JOURNAL UPDATE NCV/EMG: 신경전도 / 근전도검사 / Two sets of nerve conduction studies may suffice in reaching a reliable electrodiagnosis in Guillain-Barre synd

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1 Journal Update 대한임상신경생리학회 Journal Update 7 호 CONTENTS NCV/EMG: 신경전도 / 근전도검사 2 Two sets of nerve conduction studies may suffice in reaching a reliable electrodiagnosis in Guillain-Barre syndrome 4 Quantitative neuromuscular ultrasound in the intensive care unit 5 Reproducibility of peroneal motor nerve conduction measurement in older adults Evoked potential (EP): 유발전위 8 Axonal loss in non optic neuritis eyes of patients with multiple sclerosis linked to delayed visual evoked potential 10 On the relationship between nociceptive evoked potentials and intraepidermal nerve fiber density in painful sensory polyneuropathies 12 Utility of somatosensory evoked potentials in chronic acquired demyelinating neuropathy Polysomnography: 수면다원검사 14 Sleep spindle activity and cognitive performance in healthy children 15 Effectiveness of non-benzodiazepine hypnotics in treatment of adult insomnia: meta-analysis of data submitted to the Food and Drug Administration 17 An observational clinical and video-polysomnographic study of the effects of clonazepam in REM sleep behavior disorder Neurotology/Neuro-ophthalmology: 신경이안과 19 Active MS is associated with accelerated retinal ganglion cell/inner plexiform layer thinning 20 Isolated floccular infarction: impaired vestibular responses to horizontal head impulse. 21 Randomized clinical trial for geotropic horizontal canal benign paroxysmal positional vertigo

2 JOURNAL UPDATE NCV/EMG: 신경전도 / 근전도검사 / Two sets of nerve conduction studies may suffice in reaching a reliable electrodiagnosis in Guillain-Barre syndrome Clin Neurophysiol Feb 7. doi:pii: S (13)00014-X /j.clinph [Epub ahead of print] 연구배경 - (Guillain-Barre syndrome, GBS) GBS (acute motor axonal neuropathy, AMAN). AMAN. GBS.. 연구목적 GBS, 6 Erasmus GBS outcome score (EGOS). 연구방법 GBS. GBS Asbury ,.,,, Hughes functional scores, EGOS, modified EGOS (megos),, GM1, GM1b, GD1a, Gal-NAc-GD1a, GD1b, GT1a, GQ1b. 2, 3-8, Ho 1998 Hadden AIDP, AMAN, acute motor sensory axonal neuropathy (AMSAN). 결과 (57%), 5 (24%), 4 (19%). 12 AIDP, 3 AMAN, 4 AMSAN, (81%) AIDP 2 (9.5%) AMAN/AMSAN (57%) AIDP, 7 (33%) AMAN/AMSAN (Table 1). 6. 2

3 Journal Update 7, EGOS megos 6 (Table 2). 결론 3-8 GBS , GBS. 논평 GBS AMAN/AMSAN GBS. AMAN/ AMSAN (conduction block) (terminal latency), GBS. AMAN/AMSAN GBS GBS. GBS 2, 3-8. EGOS. GBS,. 3

4 JOURNAL UPDATE Quantitative neuromuscular ultrasound in the intensive care unit Muscle Nerve 2013;47: 연구배경... (ICU acquired weakness, ICU-AW).. ICU-AW. 연구목적. 연구방법. 3,7,14 2,4,6. Tibialis anterior, rectus femoris, abductor digiti minimi, biceps brachii brachialis.,, image J gray-scale (Figure 1). 하., repeated measure t-test. 결과 , 5 3 7, tibialis anterior rectus femoris gray-scale, rectus femoris (Table 1).. 결론 tibialis anterior rectus femoris. Figure 2 gray-scale.. 논평 tibialis anterior rectus femoris tibialis anterior rectus femoris,. 4

Journal Update 7 Reproducibility of peroneal motor nerve conduction measurement in older adults Clincal Neurophysiology 2013;124:603-609 Figure 2.

