The National Conference of ASNER The Romanian Society of ... · 17.30 - 18.00. Dan Filip - Neuromonitorizarea intraoperatorie a nervilor cranieni ... the assesment of lower motor

www.asner.org

The 10th National Conference of ASNER,

The Romanian Society of Electrodiagnostic Neurophysiology

CN2018, Bucharest, RomaniaOctober 26 – October 28, 2018

Program & Abstract book

Daniel Danielopolu 44 Bucharest 014134

ASNER CN2018 Bucharest, 26-28 October 2018 – Program & Abstract book10th National Conference of the Romanian Society of Electrodiagnostic Neurophysiology

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Scientific partners:

.ROSocietatea Națională

de Neuroștiințe

Societatea RomânăÎmpotriva Epilepsiei


Dear Friends,

So here we are again, for the 10th time, and I find itreally remarkable. Every single year since 2009 wehave managed to organize a National Conference inClinical Neurophysiology, in which we tried to invitethe best experts in the field. Our goal was to spreadgood practice in clinical neurophysiologicaltechniques among those who are interested anddedicated, but also to promote research. And I daresay, we are on the right path, and we are determinedto continue. Some of you have been with us from thebeginning, many of you have attended a few times,and others are newcomers, but all of us have one thingin common, namely our passion for neurophysiology.

As always, this year we have organized practicalsessions, plenary sessions, and case presentations. Weintend thus to present some practical aspects, to hearinteresting lectures from our guests, and to share ourown experiences with each other.

So prepare for a few days of intense scientific activitywith ample opportunities for networking, and to makenew friends.

The conference has been awarded 14 CME credits.

Welcome to the 10th edition of the ASNER NationalConference.

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.

ASNER Secretary

Neurology Department of Elias UniversityEmergency Hospital, Bucharest, Romania

[email protected]

Ana-Maria Cobzaru, M.D.

ASNER Treasurer

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

[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/


Vineri, Oct 26

13.00 - 17.30 Sesiune practică EEG

• Ioana Mîndruță - Criterii minime care trebuieindeplinite pentru inregistrarile EEG - oresponsabilitate medicala si legala

• Oana Tarta, Dana Craiu - Criterii minime caretrebuie indeplinite pentru inregistrarile EEG lacopil - o responsabilitate medicala si legala

• Mihai Malaia – Corelatii electroclinice

• Irina Popa - Criterii minime pentru long termmonitoring

15.00 - 15.30: Pauza de cafea

15.30 - 17.30 Ioana Mîndruță: Hands-on - înregistrareEEG, montaje, artefacte

13.00 - 18.00 Sesiune practică EMG / studii deexcitabilitate

13.00 - 15.00 EMG

• Jonathan Cole - Evaluarea pacienților în vedereaorientării studiilor de conducere nervoasă și aelectromiografiei

• Tudor Lupescu - Înregistrari nervi periferici,mușchi - repere, tehnică, artefacte.

15.00 - 15.30: Pauza de cafea

15.30 - 17.30 Studii de excitabilitate

• Hatice Tankisi - Principii ale studiilor deexcitabilitate musculara

• Mihai Moldovan - Aplicații ale studiilor deexcitabilitate nervoasă

Sâmbătă, Oct 27 – Partea 1

08.30 - 09.00 Deschiderea Conferinței

09.00 - 11.00 Sesiune plenară 1 (Chair: TudorLupescu)

09.00 - 09.45 Jonathan Cole - Neurofiziologiasistemului senzitiv

09.45 - 10.30 Hatice Tankisi - Metode noi deevaluare a pacienților cu scleroză laterală amiotrofică

10.30 - 11.00 Tudor Lupescu - Rasfoindelectromiografii

11.00 - 11.30 Pauză de cafea

11.30 - 13.30 Sesiune plenară 2 (Chair IoanaMîndruță)

11.30 - 12.15 . Jean-Baptiste Eichenlaub - Creierulvisător - aprofundare a comportamentului și aelectrofiziologiei

12.15 - 13.30. Evaluarea prechirurgicală în epilepsie

Irina Popa - Afectarea cortexului cingular în epilepsiade lob frontal

Mihai Malaia - Epilepsia insulară

Ioana Mîndruță - Epilepsia cortexului orbitofrontal

13.30 - 14.30 Pauză prânz

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Sâmbătă, Oct 27 – Partea 2

14.30 - 16.30 Sesiune plenară 3 (Chair MihaiModovan)

14.30 - 15.00. Mihai Moldovan - Excitabilitatea îndegenerarea și regenerarea nervilor

15.00 - 15.30 Florin Antonescu Marin Adam -MUNIX – Principii și utilitate. Aplicare practică lapacienții cu SLA.

15.30 - 16.00 Mircea Moldovan - Gestul antagonist(manevra care poate ameliora temporar distonia )Prezentare de caz cu date din literatura

16.00 - 16.30 Simpozion - Aspecte practice alediagnosticului și tratamentului în polineuropatiaamiloidotică transtiretinică (Mirela, Drăghici, AmaliaEne)

16.30 - 17.00 Pauză cafea

17:00 – 19:00 Sesiune plenară 4 (Chair Ana MariaCobzaru)

17.00 - 17.30. Adina Roceanu - Migrena – actualitățiîn tratament

17.30 - 18.00. Dan Filip - Neuromonitorizareaintraoperatorie a nervilor cranieni

18.00- 18.30. Ionela Codiță - Monitorizarea închirurgia tumorilor spinale intradurale - metodologieși prezentare de caz.

18.30 - 19.00 Oana Obrișcă, Ana Maria Cobzaru - Ceascunde un picior căzut?

Duminică, Oct 28

08.30 - 10.00 Prezentări de cazuri EEG și EMG(Chair Ionela Codiță)

• Florentina Melania Ivanciu. Durerea în SLA –Prezentare de caz

• Eliza Mihai. Aspecte genetice in SLA

• Mircea Modovan, Dr Ionela Codita, Dr PatriciaToboc - Neuropatie izolata de nerv peronealsuperficial-posibil septinevrită

• Izabela Popa - AIDP sau CIDP cu debut acut?

• Nicu Drăghici - Un caz (a)tipic de slăbiciunegeneralizată

• Gianina Maria Balea, Livia Livinț Popa, RoxanaAiloaiei, Adina Danci, Tudor Lupescu, Dafin FiorMureșanu - Stiff Person Syndrome: boalaneurologica cu caracteristici neurofiziologiceparticular

• Raluca Simona Gurgu - Capcane in diagnosticuldiferential dintre sincopa si criza epileptica -prezentare de caz

• Alina Popescu - Physio-pathological aspects andEEG patterns in acute post stroke epilepticseizures and vascular epilepsy

10.00 - 10.30 Simona Petrescu - Aderența la terapieîn scleroza multiplă

10.30 - 11.00 Pauză

11.00 - 12.00 Quiz EMG/EEG

12.00 - 13.00 Discuții, concluzii, înmânareacertificatelor de participare, feed-back.

