The 7th Summer School of ASNER, The Romanian Society of

The 7th Summer School of ASNER,

The Romanian Society of

Electrodiagnostic Neurophysiology

SDV2016, Eforie Nord, Romania

8-10 July 2016

Abstract book

www.asner.org

ASNER SDV2016 Eforie Nord, 8-10 July 2016– Abstract book

7th Summer School of the Romanian Society of Electrodiagnostic Neurophysiology

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Scientific partners:



Dear Friends,

It’s again July, and that means it is again time for theSummer School in Clinical Neurophysiology. We arenow starting this scientific event for the 7th time, so Isuppose we are entitled to call it a tradition. Some ofyou have participated every year, many of you haveattended this school a few times, and others arenewcomers, but all of us have one thing in common,namely our passion for neurophysiology. We haveprepared a scientific program that will contain aplenary session, and, workshops in EEG, EMG andtranscranial magnetic stimulation. Again, we haveimportant guests who have accepted our invitation forthis event.

So we are expecting two days of intense scientificactivity, in a beautiful environment, and maybe willtake a few minutes to enjoy the beautiful beach andthe sea, to chat, to make new friends.

Welcome to the 7th Edition of the Summer School inClinical Neurophysiology !

Sincerely,

Tudor Lupescu M.D. Ph.D.

ASNER President

[email protected]

http://www.asner.org

https://www.facebook.com/asner.org/

Ioana Mindruta, M.D. Ph.D.

ASNER Vice-President

Neurology Department, “Carol Davila” University ofMedicine and Pharmacy, Bucharest, Romania

[email protected]

Ionela Codita, M.D. Ph.D.

ASNER Secretary

Neurology Department of Elias UniversityEmergency Hospital, Bucharest, Romania

[email protected]

Ana-Maria Cobzaru, M.D.

ASNER Treasurer


[email protected]

Mihai Moldovan, MD, PhD

ASNER Scientific director

Copenhagen University, Denmark and “Carol Davila”University of Medicine and Pharmacy, Bucharest,Romania

[email protected]

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http://www.asner.org/

https://www.facebook.com/asner.org/



Friday July 8th

12.00 - 13.00 Welcome cocktail

13.00 - 13.15 - Opening remarks

13.15 - 15.15 EEG workshop (Chair IoanaMindruta)

Activation procedures in EEG recordings andmaturation of EEG rhythms - Dana Craiu, Bucharest,Romania

Vegetative seizures - need for additional electrodes inthe EEG protocols - Oana Tarta, Bucharest, Romania

Source localisation method - Mihai Malaia,Bucharest, Romania

EEG recordings

15.15 - 15.45 Coffee Break

15.45 - 18.30 EMG workshop (Chair Ana-MariaCobzaru)

Miller Fisher Variant of Guillain-Barre Syndrome: ACase Report – Ionela Codita

Subacute tetraparesis with axonal polyneuropathy - atricky differential diagnosis -Anca Adriana Arbune.Ana-Maria Cobzaru, Cristina Tiu

Asymmetrical amyotrophy of the small muscles ofthe hand A historical retrospective of diagnosis andtherapy as homage to our professors – MirceaMoldovan

EMG recordings

Free time

Saturday, July 9th

Plenary Session 1 (Chair Tudor Lupescu)

9.00 - 9.45 Vagus Nerve Stimulation - Criteria ofpatient selection - Nicola Specchio, Roma, Italy

9.45 - 10.15 SEEG guided RFTC for drug resistantepilepsy - Ioana Mindruta, Mihai Malaia, Irina Popa,Cristian Donos, Jean Ciurea, Alin Rasina, AndreiBarborica.

10.15 - 10.30 Coffee break

Plenary Session 2 (Chair Mihai Moldovan)

10.30 - 11.15 Restless legs syndrome - MauroManconi, Lugano, Switzerland

11.15 - 12.00 Transcranial Direct ElectricalStimulation - Basics - Andrea Antal, Gottingen,Germany

12.00 - 12.30 TMS in neurological disorders - TudorLupescu, Bucharest, Romania

12.30 - 13.00 ‘Safety factor for conduction’ ofperipheral axons - Mihai Moldovan, Copenhagen,Denmark

13.00-14.30 - Lunch

14.30 - 15.00 Sympozion Genzyme

15.00 - 15.10 Coma EEG reactivity monitor (CosminSerban, Termobit PROD Srl.)

15.10 - 15.15 Coffee break

15.15 - 16.15 Sleep lab: case presentations anddiscussions: Sleep-related movement disorders(Mauro Manconi); Motor behaviors during sleep(Floriana Boghez)

16.15- 18.30 EMG workshop: TDCS (Andrea Antal);Ultrasound (Pavel Bogdan)

19.00 Get together dinner

Sunday, July 10th

9.00-12.00 cases/presentations from the audience(Chair Ionela Codita)

Optic nerve assessment identify biomarkers of axonalpathology in multiple sclerosis – Simona Petrescu

Visual evoked potentials – the influence of technicalrecording factors – Mircea Moldovan

Hypometabolism on PET imaging of epilepticpatients – SOZ or hubs of the epileptogenic network?- Anca Adriana Arbune

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The presentation consists of some interestingelectroneuromyographic results and their correlationwith the clinical examination, in order to provideexamples of good clinical reasoning that leads to acorrect evaluation and diagnosis. All the examplesoriginate from the author’s own clinical experience.

Tudor Lupescu obtained his medical degree from“Carol Davila” University of Medicine in Bucharest,in 1989. After 3 years of training at Colentina ClinicalHospital he became Specialist in Neurology in 1994.Since 2006 he is running the Neurology Departmental Agrippa Ionescu Hospital in Bucharest. 1998, hequalified as Consultant Neurologist. Since his earlyyears of training in Neurology, Tudor Lupescu hasshown a special interest in Clinical Neurophysiology.In 2000 he earned a Competence in ClinicalNeurophysiology (EEG, EMG, and EvokedPotentials). 1997 he was the first to use TranscranialMagnetic Stimulation in Romania. This was also thesubject of his PhD thesis presented in 2005. Since2008, Tudor Lupescu is President of ASNER –Romanian Society of ElectrodiagnosticNeurophysiology. He is also founding member andvicepresident of the the Romanian Society of DiabeticNeuropathy.

