stimuli (click)

Its a set of positive wave recorded during the first 10 seconds after a click stimuli

Clinical useful?
For assess conduction through lower brainstem auditory pathway! In patient with!
Multiple sclerosis Structural lesion of brainstem Intraoperative monitoring of auditory pathway during neuroSx of posterior fossa tumour! Prognosis of anoxic coma in ICU

Left-sided acoustic neuroma

Aminoffs Electrodiagnpsis in clinical

35-year-old woman who was comatose Comatose following a mixed drug --------Recover overdose and a respiratory arrest Karger, Basel, 1980 .Clinical Uses of Cerebral, Brainstem and Spinal Somatosensory Evoked Poten

Loss of waves V and VI due to brainstem infarction

Legatt AD, Arezzo JC, Vaughan HG, Jr: The anatomic and physiologic bases of bra stem auditory evoked potentials.

Somatosensory evoked potentials(SEPs)


Evoked potentials of large diameter sensory nerves in the PNS and CNS!
!

Used to diagnose nerve damage or degeneration in the spinal cord!


!

Can distinguish central Vs peripheral nerve lesion!


!

Confirmation of a nonorganic cause of sensory loss

Median nerve SEPs


Erbs point :N9 brachial plexus! Cervical spine : N13 dorsal column nuclei ! Scalp : N20 P23 thalamocortical radiations & primary sensory cortex

The lesion of proximal segment of the peripheral nerve or the cervical cord(. A prolonged N9 to N13 inter-wave peak latency beyond the upper limit of normal)

Tibial nerve SEPs


L3 negative peak with latency 19 ms (L3 S)nerve roots of cauda ! equina T12 - negative peak with latency 21 ms (T12 S) dorsal fibers of ! spinal cord Scalp: positive peak P37 negative peak N45! thalamocortical activity

Dispersed P37 potential with a prolonged latency

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