5 Journal Update 7 Reproducibility of peroneal motor nerve conduction measurement in older adults Clincal Neurophysiology 2013;124: Figure 2. The image on the left shows the tibialis anterior muscle in cross-section at baseline. The image on the right shows the same tibialis anterior muscle after the patient has been in the ICU for 14 days. After the prolonged ICU stay the muscle has lost its normal echotexture and is hyperechoic with a homogeneous, ground-glass appearance. 연구배경.,. (reliability) (reproducibility).,.. 연구목적 (CMAPs). 연구방법 Health, Aging, and Body Composition (Health ABC) (3075 ; 48.4% ; 41.6% ; ) Health ABC ( 17, 17 ; 17, 16 ) t-test chi-squared test, coefficients of variation (CVs) interclass correlation coefficients (ICCs). Bland Altman plot,. 결과,,,,. CMAPs (Table 2). 5

6 JOURNAL UPDATE Bland Altman plot, 1.96 (Figure 1,2). (Table 3). 결론,,,.. Figure 1. Bland Altman plots for ankle head (A), fibular (B), and popliteal fossa (C) CMAP amplitudes. AK = ankle; FH = fibular head; PF = popliteal fossa; CMAP = compound muscle action potential; SD = standard deviation. 6

7 Journal Update 7.,. 논평..., (sural nerve) (plantar nerve). Figure 2. Bland Altman plots for Fibular head (A) and popliteal fossa (B) NCV. FH = fibular head; PF = popliteal fossa; NCV = nerve conduction velocity; SD = standard deviation. 7

8 JOURNAL UPDATE Evoked potential (EP): 유발전위 / Axonal loss in non optic neuritis eyes of patients with multiple sclerosis linked to delayed visual evoked potential Neurology 2013;80: 연구배경 (Multiple Sclerosis, MS). (retinal ganglion cell, RGC) (retinal nerve fiber layer, RNFL), (visual evoked potential, VEP). MS (optic neuritis, ON) (MS non-optic neuritis, MS-NON) RNFL RNFL CNS. MS-NON RNFL. 연구목적 RNFL mfvep (multifocal VEP). 연구방법 MS ( ON, (>5 diopters)). Optical coherence tomography mfvep, 25. 결과 45 MS ( , 33 / 12, ON (22 ), ON ). RNFL(, ) MS-NON ( µm vs µm, = and µm vs µm, p = 0.006, respectively), mfvep MS-NON ( milliseconds vs milliseconds, p < ). ON MS MS-NON RNFL(, ) mfvep. RNFL (, ) mfvep (Fig 1). 2 ( mfvep (19 ) vs. mfvep (26 ), 99 ) mfvep RNFL, mfvep RNFL ( µm vs µm, p=0.001 and µm vs µm, mfvep latency, ms A B R 2 = R 2 = Total RNFL thickness, µ mfvep = multifocal visual evoked potential; RNFL = retinal nerve fiber layer. Figure 1. Correlation between mfvep latency and (A) total and (B) temporal RNFL thickness Temporal RNFL thickness, µ 8

9 Journal Update 7 p= for total and temporal RNFL, respectively) (Fig 2). ON MS RNFL mfvep (r 2 = 0.84 and r 2 = 0.70, respectively, p < for both) (Fig 3). 결론 MS-NON RNFL VEP. RNFL, RNFL. VEP, checkerboard 60 sector (Fig 4). Figure 4. 논평 MS RNFL VEP RNFL. mfvep pattern-shift VEP. mfvep 1994 Baseler Sutter, VEP ** p, MS 5 multiple sclerosis; ns 5 not significant; RNFL 5 retinal nerve fiber layer. difference between delayed and normal latency groups measure of demyelination along the visual pathway in Figure 2. Total (A) and temporal (B) RNFL thickness in normal controls, normal latency MS group, and delayed latency MS group (A) Correlation between total retinal nerve fiber layer (RNFL) thickness of the left eye (LE) and right eye (RE). (B) Correlation between multifocal visual evoked potential (mfvep) latency of left and right eyes. Figure 3. Intereye correlation in multiple sclerosis patinets with no optic neuritis in either eye 9