Dr Tudor Lupescu is associate member of theAmerican Academy of Neurology, and associatemember of the American Association ofNeuromuscular and Electrodiagnostic Medicine.Between 2008 and 2014 he was also member of theNeurophysiology Subcommittee of ENS, and since2015, he is member of the NeurophysiologySubcommittee of the European Academy ofNeurology.

TRANSCRANIAL MAGNETIC STIMULATION- principles, technique, applications

Tudor Lupescu,

Tudor Dimitrie Lupescu

MD, Ph.D.

[email protected]

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Agrippa Ionescu Hospital, Bucharest

RoNeuro Institute for Neurological Research andDiagnosis



Restless legs syndrome (RLS) is a commonsensorimotor disorder characterized by an unpleasantsensation in the limbs that appears or worsens duringrest and night-time and disappears or improves bymovement. Other frequently associated features areinsomnia, positive family history, periodic legmovements during sleep (PLMS) and response todopamine-agonist treatment. Preferential D3 selectivedopamine-agonists are considered the first linetreatment in RLS, they improve the sensorysymptoms and suppress PLMS even at very low dosesand since the first night of administration.

PLMS are repetitive leg jerks characterized by aflexion movement at ankle, knee and hip, which arisefrom sleep and are recorded by placing two surfaceelectrodes on each tibialis anterior muscle in apolysomonographic (PSG) context. Contractionslasting from 0.5 to 10 seconds, separated by an inter-movement interval ranging between 5 and 90 seconds,and occurring at least four in a row, belong to thePLMS category. Approximately 90% of RLS patientspresent PLMS; however, PLMS can also be observedin other neurological or sleep disorders and in healthyadult/elderly subjects. Only PLMS withintermovement interval around 10-40 s responddramatically to dopamine-agonists; on the contrary,other leg movements during sleep separated byintervals approximately <5 s or >50 s and isolated legmovements are not modified, probably because theyare not under dopaminergic control.

PLMS are associated with cortical(electroencephalography, EEG) arousals andautonomic sympathetic (heart rate variability, HRV;arterial blood pressure) activations. Insomnia, on oneside, and the increased cardiovascular risk recentlyobserved in RLS patients on the other, are suspectedto be the direct clinical consequence of these corticaland autonomic activations that can occur chronicallyfor years. PLMS can be associated with insomnia atnight or daytime hypersomnia even in the absence ofRLS symptoms, in the context of the so-calledperiodic limb movement disorder. Moreover, thecardiovascular risk, especially hypertension, seems tobe correlated more with PLMS than with RLS.

Associate Professor in Neurology. NationalConcourse, from the Italian Ministry of University.

Head of the Service at the Neurocenter of theSouthern Switzerland of Lugano, Civic Hospital(Lugano, Switzerland). He is the responsible of theSleep and Epilepsy Center, coordinating a clinicalteam (5 MDs, 8 Technicians), a clinical research team(2 PostHoc), and a basic research team (2 Post Hoc)

Principal Investigator: “Swiss National Foundation”,competitive National Grant. Perinatal depression:chronobiology, sleep related risk factor and lighttherapy. Identification Number: 320030_160250 / 1(525.000 CHF).

Co-Investigator: “Swiss National Foundation”,competitive National Grant. Infra-slow oscillationsduring sleep, after acute sleep deprivation, and inpatients with restless legs syndrome/periodic legmovements during sleep (RLS/PLMS).

Head of the Service at the Sleep Center of theNeurocenter of Lugano, Civic Hospital, Switzerland.

The main field of my research regards sleep disorders,particularly sleep related movement disorders, such asrestless legs syndrome (RLS) and periodic limbmovements (PLM).

Mauro Manconi,

Mauro Manconi MD, Ph.D.

Assoc. Prof.

[email protected]

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Restless legs syndrome

Neurocenter of the Southern Switzerland of Lugano,Civic Hospital (Lugano, Switzerland)

Despite these considerations, the pathologicalmeaning of PLMS is still controversial. Are PLMSthe cause of cortical and autonomic oscillations? ArePLMS the consequence of one or both of the othertwo phenomena? Are all of these phenomena simplysynchronized but not directly related? The availabilityof powerful pharmacological suppressors of PLMS –dopamine agonists – makes it crucial to clarify ifthere is a causal relationship or a sort of hierarchicorganization of these three categories of events(cortical, autonomic, and motor) and, possibly, tocharacterize its direction.



Vagus nerve stimulation (VNS) is a worldwideapplied technique for the treatment of intractableepilepsy that cannot benefit from resective surgery.Recent clinically-controlled trials have reported a50% seizure control rate in about 30% of patients’.However, its efficacy seems to vary among teams andthe type of patients who can benefit from thistechnique is so far unknown

This safe, simple, and adjustable technique reducesthe number of seizures and multiple publicationssupport its increasing efficacy and effectiveness, withfew adverse effects. The goal of the use of VNSwould significantly increase whether the efficacy ofthis procedure and the factors predicting a response,would be known in details. Particularly the question iswho are the best candidates for VNS implantation.

VNS is not a cure, and the total elimination ofseizures is rare. However, many people who undergoVNS experience a significant (more than 50%)reduction in the frequency of seizures, as well as adecrease in seizure severity. This can greatly improvethe quality of life for people with epilepsy.

Cleveland clinic group performed an experimentaltrial in the kainic acid limbic model of epilepsy in ratstreated by VNS stimulation using the sameparameters usually used in humans.

The group from Ghent in Belgium have very recentlyreported the effect of VNS in amygdala-kindledseizures in rats. When left VNS was applied 2s afterinduction of the kindling stimulus the mean afterdischarge duration was significantly reduced after a60 s VNS train compared to the control situation(50% reduction approximately).