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When navigating in a spatial environment or whenhearing its description, we can develop a mentalmodel which may be represented in the centralnervous system in different coordinate systems suchas an egocentric or allocentric reference frame. Theway in which sensory experience influences thepreferred reference frame has been studied with aparticular interest for the role of vision. The presentstudy investigated the influence of proprioception onhuman spatial cognition. The main finding of thisstudy is that proprioception can influence the timenecessary to use spatial representations while otherfactors such as visuo-spatial abilities can influence thecapacity to form accurate spatial representations.https://doi.org/10.3389/fpsyg.2018.01322

At the workshop, he will present his clinical approachto EMG and NCS: take a clinical history, listen to thepatient, decide what could be wrong and thenconfirm/exclude it and decide on severity etc.

The neurophysiology of severe sensory loss

Clinical Neurophysiology, Poole Hospital, andCentre of Postgraduate Research and Education,University of Bournemouth, Poole, United Kingdom

Jonathan Cole

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Jonathan Cole is a consultant in ClinicalNeurophysiology at Poole Hospital and professor atthe University of Bournemouth. His research has beenin sensory loss and its consequences, motor controland in spinal cord injury and pain, tremor. His booksinclude Pride and Daily Marathon (1995) and LosingTouch, (2016) on Ian Waterman who lives withouttouch and proprioception, and Still Lives (2004), onliving with spinal cord injury. His other enduringinterest is on the face and its relation to self. He haswritten About Face, (1998) and The Invisible Smile,(2008).

He is a past-President of the British Society forClinical Neurophysiology, was Chair of theInternational Conference in Clinical Neurophysiologyin 2006 and is at present Chair of the EuropeanChapter of the International Federation of ClinicalNeurophysiology and its representative on the IFCNExecutive.

Professor Jonathan Cole

[email protected]

https://doi.org/10.3389/fpsyg.2018.01322


Amyotrophic lateral sclerosis (ALS) is a a fatalneuromuscular disease characterized by involvementof upper and lower motor neurons.Electrophysiological studies are of great importancefor the diagnosis and the exclusion of ALS-mimicking disorders. The focus of this talk will be toreview the conventional and novelelectrophysiological methods in diagnosis and follow-up of ALS.

Quantitative or qualitative electromyography (EMG)and nerve conduction studies (NCS) are the mainlyused conventional electrophysiological methods forthe assesment of lower motor neuron involvement inALS. The limitations of these conventional methodswill be discussed and the use of novel motor unitnumber estimation (MUNE) method, MScanFitMUNE in diagnosis and follow-up of ALS will beintroduced to the audience. Moreover, nerve andmuscle excitability testing in ALS will be discussed.For the upper motor neuron involvement, the use ofconventional single pulse trancranial magneticstimulation (TMS) methods will be reviewed. Finally,the literature for triple stimulation TMS and the novelpaired-pulse TMS technique, threshold tracking TMSfor the diagnosis of ALS will be summarised.

Medical doctor:1990, Bursa, Turkey

Specialist in Neurology: 1995, Ankara, Turkey

PhD dissertation:2004, Aarhus University, Denmark

Specialist in Neurology: 2010, Denmark

Specialist in Neurophysiology: 2011, Denmark

Present appointments

Consultant, Department of Clinical Neurophysiology,Aarhus University Hospital, Denmark, Feb 2012-

Associate professor, lecturer, Aarhus University,February 2011-

Membership and leadership activities

Secretary/treasurer, European Chapter- InternationalFederation of Clin. Neurophysiol., ExecutiveCommittee

Member of International Multicenter DOLOriskproject, 2016-

Member of International Diabetic NeuropathyConsortium (IDNC), 2015-

Member of the European Multicenter EMG networkESTEEM 2000-

Main research interests

Electrodiagnostics and pathophysiology inpolyneuropathy and ALS

Quantitative EMG and MUNE methods in normal anddiseased muscles/nerves

Laser evoked potentials in diagnosis of small fibrenerve involvement

Peripheral nerve, muscle and cortical excitability testswith threshold tracking

Novel electrophysiological methods in diagnosisand follow-up of ALS

Department of Clinical Neurophysiology, AarhusUniversity Hospital, Aarhus, Denmark.

Hatice Tankisi, Associate Professor, MD, PhD.

Hatice Tankisi, AssociateProfessor, MD, PhD.

[email protected]

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LPNC, CNRS 5105, University of Grenoble Alpes,Grenoble, France

Jean-Baptiste Eichenlaub holds a PhD inneuroscience from Lyon University (France, 2011).His research interest includes the incorporation ofwaking-life experiences into dream content, thecerebral correlates of dream recall frequency, andthe neural mechanisms underlying offline memoryprocessing.

Jean-Baptiste Eichenlaub

[email protected]

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The dreaming brain is complex and poorlyunderstood. However, recent advances inneuroscience have provided a better understanding ofhow and why we dream. This presentation willintroduce recent behavioral and electrophysiologicalstudies that explored the content and the neuralcorrelates of dreaming. More precisely, I will describethe relationship of dream content to previous wakinglife experiences and possible electroencephalographicmarkers of such phenomenon

The Dreaming brain: insights from behavior andelectrophysiology

Laboratoire de Psychologie et NeuroCognition(LPNC), Grenoble, France

Jean-Baptiste Eichenlaub


In the constantly developing field of clinicalneurophysiology, in which technology and knowledgehave made possible very precise and detaileddiagnostic findings, as in intracranial EEG recordingsor magnetoencephalography, and also therapeuticapproaches with transcranial stimulation (fordepression, migraine, neuropathic pain), EMG maylook kind of old-fashioned and obsolete. Recently, Iread an article by a Belgian author: "Pourquoil'ENMG ne disparaitra pas en 2046...", and it mademe more optimistic, because there are certain aspectsin diseases of the peripheral nervous system thatcannot be described yet by other means.

A purposeful, skilled, and logicalelectroneuromyographic examination that follows athorough clinical examination, can lead to valuableand meaningful conclusions.

This presentation will try to exemplify some clinicalsituations in which the EMG recordings are helpfuland revealing.

Surfing EMG Waveforms

Spitalul Clinic de Urgenta "Prof Dr Agrippa Ionescu"

Tudor Lupescu

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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 Fellow of the AmericanAcademy of Neurology, and associate member of theAmerican Association of Neuromuscular andElectrodiagnostic Medicine. Between 2008 and 2014he was also member of the NeurophysiologySubcommittee of ENS, and since 2015, he is memberof the Neurophysiology Subcommittee of theEuropean Academy of Neurology.

Tudor Dimitrie Lupescu

MD, Ph.D.

[email protected]


48-year old, neurologist, with competence inelectrophysiology and special interest in epileptology,mainly invasive presurgical exploration for epilepsysurgery, neurostimulation and brain connectivity. PhDthesis on “Sleep studies in epileptic syndromes” in2006.

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.