10 JOURNAL UPDATE On the relationship between nociceptive evoked potentials and intraepidermal nerve fiber density in painful sensory polyneuropathies Pain 2011;152: 연구배경 (small fiber neuropathy, SFN), (laser-evoked potentials, LEPs) (contact heat-evoked potentials, CHEPs). CHEPs LEPs SFN intraepidermal nerve fiber (IENFs), mixed fiber neuropathy (MFN). CHEPs LEPs,. 연구목적 (CHEPs, LEPs) SFN MFN, SFN. 연구방법 (syndromic diagnosis),, (healthy subject, HS) 35. Neuropathic Impairment Score, 10-cm long visual analogue scale, small form of the Brief Pain Inventory., QST. LEPs( 7.1 mm2) CHEPs( mm2) N2 N2/ P2 ( Cz, A1-A2). 3-mm circular punch biopsy IENF ( >1.5 µm). 결과 SFN 52, MF 40. CHEPs LEPs Fig 1 SFN LEPs 8 (15.4%), CHEPs 5 (9.6%) EPs, MFN LEPs 25 (62.5%), CHEPs 14 (35.2%). MFN EPs CHEPs LEPs SFN, HS, SFN Figure 1. Examples of single traces to nociceptive EPs (LEPs and CHEPs) in HS, SFN, and MFN patients. The figure shows 6 selected single electroencephalogram traces, and 2 superimposed averages of 6 traces each, obtained after foot stimulation on a representative subject. Note the consistent waveform in single traces, which corresponds with the EPs seen in the averaged waveform. LEPs = laser-evoked potentials; CHEPs = contact heat-evoked potentials; HS = healthy subjects; SFN = small-fiber neuropathy; MFN = mixed-fiber polyneuropathy. 10

11 Journal Update 7 CHEPs HS (Table 3). EPs SFN MFN CHEPs LEPs. IENF CHEPs (r = 0.68, p < 0.001) LEPs (r = 0.69, p < 0.001) N2/P2, CHEPs (r = , p < 0.001) LEPs (r = -0.22, p = 0.034) (Fig 4). CHEPs LEPs.. 결론 LEPs CHEPs. EPs SFN MFN. 논평.. IENF. corneal confocal microscopy LEPs CHEPs., Figure 4. Correlation analysis between CHEPs, LEPs, and the IENF density. Scatterplot showing the relationship between the N2/P2 amplitude in µv and the N2-peak latency in ms of CHEPs (A and C, respectively) and LEPs (B and D, respectively) with the IENF density. Black dots represent the values obtained from all subjects, and solid lines represent the regression lines. All EPs were obtained at foot stimulation. Subjects with absent EPs were considered as 0 µv for amplitude and missing value for latency. LEPs = laserevoked potentials; CHEPs = contact heat-evoked potentials; IENF = intraepidermal nerve fibers. 11

12 JOURNAL UPDATE Utility of somatosensory evoked potentials in chronic acquired demyelinating neuropathy Muscle Nerve 2008;38: 연구배경 (chronic acquired demyelinating polyneuropathy, CADP). (nerve conduction study, NCS). (somatosensory evoked potentials, SSEPs) NCS. 연구목적 CADP NCS SSEPs. 연구방법 47 ( 31, : 27~88 ). NCS NCS,,, NCS,,,. SSEPs SSEPs (N20) (P37) SSEPs Erb s potential (EP), (NP13/14), (N19-P22). 결과 NCS SSEP 5. 1: NCS, NCS, SSEP (N=5) (Fig 1) - SSEPs N20, P37 ( (ULN) %). - SSEPs EP ( %), NP13 ( %), NP19-P22 ( %), EP-NP13 (ULN 62%), EP-NP19 (ULN 48%), N13-N19. 2: NCS, NCS, SSEP (N=18, CIDP variant) - SSEPs N20 (17 ) (1, ULN 47%). P37 (16, %). - SSEPs (N=8): EP (3 ) (5, %). NP ( %). NP19-P22 (2 ) ( %). 3: (SSEP (N=4. Distal acquired demyelinating neuropathy (DADS) variant) - Anti-MAG Ab (2 ), SSEPs. - Anti-MAG Ab (2 ), SSEPs. 4: NCS, NCS, SSEP (N=2, pure sensory CIDP variant) - SSEPs N20, P37 (30% ULN). 5: NCS, NCS, SSEP (N=18) (Fig 5) - 2 CIDP, 16. 결론 SSEP, 1 NCS. NCS NCS SSEP. 논평,. AIDP CIDP F-wave, MRI, ultrasound. SSEP,,,. F-wave, F-wave SSEP. 12