Patients with epilepsy uncontrolled by anticonvulsantmedications may be candidates for VNS. Thedefinition of medically intractable generally includesa description of an adequate drug trial withoutunacceptable side effects. Moreover it should bestated that candidates to VNS should have beencarefully evaluated and excluded from respectiveepilepsy surgery.

In 1999 I graduated in Medicine at the University ofBari, Bari, Italy. Research collaboration started in1994. Between 1999 and 2004 I trained as aNeurologist at the Neurological Institute of theUniversity of Bari, attending the general neurologicalward, the Centre for the Study and Treatment ofEpilepsy and the laboratory of neurophysiology. In2004 I enrolled for a PhD course in Neuroscience atthe "Department of Neurological and PsychiatricScience, University of Bari, Italy. From 2008 to 2013I had a Full position as a Consultant at Division ofNeurology, Bambino Gesu Children Hospital, Roma.

From the 2011 I am tutor for the Virtual EpilepsyAcademy (VIREPA) of the International LeagueAgainst Epilepsy leading the course on non-epilepticparoxysmal disorders.

From 2014 I am Head of Epilepsy Surgery Unit atDepartment of Neuroscience, Bambino GesuChildren’s Hospital.

I participated as invited speaker to several nationaland international congresses and workshops, andmore recently to the 10th and 11th European Congressof Epilepsy (ECE) and to the 31st InternationalEpilepsy Congress (IEC)

For the period 2011-2014 and 2014-2017 I waselected to the Board of Directors of the Italian LeagueAgainst Epilepsy.

Vagal nerve stimulation: indications and outcome.

Bambino Gesù Children’s Hospital, IRCCS, Rome,Itay

Nicola Specchio

Nicola Specchio

[email protected]

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The patient and family should be educated about thenature of the device being implanted. This includes adiscussion of the expectations of the patient and thereality that they will likely not be seizure free.

VNS has been investigated in pediatric patients withepileptic encephalopathies, Lennox-Gastautsyndrome, tuberous sclerosis, hypothalamicharmatomas and Landau-Kleffner syndrome.

More recently has been approved and commercializeda closed loop system of VNS (Aspire®) thatautomatically deliver an extra stimulation as far as itreveal an ictal tachycardia. This method mightincrease the chance of interrupting seizures and theoverall outcome of implanted patient.



Neuroplasticity became one central topic ofneuroscience research in the last decades. Dynamicmodifications of neuronal networks are an importantsubstrate for learning and memory formation.Pathological neuroplasticity might be one foundationof numerous central nervous system diseases.Transcranial direct current stimulation (tDCS) wasdeveloped by our group as a non-invasive tool toinduce neuroplasticity in the human cerebral cortex.tDCS as a tool aims to induce prolonged neuronalexcitability and activity alterations in the human brainvia alterations of the neuronal membrane potential.Accordingly, tDCS in the human is a promising toolin the treatment of diseases that are accompanied bychanges of cortical excitability. tDCS seems also tobe an efficient tool to alter learning and cognitiveperformance in healthy humans. The effects havebeen most extensively tested for the motor cortexstimulation. Unfortunately the results of the differentstudies are not always consistent. It was frequentlyobserved that the efficacy and direction of the effectsdepends on the timing of stimulation, electrodearrangement, and task characteristics, besidesanatomical and physiological factors. Future studiessystematically probing the stimulation parameters anddeveloping new protocols are needed to explore thereasons for the inconsistencies.

Extraordinary Professor, Dept. of ClinicalNeurophysiology, University Medical Center,Göttingen

2005 Habilitation, Cognitive Neuroscience, GeorgAugust University Göttingen

1998 PhD, Biological Sciences, Albert Szent-GyörgyiUniversity (Hungary)

1993 Dr. univ., Comparative Physiology, József AttilaUniversity of Szeged, (Hungary)

1990 Graduation in Molecular Biology andBiotechnology, József Attila University of Szeged(Hungary)

Research areas (present and past):

Transcranial stimulation, Neuroplasticity,Neurodegenerative disorders, Parkinson’s disease,chronic pain, Migraine

Transcranial direct current stimulation (tDCS):possibilities, clinical applications and commonpitfalls

Department of Clinical Neurophysiology

University Medical Center, Göttingen, Germany

Andrea Antal

Prof. Dr. Antal, Andrea

[email protected]

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ILS is a stimulation method that is obligatory to beperformed, along to hyperventilation during standardEEG (electroencephalogram) recording. It can beperformed using a stroboscope with variablefrequencies, between 1 and, ideal, 60 Hz in threedifferent situations: at eyes closure, with eyes closedand with eyes open for each frequency. Anothermethod may be the use of disks with with stripeshaving different diameters. clinical examples arepresented and interractively discussed aiming toundeline tips and triks of performing and interpretingILS.

Dana Craiu is Professor of Pediatric Neurology at“Carol Davila” University of Medicine Bucharest.She is a member of the EPNS Board (EuropeanPediatric Neurology Society) since 13 years ago andChair of TAB (European Training Advisory Board forPediatric Neurology) si al CNA (EuropeanCommission of National Advisors for PediatricNeurology). Since 2010 she is Chairing the EducationCommission of SRNP (Romanian Society of PediatricNeurology), and since 2015 is President of SRIE(Romanian Society Agains Epilepsy).

She is specialized in EEG, Epileptologye, video-EEGand presurgical investigation for epilepsy surgeryafter numerous courses offered by ILAE (Basic EEG,Pediatric EEG, Epilepsy treatment), San Servoloepileptology courses (2006 Epilepsy surgery, 2007Epileptology in children, 2012 Epileptology inchildren - trainer), Postdoctoral Fellowship inHeemstede, The Netherlands, for EEG, video-EEG,presurgical evaluation for epilepsy surgery.

In present she is trainer VIREPA in Basic EEG ILAEcourse.