Ioana Mindruta

Lecturer, MD, PhD

[email protected]

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Orbitofrontal cortex epilepsy is characterized by:

Interictal epileptiform discharges are distributed inthe frontal, frontopolar, or frontotemporal areasand sometimes exclusively in temporal areas

Orbitofrontal cortex through its anatomo-functionalconnections engage two types of propagationnetworks

to mesial temporal structures (deja-vufeelings, oroalimentary and manualautomatisms)to dorsolateral or medial frontal regions(hyperactive automatisms with frenetic,agitated movements)

Ictal discharges starting in the orbitofrontal region areclinically silent until they propagate to otherstructures (Munari and Bancaud, 1992)

Ictal discharges, recorded either over the temporal orfrontal areas, are often diffuse or obscured bymotion artifacts - no localizing value

Flattening or attenuation of the backgroundactivity sometimes precedes the seizure onset

The final diagnosis is usually established byintracranial EEG

Recent review of 17 cases – surgical outcome isgenerally good but neuropsychological outcome isless well documented (Chibane et al, 2016)

Orbitofrontal cortex epilepsy

1,2,3Neurology Department, University EmergencyHospital, Bucharest, Romania4Neurosurgery Department, Bagdasar-ArseniHospital, Bucharest, Romania5Physics Department, University of Bucharest,Bucharest, Romania

Ioana Mindruta1,

Anca Arbune2, Andrei Daneasa3, Jean Ciurea4,Andrei Barborica5


Conventional nerve conduction studies provideinformation about the number of conducting axons aswell as their conduction velocity along theinvestigated segment, a surrogate marker ofmyelination. In contrast, nerve excitability testingasses ion channel function and resting membranepotential at the site of stimulation providing an uniqueinsight into the disease mechanisms.

From the patients’s perspective, excitability testing isa simple continuation of conventional studies. Thetest is commonly performed on the median nervemotor and sensory axons stimulated at wrist. A testtakes about 15 minutes and consists of a sequence ofmeasures controlled automatically by a computer: 1)charge-duration, threshold electrotonus, current-threshold and recovery cycle. Results are given as aset of numeric excitability indices derived from themeasures. Deviations from control values isinterpreted based on a increasing number of literaturereports in different pathologies. A mathematicalmodel is available to aid the interpretation.

The presentation will review the use of nerveexcitability methods in the investigation of changes inaxonal passive cable properties as well as axonalvoltage-dependent properties that occur indegenerating/regenerating axons A comparison willbe made with demyelination/remyelination inhereditary polyneuropathies.

The presentation will be supported by a “hands-on”demonstration on the practical steps leading torecording/analysis of a nerve excitability test and itsthe interpretation.

Mihai Moldovan obtained his medical degree from“Carol Davila” University Bucharest in 1999 and PhDdegree in neurophysiology from CopenhagenUniversity in 2004 where he continues his academiccareer.

2019 Organizer of the Nerve excitability hands oncourse at the Congress of the European Academy ofNeurology EAN2019, https://www.ean.org/oslo2019

2019 Faculty at the Master Course Electrodiagnostictechniques (University of Barcelona)https://edxneuro.com)

2019 Co-Chair of the Federation of EuropeanNeuroscience Societies (FENS) forum 2019https://www.fensfrm2019.rs

•2016, ‘P.K.Thomas’ prize of the European Academyof Neurology.

• Since 2014, elected full member in the EuropeanDana Alliance for the Brain (EDAB).

• Since 2013, serving on general council of Federationof European Neuroscience Societies (FENS) andInternational Brain Research Organization (IBRO).

• Since 2012, President of the National NeuroscienceSociety of Romania (SNN), a FENS member.

• 2012-2018, editorial board member for ClinicalNeurophysiology, the official scientific journal of theInternational Federation of Clinical Neurophysiology(IFCN).

• Since 2009, Scientific director of the Romaniansociety for electrodiagnostic neurophysiology(ASNER), an IFCN member.

• Since 2009, Invited professor and research directorassociated to the Department of Physiology andFundamental Neurosciences, "Carol Davila”University of Medicine and Pharmacy, BucharestRomania;

Nerve excitability testing as a tool to investigateperipheral nerve degeneration/regeneration

1) Copenhagen University DK;

2) Carol Davila University, Bucharest, RO

Mihai Moldovan (1,2)

Mihai Moldovan

Assoc. Prof., MD, Ph.D.

[email protected]

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https://www.ean.org/oslo2019

https://edxneuro.com/

https://www.fensfrm2019.rs/


nvoluntary movements with many unknownmechanisms and difficult to appreciate.Blepharospasm – involuntary, unpredictable,synchronic, bilateral contractions of the orbicularmuscle – is a form of focal dystonia with a frequencyof 16-133 cases per million, more frequent in thefemale sex. Along with numerous drugs administeredwith inconsistent results, the antagonist gesture hasreceived the test of time. Antagonist gesture meanstouching the face, chin or head region, contralateral oripsilateral to the direction in which dystonia occursThe mechanism of action by which the "sensory trick"used by patients with dystonic blepharospasm arerelieving symptoms is not known. The duration ofsymptom relief by this gesture is variable. In 42% ofcases is about 1 minute or less; however in 30% ofpatients the normal posture of the head can bemantained as long as the gesture is continued almost50%

The case of a XX patient with blepharospasm.Usually, the neurophysiological exploration consistsin performing a blink reflex in a classic way with theactive electrode in the orbital angle ,the referenceelectrode on the nsasal wing and the earth electrodeon thhe tip of the chin. The stimulation is made on thetrigeminal branch at the level of the supraorbitaltrench with the cathode on the forehead. During theapplication of the electrodes, a reduction ofinvoluntary eye movement was observed. Thelattency and the amplitude of the R1 and R2 ipsi andcontralateral responses were normal. After the end ofthe exam, the electrode was left in place (righttemporal orbital) and reduction of involuntarymovements was observed This observation wascommunicated to the patient, with therecommendation to use the method. After approx. 3months, the outcome is not known. This observation,supported by literature data, is an argument forframing amelioration in the category of antagonisticgestures and is perceived as a simple (trick) maneuverthat can be tried in cases of blepharospasm

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.

Mircea Moldovan

MD, PhD

[email protected]

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The Geste Antagoniste, or sensory “ trick”maneuver that can temporarily relieve dystonia

Case presentation with literature data

Neurology Department of Elias University EmergencyHospital, Bucharest

Mircea Moldovan*

Dr Ionela Codita SUU Elias, Dr E Georgescu SUUElias, Dr Patricia Toboc - Medlife, Dr AnamariaDragomir -Polimed Targoviste

*


Senior neurologist since 2005

Certificate of complementary studies inelectromyography - Bucharest, 2013

International Course on Intraoperative Spinal Disease- Istanbul 2014

Intraoperative Neuromonitoring Course - "TheEssentials" - EANS Verona 2015

Cerebral Intraoperative Neuromonitoring Course -Groningen 2016

Physician Doctor - ULB Sibiu - 2017, with the theme"The contribution of intraoperative neurophysiologicmonitoring in neurosurgery"

Experience gained in Neurophysiologic IntraoperativeMonitoring with the Polisano Hospital Brain Team -over 100 cases since 2014 - of which 42 brain tumors,35 cases with cervicodorsal pathology, 10 cases withsubtentorial pathology and 13 cases with complexlumbosacral conditions.