13 Journal Update 7 A B C FIGURE 1. (A) The sural nerve sensory conduction study was norma D Figure 1. (A) The sural nerve sensory conduction study was normal in one patient with a chronic acquired demyelinating polyneuropathy. (B) Tibial nerve somatosensory evoked potentials (SSEPs) disclosed absent lumbar potential (N20) along with a markedly prolonged and poorly formed cortical (P37) potential indicating the presence of proximal demyelination (P37 latency, 56 ms). (C) In the same patient the median nerve sensory nerve conduction study was normal. (D) The corresponding median nerve SSEPs disclosed absent Erb s point (N9) and neck (NP13) potentials along with markedly prolonged and poorly formed cortical (N19-P22) potential indicative of proximal demyelination (N19 latency, 32.4 ms). A C B E 2. (A) Figure 5. In one patient with clinical features of pure motor demyelinating neuropathy who exhibited (A) conduction block in the ulnar nerve which was stimulated at the wrist, below elbow (BE), above elbow (AE), axila and Erb s point (EP), (B) the median, and (C) tibial nerve somatosensory evoked potential (SSEP) were normal. 13

14 JOURNAL UPDATE Polysomnography: 수면다원검사 / Sleep Spindle Activity and Cognitive Performance in Healthy Children Sleep Feb 1;36(2): doi: /sleep.2380 연구배경 NREM 2 sleep spindle 13Hz sleep spindle (fast spindle) 13Hz sleep spindle (slow spindle). fast spindle, 13Hz sleep spindle, -,,., sleep spindle. 연구목적 sleep spindle,. 연구방법 27 (14, 13 ),,,. Stanford-Binet Intelligence scale, neuropsychological development assessment (NEPSY), 1. sleep spindle,, (spindle/min of stage 2 sleep), stage 2 sleep spindle,. 결론 spindle, spindle, fast spindle nonverbal working memory, planning, sensorimotor functioning,.. proliferation, migration, organization, myelination of neural circuitry,,. sleep spindle., sleep spindle. 논평,,. sleep spindle, hippocampal theta rhythm. sleep spindle,, sleep spindle. 결과, Stanford- Binet Intelligence scale, NEPSY. Sleep spindle, spindle (nonverbal working memory) (r s = -0.54), planning (r s = -0.41), fine motor function (r s = -0.41) (Figure 1), fast spindle sensorimotor functioning (r s = -0.42), fine motor function (r s = -0.41). Fast spindle sensorimotor functioning (r s = -0.43), fine motor function (r s = -0.43) narrative memory (r s = 0.38). 14

15 Journal Update 7 A B C D Figure 1. Scatterplot of spindle mean central frequency against hand positioning (fine motor performance; NEPSY, standardized mean (SD) = 10.0 (3.0)), r s = -0.41, P = 0.03 (A), planning ability (NEPSY, standardized mean (SD) = 10.0 (3.0)), r s = -0.41, P = (B), and working memory (Stanford Binet, standardized mean (SD) = 10.0 (3.0)), r s = -0.54, P = (C), and of fast spindle density (n/min stage 2) also against fine motor performance (NEPSY, standardized mean (SD) = 10.0 (3.0)), r s = -0.43, P = 0.03 (D). SD, standard deviation. Effectiveness of non-benzodiazepine hypnotics in treatment of adult insomnia: metaanalysis of data submitted to the Food and Drug Administration BMJ Dec 17;345:e8343. doi: /bmj.e8343 연구배경 Z drugs (eszopiclone, zaleplon, and zolpidem). Z drugs,,,,,..., Z drug, Z drug, -. 연구방법 Z drugs, ,, 65 Z drug. primary outcome, secondary outcome,,,. 연구목적 Z drugs - 결과 Z drugs 15

16 JOURNAL UPDATE primary outcome, secondary outcome.,,,, zolpidem. 결론 Z drugs,.,,,. 논평 Zolpidem,,,,. Z drugs, Z drug. Z drug. Fig 2 Forest plot for polysomnographic sleep latency under random effects assumptio Figure 2. Forest plot for polysomnographic sleep latency under random effects assumptions 16

