Академический Документы
Профессиональный Документы
Культура Документы
Clinical neurophysiology Nerve conduction studies and electromyography! Evoked potentials! Electroencephalography! Transcranial magnetic stimulations
Extracellular
uid
Axon hillock
Saltatory conduction
Myelin sheath Node of Ranvier
Myelinated axon
+ +
+ +
+ +
+ +
+ +
+ +
+ +
+ +
+ +
+ +
+ +
+ +
+ +
+ +
+ +
+ +
+ +
+ +
+ +
+ +
Intracellular + + + Extracellular
uid + uid +
+ +
+ +
+ +
+ +
+ +
+ +
+ +
+ +
+ +
+ +
+ +
+ +
+ +
+ +
+ +
+ +
+ +
+ +
+ +
+ +
+ +
+ +
+ +
+ +
+ +
Orthodromic
Antidromic
Motor neuron
Orthodromic
Sensory neuron
Antidromic
Objective of NCS
Confirm clinical diagnosis Localization Pathology ( e.g. axonal vs demyelination Disease state Prognosis
Lower extremity
Peroneal! Tibial! Sural
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
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
Temporal dispersion
Temporal dispersion
A
C
Delayed DL C
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
B A
Axonal degeneration
Amplitude : change > 70 %
B A C C
Axonal degeneration
A A
BK AK
Left peroneal Right peroneal
This 50 y.o. woman has had nocturnal numbness in both hands for 2 months
.
Left
Right
1.56 2.5
2.5
F wave
H reflex
F wave
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
AIDP
H reflex
Objective of NCS
Confirm clinical diagnosis! Localization! Pathology ( e.g. axonal vs demyelination)! Disease state ! Prognosis
! ! ! ! !
dL amplitude
! ! ! ! !
! !
CB/Temporal
Present
Pattern of abnormality
Normal NMJ
Action Potential
Presynaptic
Acetylcholine receptor
Postsynaptic
Action Potential
Ca2+
Presynaptic
Acetylcholine
Acetylcholine receptor
Postsynaptic
Action Potential
Ca2+
Presynaptic
Immediate pool
Acetylcholine
Acetylcholine receptor
Postsynaptic
normalNMJ
M gravis
Stimulate only immediate Ach Storage
botulism
> 10 Hz
> 10 Hz
Giant CMAP
normalNMJ
M gravis
botulism
Ach quanta Released by Ca++ which was previously blocked by toxin becomes more important
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
"End-plate noise (solid arrows) :seashell held to the ear! ! End-plate spikes (dashed arrow) :"sputtering fat in a frying pan
A. Fibrillation potential!
! !
Drive bomber
C. Myotonic discharge
! ! !
D. Myokimic ! discharge!
Machine
! ! !
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
Any abnormality that affects the visual pathways or visual cortex in the brain can affect the VEP!
!
104
Left eye
Patient with right optic neuritis, illustrating delay of the P100 component from the right eye
Right eye
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
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
Legatt AD, Arezzo JC, Vaughan HG, Jr: The anatomic and physiologic bases of bra stem auditory evoked potentials.
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)