2 Journal Update 6 3 NCV/EMG: 신경전도 / 근전도검사 PMA ALS R-EEC. Awaji algorithm. / Fasciculation potentials in amyotrophic lateral sclerosis and the diagnos

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1 Journal Update 대한임상신경생리학회 Journal Update 6 호 CONTENTS NCV/EMG: 신경전도 / 근전도검사 2 Fasciculation potentials in amyotrophic lateral sclerosis and the diagnostic yield of the Awaji algorithm 4 Electrodiagnostic criteria for Guillain-Barre syndrome: A critical revision and the need for an update 7 Quantitative pilomotor axon reflex test; A novel test of pilomotor function 9 Usefulness of distal motor latency measurement after palmar stimulation in advanced carpal tunnel syndrome Electroencephalography (EEG): 뇌파 1 Continuous high-frequency activity in mesial temporal lobe structures 11 Risks and benefits of invasive epilepsy surgery workup with implanted subdural and depth electrodes Intraoperative neurophysiologic monitoring (INM): 수술중신경생리감시 13 Evidence-based guideline update: Intraoperative spinal monitoring with somatosensory and Transcranial electrical motor evoked potentials 13 Facial nerve motor-evoked potential monitoring during microvascular decompression for hemifacial spasm 15 Impact of changes in intraoperative somatosensory evoked potentials on stroke rates after clipping of intracranial aneurysms Transcranial Doppler (TCD): 경두개초음파 16 High-risk asymptomatic carotid stenosis: Ulceration on 3D ultrasound vs TCD microemboli 16 Association between the amount of right-to-left shunt and infarct patterns in patients with cryptogenic embolic stroke: a transcranial Doppler study 18 The influence of anterior cerebral artery flow diversion measured by transcranial Doppler on acute infarct volume and clinical outcome in anterior circulation stroke

2 2 Journal Update 6 3 NCV/EMG: 신경전도 / 근전도검사 PMA ALS R-EEC. Awaji algorithm. / Fasciculation potentials in amyotrophic lateral sclerosis and the diagnostic yield of the Awaji algorithm Muscle Nerve 212;45: (Amyotrophic Lateral Sclerosis, ALS) El Esocorial (revised El Esocorial criteria, R-EEC). R-EEC (fasciculation potential, FP) (denervation potential) Awaji algorithm. Awaji algorithm, FP (bias). ALS FP ALS FP. ALS R-EEC Awaji algorithm. ALS FP (specificity). ALS. R-EEC Awaji algorithm (clinically definite), (clinically probable), (clinically probable laboratory supported, R-EEC ), (clinically possible), ALS. (lower motor neuron) (Progressive Muscular Atraophy, PMA) ALS. FP ALS (cervical radiculopathy), (lumbar radiculopathy), (poliomyelitis), (spinobulbar muscular atrophy), (demyelinating neuropathy), (plexopathy) FP. R-EEC 43%, Awaji algorithm 37% ALS (Figure 2). R-EEC 2 13 (upper motor neuron) 1 Awaji algorithm. R-EEC 4 Awaji. ALS 89% FP, 68% FP. PMA 88% FP, 55% FP. ALS FP (Figure 3). (tongue), (sternocleodimastoid), (thoracic paraspinal muscle) FP. FP %, %,.3%, 4%, 22%, 22%. ALS, FP FP ALS. Awaji algorithm R-EEC 1 Awaji algorithm. PMA ALS FP,. ALS. PMA ALS, ALS PMA. Awaji algorithm FP. R-EEC 2 ALS. Awaji algorithm bulbar onset. FP, bulbar onset.. Awaji algorithm 2 ALS, Awaji algorithm Suspected ALS Initial diagnostic catagory (R-EEC or Awaji) Enrolled N=176 confirmed N=64 yes N=2 yes N=27 yes N=46 unconfirmed N=112 familial with SOD1 follow-up information rise in category to confirmed critical endpoints Excluded N=139 N=37 Figure 1. Flowchart of the enrollment of the patients for this study. ALS, amyotrophic lateral sclerosis; R-EEC, revised El Escorial Criteria; Awaji, Awaji algorithm. no no no Awaji 1 PRO DEF R-EEC DEF 3 (2%) DEF 2 (1%) Confirmed ALS 51 (37%) PRO 48 (35%) 7 PRLS PRO PRO 38 (27%) Confirmed ALS 6 (43%) PRLS 2 (14%) POS 46 (33%) 13 PRLS POS 4 POS PRO POS 37 (27%) PMA 42 (3%) PMA 42 (3%) Figure 2. The diagnostic categories using the Awaji algorithm and R-EED in 139 ALS patients. The arrows represent how the category would shift between the two criteria. ALS, amyotrophic lateral sclerosis; Awaji, Awaji algorithm; R-EEC, revised El Escorial Criteria; DEF, clinically definite; PRO, clinically probable; PRLS, clinically probable laboratory-supported; POS, clinically possible; PMA progressive muscular atrophy.