17 Journal Update 7 Fig 3 Forest plot for subjective sleep latency under random effects assumptions Figure 3. Forest plot for subjective sleep latency under random effects assumptions An observational clinical and video-polysomnographic study of the effects of clonazepam in REM sleep behavior disorder Sleep Med Jan;14(1):24-9. doi: / j.sleep Epub 2012 Oct 23 연구배경 Clonazepam REM sleep behavior disorder (RBD) RBD. clonazapam 90%,, RBD clonazapam double-blind, placebo-controlled, randomized trials. RBD clonazepam, clonazepam REM-atonia, phase motor-behiavior activity. Clonazepam RBD. clonazepam (motor activity), Clonazepam. 연구목적 RBD clonazepam RBD clonazepam, clonazapam. 연구방법 idiopathic RBD (irbd)., clonazapam, Clinical Global Impression-Severity scale. 2 RBD, MRI.,. RBD severity, REM sleep behavior disorder severity scale (RBDSS) 8. REM sleep epoch 1 30 miniepoch mini-epoch, muscle atonia index. 결과 57 irbd ( 52, 5, ). RBD , ( 39, 3 ) (irbd - Clo), 15 ( 13, 2 ) clonazepam (0.5 1 mg) (irbd + Clo). irbd + Clo RBD,,, 1, 2.,, RBDSS, Atonia Index (Table 1). RBD clonazepam 13 irbd + Clo,, (effect size) clonazepam,, 17

18 JOURNAL UPDATE 2,, 1. 8 clonazepam CGI-I, RBDSS, Atonia Index, CGI-I, RBDSS, atonia index (Figure 2). 결론 clonazepam,,, 1, 2. 논평 REM generator corticospinal tract,, RBD REM generator,. RBD clonzepam,. RBD clonazepam,, RBD. Figure 2. Top panel: time course of the CGI-I in the irbd patients included in the longitudinal study; middle panel: RBDSS modified; bottom panel: Atonia index. Each line identifies a single patient. 18

19 Journal Update 7 Neurotology/Neuro-ophthalmology: 신경이안과 / Active MS is associated with accelerated retinal ganglion cell/inner plexiform layer thinning Neurology 2013; 80: 연구배경 (optical coherence tomography, OCT) (retinal nerve fiber layer, RNFL)., RNFL (ganglion cell layer) (retrograde degeneration) (Figure). (conventional) OCT RNFL, OCT (segmentation). 결론, GCIP,. 논평 OCT RNFL. OCT, GCIP. 연구목적, / (ganglion cell layer/inner plexiform layer, GCIP), RMFL. 연구방법 OCT ( : 21.1 )., Expanded Disability Status Scale (EDSS),..,, EDSS,,,,, /T2. 결과, /T2,, 5 GCIP (p < 0.05). /T2, 5 GCIP 70%. GCIP RNFL, (Table). Figure. Illustration of the layers of the retina Note that the retinal nerve fiber layer is composed of axons of the ganglion cells. Demyelination or transection of optic nerve axons (derived from the retinal nerve fiber layer) cause retrograde degeneration, resulting in atrophy of the retinal nerve fiber layer and ganglion cell body death. 19

20 JOURNAL UPDATE Table. Effect of clinical and radiologic characteristics on the rate of change GCIP and RNFL thicknesses in patients with MS and CISa Isolated floccular infarction: impaired vestibular responses to horizontal head impulse. J Neurol 2013 Jan 31. doi; /s y 연구배경 (flocculus) (smooth pursuit), (gazeholding),. (paraflocculus),,, postsaccadic drift,,.,,.. 연구목적. Abbreviations: CIS 5 clinically isolated syndrome; EDSS 5 Expanded Disability Status Scale; GCIP 5 ganglion cell/inner plexiform; MS 5 multiple sclerosis; MSFC 5 Multiple Sclerosis Functional Composite; MSSS 5 Multiple Sclerosis Severity Scale; ON 5 optic neuritis; RNFL 5 retinal nerve fiber layer. a Values are b coefficients from the regression model indicating the difference in the rate of GCIP or RNFL change between those with and without the covariate, measured in mm/year (p value) (except age in which the b coefficient is the difference in rate of change per year of baseline age and EDSS and MSFC scores in which the value represents the rate difference associated with a difference of 1 point on the EDSS or MSSS). All analyses are adjusted for age and sex. b Statistically significant association. 연구방법,,,. 결과 > : > :, > : > : > - : - ( Hz): [range; , normal range (mean 2SD); ] Figure. During the head impulse test using the scleral search coil technique, there were impaired vestibular responses only during stimulation of both horizontal semicircular canals. AC anterior semicircular canal, HC horizontal semicircular canal, PC posterior semicircular canal 20