Member of ASNER (Asociația Societatea deNeurofiziologie Electrodiagnostică din România) andISIN (International Society of IntraoperativeNeurophysiology)

Intraoperative neuromonitoring (IONM) ofcranial nerves

Spitalul European Polisano Sibiu

Filip Dan

Filip Dan , MD, PhD

<[email protected]

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Introduction:

Due to the dense concentration of nervous structuresand neurophysiological functions in the brainstem,surgical morbidity is high as compared to otherstructures of the central nervous system. IONM aimsat reducing complications and postoperativeneurological morbidity by delivering real timeinformation about the integrity of nervous structures,thus becoming one of the most valuable means ofprotection for patients during surgical interventions.IONM warns the surgeons in due time in order forthem to take corrective measures so that irreversibleneurological injuries do not occur. At the same time,IONM allows that a more radical resection isperformed.

Methods: IONM trough spontaneouselectromyography of the cranial nerves.

We used needle electrodes inserted sub-dermally atthe level of the main cranial nerves which neededmonitoring. The spontaneous activity on theelectromyography was continuously monitored, whilesignificant pathological electrical discharges werenoted.

IONM through direct stimulation of the cranial nerves(mapping)

The recording of the compound motor potentials as aresult of the direct nervous stimulation is done at thelevel of the same muscles used for the spontaneouselectromyography. Thus, the eloquent cranial nerveswere identified from the operation field and theirfunctionality was verified in real time.

Corticonuclear MEP monitoring

The aim was to obtain corticonuclear motor evokedpotentials especially for the trigeminal nerve, thefacial and glossopharyngeal nerve, while monitoringthe stimulation threshold, the latency, the amplitudeand their morphology.

Brainstem auditory evoked potentials (BAEP)

As a result of the auditory stimulation successivenegative potentials at 1.5 – 6 ms, registered from I toV are obtained. We continuously observed thelatencies of these waves, the interval between themand their amplitude, as well as the modifications ascompared to the basic traces.

Visual evoked potentials VEP

There were two cases of hypophysealmacroadenomas, which were surgically approachedtransnasal and which required monitoring of visualevoked potentials. These were acquired throughintermittent light stimulation with the help of specialglasses provided with LEDs.

We will present our experience in monitoring thecranial nerves intraoperatively.


OBIECTIVUL ŞI METODA

Evaluarea progresiei SLA, mai ales în stadiile inițiale,este relativ dificilă, iar metodele uzitate curent, bazatepe scoruri funcționale (ALSFRS-R) sau pe evaluareaclinică a forței de contracție (MRC) tind să fiegrosiere. Tehnicile de estimare ale număruluiunităților motorii (MUNE) s-au dovedit fiabile înaceastă direcție, dar sunt adesea laborioase,consumatoare de timp şi dificil de tolerat de cătrepacienți. MUNIX reprezintă o metodă nouă careactual pare să aibă fiabilitate cel puțin similară cutehnicile MUNE, dar cu evidente avantaje practice.

Recent am desfăşurat în clinica noastră un studiupentru evaluare abilităților diagnostice ale MUNIXcomparând pacienți cu SLA cu pacienți fără bolineuromusculare și ne propunem să împărtăşim dinexperiența noastră, prezentând unele aspecte practiceaşa cum le-am perceput și implementat noi.

REZULTATE

Analiza MUNIX s-a dovedit relativ simplu deefectuat, adăugând duratei examinării aproximativ 5minute pentru fiecare mușchi examinat și 10 minute lafinal pentru prelucrarea datelor. Sistemele de EMGîncep să integreze în dotarea standard analizaMUNIX, automatizând procesul de interpretarea șiraportare, astfel încât cel mai probabil timpii vorscădea în viitorul apropiat.

Mușchii distali ai mâinii și tibialul anterior sunt ceimai ușor de evaluat, dar practic MUNIX poate fiefectuată pentru orice mușchi pentru care putemobține un CMAP adecvat și putem grada forța decontracție. Calitatea rezultatelor depinde foarte multde optimizarea poziționării astfel încât să obținem ovaloare maximă a CMAP pentru mușchiul vizat.

În studiul nostru evaluarea pacienților cu SLA deșiperfect fiabilă s-a dovedit mult mai dificilă decât apacienților din lotul de control, aspect care trebuieluat în calcul în proiectarea studiilor viitoare.

Este medic specialist neurolog în cadru InstitutuluiNațional de Neurologie și Boli Neurovasculare,București, unde desfășoară activitate clinică șicoordonează laboratorul de EMG. Este doctorand șiasistent universitar la catedra de Neurologie a UMF„Carol Davila”

MUNIX ÎN PRACTICĂ LA PACIENȚII CU SLA

1 Institutul Naţional de Neurologie şi BoliNeurovasculare, Bucureşti2 UMF Carol Davila, Bucureşti3 Centrul de diagnostic MEDINST, Bucureşti

1,2Florian. Antonescu3 M. Adam

Florian Antonescu

[email protected]

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Principalele aspecte limitative au fost obezitatea,tremorul, deficitul motor sever care nu permitegradarea adecvată a forței de contractie și tulburărilecognitive.

După calcularea MUNIX, se dovedește utilăreprezentarea grafică a valorilor inițiale în paralel culinia de regresie, deoarece permite un control vizual alrelației matematice şi ajută la corectarea erorilor.

CONCLUZII

MUNIX reprezintă o tehnică relativ nouă care seapropie de maturitate și are șanse să devină principalametodă de urmărire a pierderii neuronale în bolile deneuron motor.

Deși poate fi utilă și pentru diagnostic și existălaboratoare care au început procesul de standardizarea valorilor normale, metoda este mai utilă înurmărirea longitudinală a pierderii neuronale, inclusivîn faza presimptomatică a unui mușchi, și estecapabilă de a prezice prezența denervării.

Metoda este relativ ușor de implementat și, deși nueste lipsită de limitări, ar trebui inclusă în evaluareastandard a pacienților cu SLA


OBIECTIV ŞI METODA

Ne-am propus o aducere la zi a aspectelor genetice înscleroza laterală amiotrofică (SLA). Am efectuat otrecere în revistă a literaturii actuale cu referire laprincipalele mutaţii genetice, particularităţilefenotipice şi prognostice specifice genelor implicate,diferenţele epidemiologice şi, nu în ultimul, rândperspectivele terapiei genice.

REZULTATE

Scleroza laterală amiotrofică familială (SLAF) esteheterogenă fenotipic şi genotipic şi reprezintă 5-10%din totalul cazurilor de SLA. Principalul tip detransmitere este autozomal dominant, iar cele maifrecvent implicate gene sunt C9ORF72, SOD1, FUSşi TARDBP.

În majoritatea cazurilor este greu de precizat, mai alesla debutul bolii, dacă ne aflăm în faţa unei formesporadice sau familiale, totuşi caracteristici atipicecum ar fi vârsta tânără de debut, istoricul familial deSLA, demenţa fronto-temporală sau alte bolineurodegenerative asociate precum şi afectareasenzitivă ar trebui să alerteze clinicianul spreposibilitatea de SLAF.