Intermittent light stimulation method (ILS)

Carol Davila" University of Medicine, PediatricNeurology Clinic, Al Obregia Hospital,Bucharest,Romania

Dana Craiu

Prof. Dana Craiu. MD

[email protected]

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Maturation of EEG rhythms

EEG interpretation may be very difficult in children ifthe age of the patient is not specified. If the readerknows the milestones of EEG maturation, may evenappreciate the age of the subject. We present the EEGchanges induced by brain maturation and EEGvariability in different subjects at the same age. Thepresentation will bring data from the statistical studiesofering the normal limits of the frequencies indifferent ages. Interractive discussions withparticipants aiming identification of maturationalaspects of the EEG at different ages are intended.



Vegetative signs in epilepsy are an important tool forunderstanding semiology and life-threatingcomplications of the seizures and also for positive anddifferential diagnosis with other paroxysmal non-epileptic events.

Depending on localization and lateralization of theepileptic focus, these could be cardiac, respiratory,pupillary, gastro-intestinal or many others.

This presentation will present a short review ofdifferent clinical signs of seizures with video-EEGrecordings and it will outline the importance of usingpoly-graphic recordings for positive diagnosis.

MD PhD, Pediatric Neurologist, Senior Doctor,Junior Lecturer, Secretary of the Romanian Chapter –International League Against Epilepsy, Bucharest,Romania

Dr Oana Tarta-Arsene received his Medical Degreefrom the ‘Carol Davila’ University of Medicine andPharmacy University, Bucharest, Romania. She hadher resident ship in Pediatric Neurology (2000-2005)under the supervision of Professor of PediatricNeurology S. Magureanu, awarded as HonoraryMember of European Pediatric Neurology Society.During this period she was also teaching assistant inthe Department of Pediatric Neurology, ‘CarolDavila’ University of Medicine and Pharmacy, andthen junior lecturer from 2005.

She is certified as pediatric neurologist from 2005,and from then she is working in a Romanian ReferalCenter for Pediatric Neurology, her specializationbeing focused to epilepsy and from almost 10 years inepilepsy surgery. She is well-trained in epilepsy,having completed a lot of national and internationalcourses in this field, especially in EEG. Herknowledge is covered by a lot of practical work,because she is reading long term monitoring video-EEGs which are made in her department, from almost10 years.

Her Phd Thesis was also focused on epilepsy, havingas title “The contribution of Functional magneticresonance imagery in assesment of language area ofchildren with non-lesional focal epilepsy’ and beingfinished in 2012.

Vegetative signs in epileptic seizures

Departamentul de Neurologie Pediatrica, SpitalulClinic de Psihiatrie ‘Al Obregia’, Bucuresti, Romania

Oana Tarta-Arsene, Cristina Pomeran, CristinaMotoescu, Dana Craiu

Oana Tarta Arsene, MD

[email protected]

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Introduction: Minimally invasive techniques inepilepsy surgery offer many advantages toconventional surgery including addressability, costreductions and a decrease in primary and secondarymorbidity. (Quigg and Hardy, 2014) Radiofrequencythermocoagulation (RFTC) on the same depthelectrodes used for diagnosis has been demonstratedto be safe and moderately effective (Guenot 2004,2008, 2011; Catenoix 2008, 2015) although a limitednumber of centers have reported their series. Weaddress this by presenting the initial results obtainedin our center.

Methods: 8 patients received RFTC treatment at theend of their SEEG procedure from Jan. 2015 to April2016. Lesions were produced between 2 contiguouscontacts on depth electrodes (Dixi, Besancon, FR)implanted with custom (FHC Inc, Maine, USA) andstandard (Leksell, Elekta, Stockholm, SW)stereotactic frames allowing reaching most difficulttargets. A 50-V, 120-mA current was applied for 10to 40 seconds to reach an estimated temperature of78-82 C. Tissue impedance was monitored throughoutthe procedure. Contacts in the cortex showing lowvoltage fast activity or spike and wave activity atseizure onset were targeted. Prior physiologicresponses obtained at direct electrical stimulation(DES) were an exclusion criteria. Lesions’morphology was estimated at 3 months with post-procedure MRI.

Results: 2 to 10 contact pairs were coagulated perprocedure (6 patients had frontal epilepsy, 1 occipitaland 1 opercular). 6 were MRI negative cases –classically not viewed as candidates for RFCT, while2 showed a malformation of cortical developmentaspect. Median follow-up was 6 months (range 1-15).3 (37%) are seizure free (Engel I A), 4 (50%)experienced a significant improvement in eitherseizure frequency or seizure duration (Engel III) 2 ofwhich after an initial seizure free period, while 1(13%) obtained no benefit. No acute or long-termcomplications were registered.

47-year old, neurologist, with competence inelectrophysiology and special interest in epileptology,mainly presurgical exploration for epilepsy surgery.PhD thesis on “Sleep studies in epileptic syndromes”in 2006.

Current position at the University EmergencyHospital in Bucharest in the Epilepsy and SleepMonitoring Unit and also hospital coordinator of theNational Programs for Pharmacoresistant Epilepsyand Rare Disorders.

Academic affiliation - lecturer in neurology at theUniversity of Medicine and Pharmacy “Carol Davila”of Bucharest.

Vicepresident of Romanian Association for ClinicalElectrodiagnosis (ASNER) since 2009 and member inthe board of Romanian Society of Neurology since2013.

SEEG guided radiofrequency-thermocoagulation:a potential standard method for pre-resectionevaluation Ioana Mindruta

Lecturer, MD, PhD

[email protected]

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University of Physics, Bucharest Romania

Bagdasar Arseni Hospital, Functional NeurosurgeryDepartment, Bucharest Romania

Ioana Mindruta, Mihai Malaia, Irina Popa, CristianDonos, Jean Ciurea, Alin Rasina, Andrei Barborica.

Conclusions: Our early experience, confirms thetechnique’s safety profile and efficiency, even in adifficult non-lesional population. A significant impacton the seizure frequency after RFCT could have aprognostic value on the chances for open surgery tosuccessfully interfere with the alleged epileptogenicnetwork or even avoid one.



Background: Miller Fisher Syndrome is an immunemediated neuropathy characterized by ataxia,areflexia and ophthalmoplegia, with a monophasic ,self-limited course and spontaneous improvement.