21 Journal Update 7 - : (Figure) [0.63 for right horizontal canal, 0.46 for left horizontal canal, normal 0.70] 결론,. (acute vestibular syndrome). 논평 Halmagyi Newman Toker, ( 91%) (Neurology, 2008; 70: ).,. Newman Toker 9% (vestibulocerebellar, pontocerebellar, pontocerebello-labyrinthine stroke),, 10 1,. -,,. Randomized clinical trial for geotropic horizontal canal benign paroxysmal positional vertigo Neurology 2012;14:700-7 연구배경 (geotropic horizontal canal benign paroxysmal positional vertigo) Barbecue, Gufoni.. 연구목적 Barbecue, Gufoni. (A) For the barbecue rotation maneuver, the head and trunk are rotated 90 at each step in the direction of the healthy ear while the patient is supine. Each Figure 1.Illustrations of barbecue rotation (A), Gufoni (B), and sham (C) maneuvers for the geotropic type of benign paroxysmal positional vertigo involving the horizontal canal (HC) (arrow: affected ear) (A) For the barbecue rotation maneuver, the head and trunk are rotated 90 at each step in the direction of the healthy ear while the patient is supine. Each step is maintained for seconds until the induced nystagmus dissipated. After 270 of rotation, the patient is brought to the sitting position. (B) In the sitting position, the debris are located in the dependent posterior arm of the left HC. Side-lying to the healthy side causes the particles to move further toward the posterior part of the HC and could produce an utriculopetal (ampullofugal) flow and intense horizontal nystagmus beating toward the ground. After the head is rotated toward the ground, particles move further toward the posterior part and fall into the vestibule, causing an ampullofugal flow and nystagmus beating toward the healthy side. Each position is maintained for 2 minutes. Then the patient is returned to the upright position. (C) For the sham maneuver, patients lie down from the sitting position. After 30 seconds, the head is rotated 90 in the direction of the affected ear, which would cause ampullopetal (utriculofugal) migration of the debris. After another 60 seconds, patients are brought to the sitting position. 21

22 JOURNAL UPDATE 연구방법 170 ( : = 63:107, = ). Barbecue (56 ), Gufoni (64 ), Sham (50 ), 1 (Figure 1, )..,. 결과 Barbecue (67.9%) Gufoni (61.3%) Sham (34.7%) (p < 0.05).. Barbecue Gufoni (Figure 2). 논평., Epley (Level A).,. (apogeotropic benign paroxysmal positional vertigo) Gufoni, (headshaking) Sham (Neurology 2012;78:159-66). 결론 Barbecue Gufoni (Class I evidence). Figure 2.Kaplan-Meier survival curve The Kaplan-Meier survival curve with a log-rank test for cumulative therapeutic effects shows a better outcome with the barbecue rotation (p = 0.005) and Gufoni (p = 0.044) maneuvers than with the sham maneuver. However, the therapeutic effects are not different between the barbecue rotation and Gufoni groups (p = 0.399). 22

23 Journal Update 7 Journal Update 대한임상신경생리학회 Journal Update 7 호 상임집필진 ( 교육위원회 ) 발행인 발행처 T / F 인쇄처 T / F 위원장 위원 NCS &EMG, EEG EP TCD Polysomnography INM 23

975_983 특집-한규철, 정원호

975_983 특집-한규철, 정원호 Focused Issue of This Month Gyu Cheol an, MD Department of Otolaryngology ead & Neck Surgery, Gachon University of College Medicine E - mail : han@gilhospital.com Won-o Jung, MD Department of Otolaryngology