Deşi toate mutaţiile genelor implicate conduc spreaceeaşi cale finală (degenerarea şi moartea neuronuluimotor), iar fenotipurile sunt similare, mecanismelefiziopatologice sunt heterogene şi complexeincluzând în funcţie de gena afectată: anomalii înmetabolismul ARN, toxicitate mediată SOD1,excitotoxicitate, defecte de citoschelet, disfuncţiimitocondriale etc..

Particularităţile fenotipice specifice diferitelor geneafectate precum şi diferența mare în ce priveşte ratamutațiilor între populația Europei și a Asiei îndrumăclinicianul în ierarhizarea genelor care trebuie testate.

Mihai Damaris Eliza este absolventa a Facultatii deMedicina si Farmacie, Universitatea Lucian Blaga dinSibiu, in prezent rezidenta in anul III, specialitateaNeurologie la Institutul National de Neurologie siBoli Neurovasculare Bucuresti

ASPECTE GENETICE ÎN SCLEROZALATERALĂ AMIOTROFICĂ

1Institutul Naţional de Neurologie şi BoliNeurovasculare Bucureşti2 UMF Carol Davila Bucureşti

Eliza Mihai1,2

Florian Antonescu

Mihai Damaris Eliza

15

În prezent principalul rol al testării genetice estestabilirea diagnosticului genetic în vederea evaluăriiriscului membrilor familiei, în plan secund cu valoarelimitată asupra prognosticului.

Deşi actual terapiile genice nu influenţează directmanangementul pacientului speranţa este ca în viitorpacienţii diagnosticaţi genetic ar putea primitratament în faza presimptomatică.

CONCLUZII

Genetica SLA este un domeniu intens heterogenă, cupotenţial important de cercetare în viitor atât dinpunct de vedere diagnostic şi patogenic, cât şiterapeutic.

Caracteristicile atipice bolii ar trebui să alertezeclinicianul spre posibilitatea de SLAF.

Există diferenţe epidemiologice importante întrepopulaţia asiatică şi cea caucaziană, care orienteazădiferit succesiunea testărilor genice.


OBIECTIVUL ȘI METODA

Durerea în scleroza laterală amiotrofică (SLA)reprezintă un aspect clinic frecvent umbrit demanifestările motorii ale bolii. Vom prezenta cazulclinic al unui pacient diagnosticat cu SLA, cusimptomatologie algică importantă care a dominatfaza de debut a bolii. Pornind de situația clinică ne-ampropus o trecere în revistă a literaturii actualereferitoare la SLA şi manifestările dureroase asociate.

REZULTATE

Vom prezenta cazul unui pacient internat în clinicanoastră pentru dureri severe la nivelul membrelorinferioare şi ușor deficit motor paraparetic, precum şitraseul complex până la finalizarea diagnosticului deSLA.

Durerea, ca simptom al SLA, a fost frecventminimizată de clinicieni, datorită paradigmei care aconsiderat multă vreme că SLA este o boală purmotorie. Alături de afectarea cognitivă care actualeste bine definită a o afectare extramotorie a SLA, înultimii ani au început să se acumuleze dovezi și înceea ce privește implicarea sistemuluisomatosenzorial.

Mecanismele durerii sunt multiple, aceasta fiind îngeneral neuropată sau nocicepitivă. Toutși la uniipacienți aceste mecanisme nu pot explica completdurerea, astfel fiind pusă în discuție sensibilizareacentrală.

Durerea este mai frecventă în stadiile tardive ale bolii,dar poate să apară în orice stadiu, inclusiv poateprecede debutul cu până la doi ani, iar apariția ei estecorelată cu deteriorarea calității vieții. Este maifrecventă la nivelul membrelor și gâtului, dar nu are odistribuție specifică. Cel mai frecvent este o durereușoară, dar, cum este şi situaţia pacientului descris denoi, poate fi sever invalidantă.

DUREREA ÎN SLA – PREZENTARE DE CAZ

1Institutul Naţional de Neurologie şi BoliNeurovasculare Bucureşti2 UMF Carol Davila Bucureşti

1 Florentina. Ivanciu1,2 Florian Antonescu

Ivanciu Florentina

[email protected]

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Un impact major pe prezența durerii în SLA îlprezintă depresia, fiind cunoscut că durerea poateconduce la depresie secundară, dar relaţia poate fiinversă.

CONCLUZII

Durerea reprezintă un simptom important în SLA,adesea minimizat de personalul de îngrijire.

Deşi prezenţa durerii implică un diagnostic diferențialextins și atent, aceasta nu exclude SLA.

Apariția durerii are semnificație prognostică nefastă,aceasta fiind dificil de tratat și ducând la o deterioraresuplimentară a calității vieții.


Spinal intradural tumors are generally benign; thesecan be located intramedullary (ependymoma, inadults) or extramedullary (meningioma andschwannoma).

The treatment of choice is surgical intervention,targeting complete resection, but without lesioningthe nearby nervous structures. In this respect,intraoperative monitoring is essential.Neuromonitoring is mainly used for preventinginjury of neural tissues and for finding specificelements during surgery.

Intraoperative neuromonitoring employs a widevariety of modalities: motor evoked potentials(MEPs), D-waves, somatosensory evoked potentials(SSEPs), electroencephalography (EEG),electromyography (EMG), H reflex, bulbocavernosusreflexe( BCR).

The neurophysiological parameters to be monitoredare chosen based on the localization of the tumor.

We will present two clinical cases- a cervicalintramedullary tumor (ependymoma) and a lombartumor (meningioma).

Ionela Codita is currently working as a SeniorNeurologist in the Neurology Department of EliasUniversity Emergency Hospital and in the PonderasAcademic Hospital in Bucharest

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 “Dinalund Summer School on EEG andEpilepsy” (July 2012) , educational course:”Brainstem and Peripheral Nervous System-Neurophysiological Monitoring”- Groningen,Netherlands (Nov 2016) , educational courseorganized by International Societhy of IntraoperativeNeurophysiology , in Seoul, Korea (Nov 2017) and“Update in Neuromuscular Disorders”, London ( 24-25 May, 2018).

She manifests interest in Peripheral Neuropathies,Motor Neuron Diseases, Myopathies andIntroperative Neuromonitoring. Dr. Ionela Codita is amember of the Romanian Society of Neurology andof the International Society of IntraoperativeNeurophysiology and she is the Secretary of ASNER-The Romanian Association for ClinicalElectrodiagnosis, since 2013.

Ionela Codita

MD

[email protected]

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Monitoring of Intradural Spinal Tumors

Neurology Department of Elias University EmergencyHospital, Bucharest

Ionela Codita

Andrei Spatariu, Daniela Godoroja, Mihai AdrianCristescu


Serotonin receptor agonist 5-HT1B/1D (the„triptans”) are useful for acute migraine treatment, butthe vasoconstrictor effect in cerebral and coronaryteritorry limits their use.