Case report: The authors present a 48-year-old femalewith limb ataxia ( > left) , gaze palsy , unilateralweakness and areflexia. The symptoms developedwithin 7 days. The brain MRI was normal. Nerveconduction studies revealed reduced amplitude ofSNAPs and abnormalities in the patient’s blinkresponse. A high titer of antiGQ1b was detected . Anintravenous immunoglobulin was given and thepatient gradually improved.

Conclusion: The presented case was atypical in itsclinical course and treatment. It could support atheory of the continuity between Miller FisherSyndrome and Guillain–Barre Syndrome. Earlycorrect diagnosis is important and avoids unnecessaryinvestigations and guides appropriate use ofimmunotherapy.

Ionela Codita is currently working as a SeniorNeurologist in the Neurology Department of EliasUniversity Emergency Hospital in Bucharest. She hasgraduated “Carol Davila” University of Medicine andPharmacy in 1995 and became a specialist inNeurology in 2000.

She earned a Competence in ClinicalNeurophysiology in 2005. During her practice, dr.Codita attended many courses and teaching programsin the field of Clinical Neurophysiology such as:scholarship in Neurophysiopathology field atPoliclinical Institute of San Donato Milanese, Italy(2002-2004), training Course in EMG andNeurography Uppsala , Sweden (2009), InternationalSFEMG and QEMG Course –Kobe, Japan (2010),VIREPA distance learning courses on “EEG in thediagnosis and management of epilepsy – BasicCourse 6th edition” (September 2011- March 2012)and “EEG SCORE course-1st edition”( November2012-March 2013), the international educationalcourse “Dianalund Summer School on EEG andEpilepsy” (July 2012).

She also manifests interest in Epilepsy, Motor NeuronDiseases and Movement Disorders. Dr. Ionela Coditais a member of the Romanian Society of Neurology,affiliated to the ENFS (European Federation ofNeurological Societies) and to the WFN (WorldFederation of Neurology) and since May 2013 she isthe secretary of ASNER-The Romanian Society ofElectrodiagnostic Neurophysiology.

Miller Fisher Variant of Guillain-BarreSyndrome: A Case Report

Ionela Codita

Neurology Department of Elias University EmergencyHospital, Bucharest

Ionela Codita

MD, PhD

[email protected]

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Myelinated peripheral axons are biological structuresspecialized in energy-efficient conduction of actionpotentials. Axonal conduction involves a complicatedvoltage-gated ion channel machinery comprised ofseveral types of Na+ channels (mediating the inwarddepolarizing currents), K+ channels (mediating theoutward rectifying currents) and hyperpolarization-activated cyclic nucleotide-gated channels(mediatingthe inward rectifying currents), as well as energy-dependent pumping mechanisms required to maintainthe ionic concentration gradients across themembranes. Additionally, the spatial distribution ofthese channels is tightly controlled by axon-Schwanncell interactions.

The complicated axonal machinery ensures thatconduction can occur in conditions of alterations innear nerve environment such as variations in ionchannel concentrations or temperature. The ‘safetyfactor for conduction’ was introduced as a concept toexplain the 5 x larger voltage-gated Na channeldensity than required for ‘saltatory conduction’which e.g. can explain maintenance of peripheralconduction during antiepileptic Na+ channel blockertreatment, or preservation of conduction in partialdemyelination. Nevertheless recent developmentsindicate that the safety factor for conduction is alsocapable of a tremendous plasticity according to nerveactivity levels. Different nerves can have differentsafety factors and along the same nerve the safetyfactor can differ.

This presentation reviews recent work in my lab onsafety factor plasticity in normal and demyelinatednerves and their implications for electrodiagnosis ofconduction failure. Furthermore, this work raises hopefor developing new therapeutic strategies forimprovement of axonal conduction, with implicationsfor both peripheral and central axons.

Mihai Moldovan obtained his medical degree from“Carol Davila” University Bucharest in 1999. Basedon his research interests as a student, after graduationhe was selected to work in the group of prof.Christian Krarup that continues the Copenhagenneurophysiology school founded by prof. FritzBuchthal in the 60’ with the aim of translatingexperimental neurophysiology into clinicalelectrodiagnostic procedures for patients with nerveand muscle disease. Mihai Moldovan obtained hisPhD degree in neurophysiology from CopenhagenUniversity in 2004 where he continues his scientificcareer as associate professor. His research is focusedon distinguishing the contribution of voltage-gatedion channel dysfunction to pathophysiology ofneurodegenerative disorders, with particular emphasison peripheral nerve excitability testing. While basedin Copenhagen, Mihai Moldovan continued tocollaborate with prof .Leon Zagrean at “Carol Davila”University, Department of Physiology andNeuroscience. In 2011, he founded theCOMAEEG.RO international network, bringingtogether Romanian neuroscientists, clinicians andengineers dedicated to improving the monitoring ofthe comatose brain excitability. Emerging from thesewide research interests are not only originalpublications and review articles in internationaljournals but also educational chapters in neuroscienceand neurophysiology textbooks in Romanianlanguage. Mihai Moldovan is a member of theeditorial board member for Clinical Neurophysiology,the official scientific journal of the InternationalFederation of Clinical Neurophysiology (IFCN) andhas scientific duties in several internationalorganizations including International Brain ResearchOrganization (IBRO) and the European Federation ofNeuroscience Societies (FENS). He is also founderand acting president of the National NeuroscienceSociety of Romania (SNN) and founder of theRomanian Society of ElectrodiagnosticNeurophysiology (ASNER) for which he now servesas scientific director. For his activity he receivedseveral international and national prizes, mostrecently the 2016 ‘P.K.Thomas’ prize of the EuropeanAcandemy of Neurology.

‘Safety factor for conduction’ of peripheral axons

1) Copenhagen University DK; 2) Carol DavilaUniversity, Bucharest, RO

Mihai Moldovan (1,2)

Mihai Moldovan

Assoc. Prof., MD, Ph.D.