As migraine preventive therapy, beta-blockers andantiepileptic drugs (sodium divalproex, topiramate)are used.

Onabotulinum toxin A is also approved for preventionof headache in chronic migraine.

Recently, monoclonal antibodies targeting CGRPreceptor (erenumab) or CGRP peptide (galcanezumab,fremanezumab, eptinezumab) are available aspreventive treatment for episodic and chronicmigraine.

Non-pharmacological interventions are appropriatefor situation in which pharmacological treatment isineffective (medication overuse headache) orcontraindicated (pregnancy).

Non-invasive neuromodulation (transcutaneouscranial nerve stimulation – supraorbital nervestimulation with Cefaly and transcutaneous occipitalnerve stimulation; non-invasive vagus nervestimulation – cervical branch - the gammaCoredevice, auricular branch –Nemos device; single-pulsetranscranial magnetic stimulation; transcranial directcurrent stimulation; percutaneous mastoidstimulation) - represent an alternative to oral orinvasive therapy, having a favorable side effectsprofiles.

Invasive neuromodulation – occipital nervestimulation, sphenopalatine ganglion stimulation andhigh cervical spinal cord stimulation – should beconsidered for the most serious and refractory patientswho have failed multiple preventive attempts.

Neurologist (since 2000) and senior research scientist(since 2003) with special interest in headache andelectrophysiology, PhD - doctor in medical sciences(since 2001), working at at the University EmergencyHospital of Bucharest Department of Neurology,

Acting as Romanian Society of Neurologyrepresentative at the European Headache Federation(since 2006) and at the International HeadacheSociety (since 2011).

New options in migraine treatment

University Emergency Hospital of BucharestDepartment of Neurology, Bucharest

Adina Maria Roceanu

Dr. Adina Maria Roceanu,MD, Ph.D

[email protected]

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Background: Stiff Person Syndrome (SPS) is a rareneurological disorder characterized by progressivemuscle stiffness, painful spasms and rigidity.SPS canbe classified into classic SPS, paraneoplastic SPS, andSPS variants.The diagnosis of SPS is established byclinical findings with supportive evidence fromelectrophysiological findings on EMG studies andserological and cerebrospinal fluid (CSF) testing thatshow elevated antibodies against several of thecomponents of inhibitory synapses.Most commonly,cases present with thoracolumbar and abdominalmuscle spasms. Variants are increasingly appreciated.One of the variants is known as stiff limb syndrome.In this variation, the axial involvement is less marked,and one or (rarely) more extremities are affected.Most cases are caused by antibodies to glutamic aciddecarboxylase (GAD). The paraneoplastic form ismost often associated with amphiphysin antibodies.

Methods: Case report: We describe the case of a 70-year-old female with stiff limb syndrome. Hersymptoms were rigidity, painful spasm, and abnormalpostures of the distal right lower limb. Anotherpatient, a 70-year-old female with classic SPS,presents with rigidity and painful spasms of thelumbar paraspinal, abdominal, and occasionallyproximal leg muscles.Neurophysiologically, they hadcontinuous muscle activity in the affected areas.

Conclusions:Electromyography plays an importantrole in establishing a diagnosis of SPS bydemonstrating the characteristic involuntary firing ofmotor units.

Dr Gianina Maria Balea obtained her medical degreeat the University of Medicine and Pharmacy "IuliuHaţeganu" Cluj-Napoca in 2001. After 3 years oftraining at Cluj Children Emergency Hospital,specialized in Pediatric Neurology and 5 years atNeurology Clinic I, Cluj-Napoca, she became aneurologist in 2013. From 2014, he works at‘‘RoNeuro’’ Institute for Neurological Research andDiagnostic, Cluj-Napoca and is student PhD inMedicine at the University of Medicine andPharmacology "Iului Haţeganu" from Cluj-Napoca. In2015 she gained competence in clinicalneurophysiology (EEG, EMG and Potentials evoked).Since 2016 she is a member of ASNER - theRomanian Electro-diagnostic NeurophysiologySociety.

Stiff person syndrome: a heterogeneousneurological disease with particularneurophysiological features

1 “RoNeuro” Institute for Neurological Research andDiagnostic, Cluj-Napoca, Romania

2 Department of Clinical Neurosciences,“IuliuHațieganu“University of Medicine andPharmacy, Cluj-Napoca, Romania

3 Emergency Military Hospital"ConstantinPapilian",ClujNapoca

4EmergencyClinical Hospital "Prof. Dr. AgrippaIonescu ", Bucharest, Romania

GianinaMaria Balea1,2

LiviaLivințPopa1,2, Roxana Ailoaiei1, AdinaDanci3, Tudor Lupescu4, Dafin Fior Mureșanu1,2

Dr Gianina Maria Balea

[email protected]

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Miastenia gravis este una dintre cele mai cunoscuteboli auto-imune ce alterează placa neuro-musuclară.Această blocare a transmiterii se realizează prinreducerea numărului de receptori post-sinaptici deacetilcolină. Examenul biologic pune în evidențăprezența unor anticorpi contra receptorilor deacetilcolină (anti - Acth) și a anticorpilor anti - MuSKdirijați împotriva unei proteine din structurareceptorilor. Tabloul clinic tipic se caractrizează prin :ptoză palpebrală și oftalmoplegie, disfonie-disfagie,fatigabilitate exacerbată la efort și uneori deficitemotorii.

Scleroza laterală amiotrofică sau Boala Charcot esteuna dintre cele mai frecvente neuropatii motorii, carese caracterizează prin degenerescența progresivă șiselectivă a neuronilor motori, cu impact atât asupraneuronilor corticospinali, dar și a neruonilor de lanivelul măduvei spinării și trunchiului cerebral. Înformele tipice, debutul este de cele mai multe orifocal, sub forma unei slăbiciuni musculare și atrofiidistale ale membrelor ( ex. atrofia primului mușchiinterosos dorsal), iar pacienții resimt fasciculatii șicrampe în lunile care preced deficitul motor șiamiotrofia. De asemenea, examenul clinic pune înevidență un sindrom piramidal cu prezența semnuluiBabinski, hiperreflexie și spasticitate.

În continuare, vrem să va prezentăm cazul uneipaciente în vârstă de 57 de ani, care prezintăslăbiciune musuclară generalizată agravată la efort,atrofii musuclare difuze, însoțite de crampe șifasciculații generalizate.

Este medic specialist neurolog și a absolvit Facultateade Medicină și Farmacie “Iuliu Hațieganu”, ClujNapoca, în anul 2010. În timpul rezidențiatului, și-acompletat pregătirea profesională cu mai multe stagiiîn Franța, iar in prezent este asistent universitar laFacultatea de Medicină și Farmacie “IuliuHațieganu”. În cadrul aceleiași instituții este membruîn Consiliul pentru Studiile Universitare de Doctorat(CSUD).

Este medic specialist neurolog la Institutul RoNeurosi asistent cercetător în cadrul Institutului IMOGEN,proiect derulat de Spitalul Județean de Urgență ClujNapoca.