[email protected]

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Purpose of the study:

Our aim was to identify possible correlations betweenphysical disabilities assessed by expanded disabilitystatus score (EDSS) and neurodegenerative processmeasured by retinal nerve fibers thickness, and alsowith demyelization process measured by visualevoked potential with P100 wave latency at opticnerve level on patients diagnosed with multiplesclerosis (MS).

This study wants to find a structural biomarker atcentral nerve system (CNS) level which couldcorrelate with clinical disability. The optic nerve is anaccessible structure of CNS easy to investigate. It canoffer this answer.

Methods:

We analyzed a population of 111 patients diagnosedwith different clinical forms of multiple sclerosisbased on 2005 revised Mc Donald criteria, for whomwe assessed clinical disability by EDSS, and bydifferent subscales of multiple sclerosis composite(MSFC) as timed to walk 25 foot (TW25F) and ninehole peg test (9HPT).

Optic nerve involvement was assessed for each eyemeasuring visual acuity (VA) (Snellen chart), P100wave latency by visual evoked potential (VEP) andretinal nerve fiber layer thickness (RNFL) by opticalcoherence tomography (OCT).

Results:

The medium age of our population was 38.09and themedium EDSS was 3.3. 76 out of 111 were women.

79 patients were diagnosed with relapsing remitting(RR) MS, 7 with clinically isolated syndrome (CIS),the other were diagnosed with progressive form ofMS: 7 with primary progressive MS and one withprimary progressive with relapse MS.

senior neurologist

The Emergency University Elias Hospital

Optic nerve assessment identify biomarkers ofaxonal pathology in multiple sclerosis


Simona Petrescu

Simona Petrescu

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We obtained positive correlations, and statisticallysignificant between EDSS and 9HPT for dominanthand (r= 0.58, p=0.0001) and also for non dominanthand (r=0.66, p=0.0001) using Pearson correlation.

EDSS score correlates statistically significant withP100 wave latency and visual acuity for both eyesusing Pearson correlation, so we obtained negativecorrelation between EDSS and VA for right eye (r=-0.45 , p=0.0001), and for left eye (r=-0.49 ,p=0.0001).

We also observed statistically significant positivecorrelation between EDSS and P100 wave latency forright eye (r=0.405, p=0.0001), and left eye (r=0.400,p=0.0001).

RNFL doesn’t correlate with EDSS, VA or P100wave latency. Using chi square correlation betweenEDSS score (we choose a cut of value of 3) andpathological value of RNFL by OCT we didn’t obtaina statistical significant result. The results were : forright eye phi=0.01 , p=0.9 ), and for left eye (phi=-0.1, p=0.3 ). Similar results were obtained for EDSS of4.0. The results were: for right eye (phi=-0.009, p=0.9), and for left eye (phi=0.017, p=0.8).

Discusion:

In order to understand the pathology of multiplesclerosis the anterior optic nerve pathway offers anattractive model.

Optic nerve assessment can be realized through noninvasive complementary methods. Functional andstructural data of optic nerve can be obtained by VAmeasurement, VEP and OCT assessments.

Our study shows that axonal pathology of the opticnerve (part of CNS exclusively composed by whitematter) correlates with clinical disability measured byEDSS, suggesting that P100 latency is a functionalbiomarker of the disease.

It is needed a prospective study to validate such amarker of the progression of the disease.



The 1-hour workshop will consist of

A brief theoretical introduction in ultrasound andultrasound anatomy for peripheral nerve and nervousplexus (20 min)

Practical demonstrations (40 min).

Assistant professor, Physiology and Neurosciences“Carol Davila” University, Bucharest, RO

Specialist in Anesthesia and Intensive Care Medicineat Spitalul Clinic de Chirurgie Plastica Reparatorie siArsuri, Bucuresti

2014 PhD at UMF “Carol Davila” , Bucharest,Romania

2013 DESA – Diplomate of the European Society ofAnesthesiology - Viena, septembrie 2013

Young Teachers’s Grant (Societatea Europeana deAnestezie) – Milano, Congresul Euroanesthesia 2009

2006 MD at “Ovidius” University Constanta,Romania

Peripheral neve ultrasound workshop

Spitalul Clinic de Chirurgie Plastica Reparatorie siArsuri, Bucuresti

Bogdan Pavel

Pavel Bogdan, MD, PhD

[email protected]

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Correctly solving the inverse problem in EEG isprobably the most useful electrophysiological skill inepileptology. That is why electrical source imaginghas emerged as a leading post-processing procedure,being routinely employed in more than half of theEuropean tertiary centers for epilepsy. A wide rangeof software each implementing a multitude ofalgorithms are available on the market, many beingopen-access, however the scarcity of well-designedstudies in the field makes an informed choice betweenthem problematic. My part of the EEG-workshop willtry to offer a brief introduction into theelectrophysiological principles and the correctimplementation of these techniques followed by apractical demonstration session. A series of interictalspikes as well as the rhythmic epileptiform dischargesat the ictal debut belonging to a candidate for epilepsysurgery will be uploaded and analyzed live withBrainstorm, an open access platform with a powerfultutorial library and online community. The resultswill be compared with the intracranial solutions asobtained by the depth electrodes implantation(stereoelectroencephalography) in the SUUBlaboratory. The participants are invited to take part inthe demonstration and to later try these analyses anddiscuss the solutions obtained on their own cases.

28 year old, 3rd year neurology intern at theUniversitary Emergency Hospital Bucharest with aspecial interest in epileptology. Graduaded UMF“Carol Davila” Bucharest with honors (3rd of mypromotion). Involved in the Romanian EpilepsySurgery Program with work and experience focusedupon presurgical evaluation, implantation design viathe SEEG technique, invasive monitoring and directelectrical stimulation, resection proposal,intraoperative functional mapping and postoperativefollow up. Completed 2 grants: 3 months EANDepartment to Department Co-operation in FreiburgEpilepsiezentrum, Germany and 6 months IFCNResearch Award in Danish Epilepsy Center,Dianalund, Denmark. Member of InternationalLeague against Epilepsy, International Federation ofClinical Neurophysilogy and E-pilepsy Consortium.Research interest in electrophysiology, in particularconnectomics, brain mapping, biomarkers of theepileptogenic zone and electrical source imaging.Published original research abstracts and articles, onebook chapter and held awarded speeches at Europeanevents in the field. As non-medical interests I ampassionate about all fields of cognitive sciences butespecially keen on the study of consciousness and thephilosophical literature derived from it.

Interictal and ictal electrical source imaging:principles and practical demonstration

1Physics Department, University of Bucharest,Bucharest, Romania 2Neurology Department,University Emergency Hospital, Bucharest, Romania3Neurology Department, Carol Davila University ofMedicine and Pharmacy, Bucharest, Romania 4FHCInc, Bowdoin ME, USA

Mihai Dragos Maliia2,

Cristian Donos1, Ioana Mindruta2,3, AndreiBarborica1,

Malaia Dragos-Mihai, MD

[email protected]

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Neurologist with competence in electrophysiologyand special interest in clinical neurophysiologyworking in the University Emergency Hospital inBucharest as general neurologist and in private sectoras neurophysiologist.

Subacute tetraparesis with axonal polyneuropathy- a tricky differential diagnosis


Anca Adriana Arbune. Ana-Maria Cobzaru, CristinaTiu

Ana-Maria Cobzaru

MD

[email protected]

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Sleep represents one third of our 24-hour cycle andalmost any sleep disorder affects quality of life. Therehas been described almost 100 sleep diseases andmany of these sleep disturbances involve a motorcomponent: from periodic limb movements tonocturnal seizure and parasomnia behaviors. Sleep-related movement disorders are relatively simple andstereotyped movements that occur during sleep or atits onset. Restless leg syndrome (RLS) and periodiclimb movement (PLM) disorder are the most frequentamong them and sleep complaints and/or daytimesomnolence are the consequences of thesedisturbances. Neurophysiology can be very helpfulwith the diagnosis because polysomnography (PSG)is the gold standard for the PLM syndrome diagnosisand its severity.

Neurologist with competence in electrophysiologyand special interest in clinical neurophysiologyworking in the Clinica Academica.

Motor behaviors during sleep

*Clinica Academica, Bucharest, Romania

Floriana Boghez*, Ioana Mindruta

Floriana Boghez

MD

[email protected]

During sleep, more complex motor phenomena canoccur and in neurology practice we often find outabout nocturnal seizures in our patients. When theirclinical aspect is not tonico-clonic but more bizarre,we might also think at parasomnias, which aredisorders characterized by the occurrence of complexmotor behavioral events or experiences at sleep onset,within sleep or during arousal from sleep. It happensfrequently to resemble nocturnal seizures andsometimes the differential diagnosis can be hard.Night video-EEG and PSG should be reserved for thecases in which the diagnosis is still unclear after acareful history and physical examination.

Tetraplegia with progressive onset in young patientsgives rise to multiple differential diagnoses, varyingfrom Guillan Barre syndrome to hypoglycemia,requiring a detailed clinical examination, extensiveworkup and careful anamnesis. We present the casesof two young males (31 and 37 years old) withtetraparesis with progressive onset, admitted andtreated in the Neurology Clinic of„ the UniversityEmergency Hospital, Bucharest in 2015. The patientsdeveloped tetraparesis progressively over 4 weeks.Accompanying symptoms were hypochomicmicrocytic anemia, increased billirubin levels, mildinflammatory syndrome, in the absence of fever. Bothpatients reported weight loss and abdominal painprior to hospitalization. which was misinterpreted as arenal colic in one case and as entherocolitis in theother. The clinical examination revealed loss ofreflexes, tetraparesis with predominent involvementof proximal muscles with the sparing of sensitivity,and in one case, extensive amiotrophy . Theelectrophysiological examination confirmed motoraxonal polyneuropathy.

The patients were referred to our hospital as possiblesubacute polyradiculoneuritis for treatment with ivIG,but more thorough investigations revealed acuteintermittent porphyria and lead intoxication. Theparticularity of the cases is the presentation oftetraparesis as main manifestation in acuteintermittent porphyria, in one case induced by leadintoxication, and in the other, the late onset of the firstattack determined by lead exposure. Thedifferentiation between demyelating and axonalpolyneuropathies can only be done throughelectrophysiological examination. Acute intermittentporphyria must always be taken intro consideration asdifferential diagnosis of subacute tetraparesis anddetailed anamnesis can bring out the precipitatingfactors.



The 74 yrs old patient was first examined by aneurologist in 1960, for loss of strength in the lefthand, accompanied by amyotrophies of the smallmuscles.

Diagnosed with cervical rib syndrome, she underwentbilateral cervical surgery in 1960 and1961.

In 1976, the persistence of the symptoms at the lefthand, together with the onset of a discrete amiotrophyof the right hand, warranted a new set ofinvestigations, comprising a rachidian aerography anda myelography with lipiodol, which were normal.

Reconsidering the symptomatology, the patient wasoperated for a right side scalen syndrome.

Repeated neurographic and EMG examinations in1976, 1978, 1983 and 1984 have evidenced – withsmall variations – an aspect of denervation in thesmall muscles of the left hand, and a discretedenervation in the right hand, with a prolonged distallatency of the right median nerve.

The differential envisaged syndromes of compressionof the brachial plexus, siringomyelia, CMT disease,motor neuron disease, monomyelinic amyotrophy,which were discarded.

About 20 years after debut, in 1983, with a stationaryneurological symptomatology, the hypothesis of amonomyelinic atrophy type O'Sulivan wasformulated.

Prof Dr V Voiculescu appreciated the association ofthe sensitivity disorders of the left forearm with theamiotrophy as being determined by a partial lesion ofthe left brachial plexus, secondary to a calcificatedfibrosis of the left lung apex after a therapeuticpneumothorax at 9 year of age.

Stabilized for 40 years, the patient returned to beconsulted subsequent to the onset of pain andparesthesia in the fingers of the right hand, as well asMRI evidenced degenerative alterations of thecervical spine.