Principalele arii de interes sunt studiul și diagnosticulneuropatiilor periferice.

Un caz (a)tipic de slăbiciune generalizată

IMOGEN Cluj - Napoca, RoNeuro Cluj - Napoca

Nicu Draghici

Nicu Draghici

[email protected]

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Introduction

Fibular neuropathy represents the most commonmononeuropathy encountered in the lower limbs,more frequently affecting adults. Along withattentive clinical examination, theelectroneurographic studies help the clinician todifferentiate between isolated fibular neuropathy,sciatic neuropathy, L5-radiculopathy or lumbosacralplexopathy. In rare cases, foot drop can be the firstmanifestation of amyotrophic lateral sclerosis orneuropathies.

Methods

We present a series of patients who were sent to ourEMG Laboratory with ankle dorsiflexion weaknessand impaired walking, with acute onset in variousconditions.

One case illustrates the classical compression of theperoneal nerve around the fibular head, withconduction block at this level, confirming ademyelinating type of injury. When patients come forelectrophysiological studies after a longer period fromsymptoms onset, it is difficult to demonstratecompression; instead, we discover severe axonal loss.Furthermore, in one patient with 2-weeks history ofleft foot drop, the fibular study showed initial severeaxonal loss in both distal and proximal muscles, withacute denervation in muscles innervated of the deepbranch and normal muscle recruitment in fibularislongus, associated with normal SNAP potentials,indicating a pure motor involvement of the deepfibular nerve.

In certain cases, the electrodiagnostic features ofpatients with initial foot drop show simultaneouslypolyneuropathy, multifocal polyneuropathy pattern orhereditary neuropathy, such as HNPP.

Conclusion

The electrodiagnostic studies reveal the type and levelof the fibular injury in the majority of foot drop cases,but in certain patients, it is important to extend ourexam in order to explain the symptoms and toappreciate the severity and prognosis of the nerveinjuries.

What lies behind foot drop? Particular cases ofapparently common fibular neuropathy

Spitalul Universitar de Urgenta Bucuresti, Bucuresti,Romania

Oana Obrisca

Nicolae Grecu, Amalia Ene, Ana Maria Cobzaru

Objectives: We aim to describe cingulate cortex (CC)involvement in frontal lobe seizures.

Methods: We included patients explored by SEEG inthe Epilepy Unit at the Emergency UniversityHospital Bucharest which had the epileptogenic zonelocated in the frontal lobe. They had at least oneelectrode sampling the CC (anterior-ACC, middle-MCC or posterior-PCC) implanted with obliqueparasagittal trajectories so each electrode had at least3 contacts in the cingulate cortex. Patients were atminimum 1 year post-resection follow up. Wesystematically reviewed seizures recorded andfunctional stimulations (bipolar, 50Hz, 0,25-3 mA).

Results: We selected 20 patients from a series of 75consecutive patients explored with intracranialelectrodes. All recorded seizures in this populationshowed an early involvement (within first 5 secondsafter seizure onset) of the electrode contacts exploringthe cingulate cortex. In 14 patients, parts of thecingulate cortex were included in the resection (n=11)and/or received radiofrequency thermocoagulation(RFTC, n=8). Four patients were not treated due tofunctional reasons. Seizure freedom rate was 68%. Nocomplication of the implantation procedure werereported.

Conclusion: Cingulate cortex is involved early infrontal lobe seizures therefore exploration of thisregion is mandatory in frontal lobe epilepsy.Electrode implantation using oblique approach is safeand effective for defining the epileptogenic zone andfor functional mapping.

Cingulate cortex involvement in frontal lobeepilepsy - exploration using Stereo-electroencephalography (SEEG).


Irina Popa

Ioana Mindruta, Andrei Barborica, Mihai DragosMaliia, Cristian Donos, Andrei Daneasa, AncaArbune, Jean Ciurea

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Neuroborliosis a complication in Lyme disease can bemanifested by CNS and SNP lesions.

The case of a patient with Lyme disease, clinicallyand serologically diagnosed, with specific antibiotictreatment, sent to the electromyographic examinationwith, for the paresthesia in the extremities,predominantly the shank and the right leg with thediagnosis of the presence of sensory polyneuropathy

Parameter values determined by motors and sensorswere within normal limits except for the lowamplitude of superficial peroneal SNAP right. It hasbeen noticed that the cutaneous scar of the bite at thelevel of the calf is on the surface of the superficialperoneal nerve. This could be an argument for theperoneal superficial right affection through nervousdissemination, septavritic. The phenomenon wasoriginally described by C Levaditi and St S Nicolauwith a subsequent contribution by Dr. T Hornet.Septieuritis is the centrifuge or centripetal virusmigration on the near nerve tract.

Isolated neuropathy of peroneal superficial-nerve -possibly septinuritis

SUU Elias, Bucuresti, Romania

M Moldovan,

Ionela Codita, Patricia Toboc

OBIECTIVUL ŞI METODA Indexul numărului deunități motorii (MUNIX) este o tehnică relativ nouă,dezvoltată de Nandedkar şi Stålberg în anii 2000,bazată pe înregistrarea EMG de suprafață, care începesă fie larg acceptată ca metodă de cuantificare apierderii neuronale în bolile de neuron motor. Ne-ampropus o trecere în revistă a metodei originale şiîmbunătățirilor aduse pe parcurs, inclusiv ultimul ghidpentru aplicarea metodei (2018), precum şi utilitățiiacesteia în practica neurologică curentă.

REZULTATE Modelul porneşte de la postularea unuinumăr ideal de unități motorii identice (ideal casemotor unit count). Evaluând aria şi puterea traseuluiinterferențial de suprafață (SIP) la diferite forțe decontracție şi raportându-le la aria şi puterea CMAP seobțin diferite valori estimative pentru numărul deunități motorii activate la fiecare nivel de contracție.Ulterior se construieşte curba de regresie a funcțieiputere între ICMUC şi aria SIP, iar ICMUCcorespunzătoare unei arii SIP de 20mV/ms e definităca MUNIX.

Procesul obținerii MUNIX poate fi defalcat în treietape. Inițial se înregistrează CMAP supramaximalprin studiile uzuale de conducere. În a doua etapă,fără a modifica montajul, se înregistrează SIPmultiple la intensități crescânde de contracțievoluntară, forța fiind menținută constantă pe perioadafiecărei epoci. În etapa finală datele obținute pentruCMAP şi SIP sunt introduse în modelul matematicpentru calcularea MUNIX.

Postulatele de la care porneşte metoda, cum ar fiaspectul identic al unităților motorii, lipsa anulării defază, alegerea puterii SIP de 20mv/ms suntaxiomatice, astfel MUNIX nu reprezintă un calculexact, ci o evaluare printr-un model matematiccomplex a numărului de unități motorii existente înmuşchi.

MUNIX pare să fie echivalentă cu high densityMUNE şi MUNE cu stimulare incrementală (HD-MUNE, repsectiv IS-MUNE) în detectarea progresieiSLA, dar cu avantaje evidente: HD-MUNE necesităaparatură specializată, iar IS-MUNE dureazăaproximativ de două ori mai mult decât MUNIX şieste mai greu de tolerat de către pacient.