Dr. Mircea Moldovan, graduate of the “Carol Davila”University Bucharest, Doctor of Medical Sciences,MD is a neurologist at the Hospital “Elias” Bucharestsince 1968. Throughout his career, he had acontinuous interest for clinical neurophysiology. Inthe 80s, his main interest was the EEG and evokedpotentials under the guidance of Prof Dr VVoiculescu. In the 90s, his interest expanded to theperipheral conduction studies and EMG. During hispioneering work in Romanian clinicalneurophysiology, Mircea Moldovan advocated thediagnostic importance of clinical neurophysiology forneurological practice through talks at nationalscientific meetings and scientific publications. Mostimportantly, however, through his wealth of practicalexperience and didactic spirit, he helped initiate inclinical neurophysiology generations of youngneurologists. During the last decade, with thetransformation of “Elias” hospital neurology into auniversity department and re-formalizing his skills inEMG (2003) and EEG (2004), Dr. Mircea Moldovandeveloped his preoccupation for clinicalneurophysiology teaching. Together with Dr. IonelaCodita he carries out practical demonstrations of post-graduate courses organized by Professor Dr. PaneaEMG. In addition, Dr. Mircea Moldovan contributedto re-launch of the clinical neurophysiology society inRomania as founding member of ASNER 2009.

Asymmetrical amyotrophy of the small muscles ofthe hand A historical retrospective of diagnosisand therapy as homage to our professors


Mircea Moldovan, Ionela Codita, E Georgescu

Mircea Moldovan

MD, PhD

[email protected]

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The actual neurographic examination confirmation ofthe sensory impairment of the left ulnar nerve and didnot show significant differences with the 1984 Acomprehensive diagnosis remains a challenge to thisday… This prezentation was determined by the wishto evaluate the historical stages of diagnostic,investigation and treatament, in homage to ourcolleagues from the Neurology department, and inmemory of the invaluable clinical lessons of Prof.Dr.V. Voiculescu.



Introduction: Treatment resistant epilepsy is agrowing problem and requires complex investigationsto identify the seizure onset zone (SOZ) for thepossibility of a surgical cure. PET imaging observesthe metabolism of tissues, so that in epilepsyhypometabolic areas in the interictal periods appeardue to increased activity during seizures and postictalglucose depletion.

Methods: We present the cases of three patients withtreatment resistant epilepsy who underwent video-EEG long term monitoring, had MRI (epilepsyprotocol), PET scan. The patients were invasivelyexplored with depth electrodes and continuouslymonitored for 7-14 days. We recorded spontaneousseizures and did functional stimulations. Individualresection plans were conceived.

Results: We observed two males, 39 and 7 years old,and one female, 34 years old, with conflictinginformation from the video-EEG recordings, brainMRI and PET. The PET hypometabolism areas werelocated in the opposite hemisphere or at a distancefrom the SOZ identified by anatomo-electro-clinicalcorrelations. SOZ surgical resections were conducted,with no postoperatory deficits. Outcome of allpatients is Engel I.

Discussions: We observed that the commoncharacteristic of all patients was the rapid propagationfrom the SOZ to the structures that were correctlyidentified by PET imaging as hypometabolic,concluding that PET had successfully identified themain hubs of the epileptogenic network. Previousstudies documented that these areas express the extentof the epileptogenic network and are correlated withseizure duration and gender.

Conclusions: PET imaging brings valuableinformation regarding the epileptogenic network butsometimes can be misleading. Epilepsy surgeryshould only be pursued after the anatomo-electro-clinical correlation of all information available.

Hypometabolism on PET imaging of epilepticpatients – SOZ or hubs of the epileptogenicnetwork?

Spitalul Universitar de Urgenta Bucuresti, Bucuresti,Romania

Anca Adriana Arbune

Mihai Dragos Măliia, Irina Popa, Andrei Daneasa,Csilla Nagy, Ioana Mindruta

The visual evoked potential – VEP – represents thecerebral cortex' answer to the stimulation by light ofthe macular and perimacular area of the retina. TheP100 latency – the constant average value – isconsidered a reliable indicator of clinical pathologicalmodifications. The amplitudes of the evoked answerwere associated with the axonal lesions. The presenceof an asymetry of VEP amplitude between the twoeyes has determined the following observations:

Case 1. A 41yrs old woman, was examined for therecent diminishing of visual acuity of the left eye,through VCR thrombosis. The MRI examinationrevealed a compression of the optical nerve, in thesupracavernous portion of ACI. On stimulation withsize 8 Check, the VEP latency and amplitude wasequal, normal, bilaterally. On stimulation with size 16Check, the left eye N45 /P100 amplitude was approx.30% smaller, and the P100/ N145 amplitude 50%smaller, in standard laboratory conditions. The P100values of amplitude are much more sensitive in ocularand retinian lesions, than the latency values.

Case 2. A 55 yrs old man was first examined inDecember 2015 for diminished visual acuity of theleft eye, onset several months earlier. Theophtalmological investigations revealed a centralscotom in the eye, lowered RNFL in the temporalquadrant, macula with normal aspect; the MRI wasnormal. The EMG examination (without dioptriccorrection) has shown normal VEP morphology, anaverage latency of 108 ms, and the N75/P100/N145amplitude 20% smaller in the left eye. Reexamined in2016, the VEP parameters without dioptric correctionwere similar to those from 2015: the average latencyP100 of 107 ms and the amplitude approx. 20%smaller in the left eye. Subsequent examination withdioptric correction of +1,25 heliomat and UVprotection, presented a VEP wider [larger saubroader] in "W", with prolonged latency and slightlyreduced amplitude, with pathological aspect.

Conclusion: The first case shows the importance ofrecording with different dimensions of the Check size,in order to reveal the ocular, retinal lesion. Thesecond case demonstrates the value of dioptriccorrection in evidencing the pathologicalmodifications compatible with a retrobulbar lesion ofthe optical nerve.

Visual evoked potentials – the influence oftechnical recording factors


Mircea Moldovan

Ionela Codita , Simona Petrescu, E Georgesu, OanaNeagu, Bogdan Catalin

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The 7th Summer School of ASNER, The Romanian Society of