MUNIX – principii şi utilitate

1 Institutul Naţional de Neurologie şi BoliNeurovasculare, Bucureşti2 UMF Carol Davila, Bucureşti3 Centrul de diagnostic MEDINST, Bucureşti

1,2F. Antonescu;3 M. Adam

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MUNIX este mai sensibil în detectarea progresiei înSLA în comparație cu ALSFRS-R și un studiu recenta demonstrat utilitatea MUNIX în evaluarea pierderiide unități motorii în muşchi încă asimptomatici.

CONCLUZII

MUNIX este o metodă mai rapidă, mai fiabilă şi multmai bine tolerată de pacienți decât majoritateatehnicilor MUNE cu rezultate cel puțin similare înurmărirea bolilor de neuron motor şi aplicațiiimportante în cercetare.

Familiarizarea cu acestă tehnică este cu atât maiimportantă cu cât în ultima perioadă ea a început săfie introdusă în pachetele software standard aleaparatelor EMG.


Acute inflammatory demyelinatingpolyradiculoneuropathy (AIDP) is an acute illnessthat typically progress over a period of 4 weeks.

Chronic inflammatory demyelinatingpolyradiculoneuropathy (CIDP) symptoms typicallyprogress for a period greater than 8 weeks.

A relapsing course of symptoms is more likely inCIDP, starting insidiously and evolving slowly. Onthe contrary, AIDP is monophasic illness. AIDP andCIDP are both immune-mediated disorderscharacterized by weakness and sensory deficits andboth can lead to significant neurological disability.

Clinical examination and electrodiagnostic studies arekey tools for diagnosis although in some cases timecourse only can clarify whether the case we study isthat of AIDP or CIDP.

AIDP or “acute” onset of CIDP?

Cabinet de Neurologie Dr Izabela Popa, Timisoara,Romania

[email protected]

Izabela Popa

When a syncope (a transient, self limited loss ofconsciousness, caused by a transient global cerebralhypoperfusion) is accompanied by involuntarymovements, the differential diagnosis with a seizure(the manifestation of paroxysmal discharge ofabnormal rhythms in some part of the brain) becomesdifficult. The gold standard for a definite diagnosis issimultaneous electroencephalographic (EEG) andelectrocardiographic (ECG) recording with multiplescalp and chest electrodes. We will present the case ofa patient with syncopes (as suggested by history andbaseline ECG changes) that underwent routine EEGassessment and presented a paroxysmal event duringthe recording and will further discuss the indicationsof EEG in the assessment of syncopes.

Pitfalls in the differential diagnosis of syncope vs.seizure - a case report

SUU Elias, Bucuresti, Romania

[email protected]

Raluca-Simona Gurgu

G. Vulpe, C. Dumitrache, S. Petrescu, C. Panea

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Making correct electroclinical correlations representsprobably the most difficult to acquire and yetstimulating skill in the training of an epileptologist. Itrepresents trying to correctly explain the ictalbehavior evolution based on the EEG evolution andvice versa. In order to successfully develop it one hasto have a working knowledge of functional anatomy,as well as to understand the major white matter tractsand thus the electrical pattern of propagation in thehuman brain. Every detail in the patient’s behaviorhas to be correctly classified as either a positive or anegative ictal sign, or a reactive behavior notprovoked by the ictal discharge per se. It is obviousthat in order to be able to make correct correlations,on has to have high quality video andelectrophysiological data as well as trainedtechnicians that can test higher and lowerneurological functions in the short interval of aseizure.

In this workshop we will try to understand basicconcepts underlying ictal behavior and to apply thisknowledge on real-case scenarios in order to correctlypredict the epileptogenic zone and consequently toevaluate candidates for epilepsy surgery.

Electroclinical correlations

Policlinica di Monza, Bacau, Romania


Mihai Dragos Maliia

Irina Popa, Ioana Mindruta

Long-term monitoring for epilepsy (LTME) refers tothe simultaneous recording of EEG and clinicalbehavior over prolonged periods of time to evaluatepatients with paroxysmal events. Even though long-term EEG recordings may be useful in a variety ofsituations, it is most frequently used in patients withepileptic seizure disorders or suspected epilepticseizure disorders for diagnostic purposes or forclassification of the disease. LTME is performed onlyin epilepsy units able to provide qualified personneland equipment to record and interpret the correlationof behavior and EEG findings. Developments indigital technology have enhanced the ability toacquire, store, and review data in LTME so thatdigital systems are now the industry standard. Thispresentation will review the indications, personnel,equipment, and procedures required for a minimumstandard of practice.

Guidelines for long term monitoring for epilepsy


Irina Popa

Ioana Mindruta, Mihai Dragos Maliia, AndreiBarborica, Cristian Donos, Andrei Daneasa, AncaArbune, Jean Ciurea

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Objective: An overview of stroke related epilepticseizures by analyzing the physio-pathological andelectro-physiological changes in a temporal relationto ischemic stroke.

Method: Analyzing and synthesizing the currentclinical studies published on this topic to date.

Results: The frequency of post stroke epilepticseizures varies between 2% and 33%, cerebrovasculardiseases representing 11% of the etiology of epilepsyin adults. In relation to the ischemic stroke event,there can be either acute or late epileptic seizures.

Acute focal brain ischemia and tissue hypoxia fromthe ischemic penumbra induces transmembraneelectric potential changes through the accumulation ofintracellular Ca2+ and Na+, as well as by theincreasing glutamatergic excitotoxic action. As aconsequence, it leads to lowering the seizurethreshold and generating acute epileptic seizures.

The late epileptic seizures are explained by apersistent altering of neuronal excitability induced bya complex process of electrogenesis which issecondary to the permanent alteration of the bloodbrain barrier, astrocytic changes, neovascularizationphenomena and axonal regeneration in the brain areaof acute ischemia.

The electroencephalogram is performed in all strokepatients for whom the nature of the new paroxysmalevent is uncertain. The EEG changes in these patientscan take the form of focal slow or slow diffuserhythms, peak focal discharges, PLEDs or BIPLEDs.Among these, the most frequent association withincreased risk of seizure recurrence are PLEDs.

Conclusions: Although there is a high frequency ofpost stroke seizures, the actual number of patientswho will later develop epilepsy is much lower thanexpected (2-14%), a fact being explained by thedifferent pathological processes of acute seizuresopposed to late seizures. The PLED typeelectroencephalographic changes in the acute phasecan be a predictor for the later development ofvascular epilepsy.

Physio-pathological aspects and EEG patterns inacute post stroke epileptic seizures and vascularepilepsy

National Institute for Neurology and CerebrovascularDiseases, Bucharest

Alina Popescu,

C. Teodorescu, E. Istrate

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Documents

The National Conference of ASNER The Romanian Society of ... · 17.30 - 18.00. Dan Filip - Neuromonitorizarea intraoperatorie a nervilor cranieni ... the assesment of lower motor