3 4 Journal Update 6 5 Ranvier), (remyelination)., acute motor conduction block neuropathy (AMCBN) AMAN., 38% (sural nerve). AIDP. AMAN 49-69% SNAP AMAN. 2) 길이에따른전도차단 AMAN CMAP CMAP (length-dependent conduction failure) (Figure 4). Waller (Wallerian degeneration) CMAP. 3. AMSAN의전기진단기준 AMSAN AMAN C. jejuni GM1, GM1b, GD1a. : 1), 2) CMAP 8%, 3) 2 (sensory nerve action potential, SNAP) 5%. 4. 감각신경전도검사 GBS.. AIDP 85% (median nerve) (ulnar nerve) 5. 전기진단기준적용시주의점 AIDP,,, AMAN CMAP. AMAN AIDP. AMAN. GBS AIDP AMAN,. CMAP. AMAN AIDP, (pathologic). Figure 3. Distribution of spontaneous activity in ALS patients. The incidence of FPs (left) and denervation potentials (right) in each muscle from the ALS patients. (A) All patients. (B) Patients in whom the five most frequently examined muscles (BB, TB, IOD-1, VM. and TA) were explored. Frequent versus infrequent FPs are distinguished. The white bar without a black rim represents the muscles for which we were unable to assess the relevant activities due to insuffincient relaxation. The number of patients in whom the relevant muscles was examined is also indicated (n). ALS, amyotrophic lateral sclerosis; FPs, fasciculation potentials; SCM, stemocleidomastoid; trap, upper trapezius: BB,bicepts brachii: TB, triceps brachii, FDS, flexor digitorum superficialis, EDC. extensor digitorum communis; IOD-1, the first dorsal interosseous; PSM, the thoracic paraspinal muscles at the Th1 level; VM, vastus medialis; TA, tibialis Electrodiagnostic criteria for Guillain-Barre syndrome: A critical revision and the need for an update Clin Neurophysiol 212;123: (Guillain- Barre syndrome, GBS) (acute inflammatory demyelinating polyradiculoneuropathy, AIDP) (antiganglioside) acute motor axonal neuropathy (AMAN), acute motor and sensory axonal neuropathy (AMSAN). AMAN AMSAN (conduction block) GBS. 1. AIDP의전기진단기준 AIDP (distal latency, DM) (Table 1). Ho Hadden. 2. AMAN의전기진단기준 (demyelination) (compound muscle action potential, CMAP). 1) 가역적전도차단 AMAN (intermediate segment) (temporal dispersion), (reversible conduction failure) (Figure 1B, C). Ranvier (node of

4 6 Journal Update 6 7 Figure 1. (A) Acute motor axonal degeneration. Compound muscle action potentials (CMAPs) recorded from abductor digiti minimi after stimulation of the ulnar at wrist below elbow, above elbow in a patient with IgG anti- GM1 and anti-gd1a. Distal CMAP amplitude was already decreased (4 mv) on day 4 and further decreased (2 mv) on day 11. Modified from Uncini et al., 21. (B) Reversible conduction failure in intermediate and distal nerve segments. CMAPs recorded from abductor digiti minimi after stimulation of the ulnar nerve at wrist, below elbow, above elbow, and at the axilla in a patient with antibodies to GM1. The abnormal CMAP amplitude ratio (.2) across the elbow on day five rapidly resolved on day 11 without the development excessive temporal dispersion. Note also the 14% increase of the distal CMAP amplitude with shortening of distal motor latency (DML) from 4.8 to 2.7 ms. Modified from Kuwabara et al., (C) Reversible conduction failure in distal nerve segment. CMAPs recorded from the extensor digitorum brevis muscle after stimulation of the per oneal nerve at ankle, below- fibular head and above-fibular head in a patient with antibodies to GD1b. Note that on day 6, DML is prolonged (7.4 ms) and distal CMAP amplitude reduced (1.6 mv). On day 12. DML is still slightly prolonged (5.9 ms) and distal CMAP amplitude is 16% increased. On day 25, DML is in the normal range (4.4 ms), and the distal CMAP amplitude is 15% compared with day 6. Modified from Uncini et al., 21. (D) CMAPs recorded from abductor digiti minimi after stimulation of the ulnar nerve at wrist, below elbow, above elbow in a patient with typical acute inflammatory demyelinating polyradiculoneuropathyand no antibodies to gangliosides. Note that on day 2, all conduction parameters were normal. On day 14, all CMAPs were dispersed, distal CMAP amplitude was greatly reduced (1 mv), distal motor latency was increased (5.7 ms), the CMAP amplitude ratio between below-elbow and wrist stimulation was.2, and conduction velocities were reduced (2 m/s in the below-elbow wrist segment and 26 m/s across the elbow). On day 4, the CMAP amplitude ratio between below-elbow and wrist stimulation was.5 but all CMAPs were still reduced in amplitude and dispersed. DML was further increased (7.2 ms) and conduction velocities further reduced (19 m/s in the below-elbow wrist segment and 16 m/s across the elbow). Modified from Uncini et al. (21). Figure 4. Length- dependent conduction failure. Compound muscle action potentials (CMAPs) recorded from abductor digiti minimi after stimulation of the ulnar nerve at wrist, below elbow, above elbow in a patient with IgG anti- GM1 and anti-gd1a antibodies. On day 2, there was a mild reduction (28%) of CMAP amplitude from below-elbow stimulation compared with wrist stimulation and an abnormal amplitude reduction of CMAP (65%) from above-elbow c ompared with below- elbow stimulation. On day 11, all CMAP amplitudes were reduced, and there was an abnormal amplitude reduction (64%) of CMAP from below-elbow stimulation compared with wrist, whereas the CMAP amplitude drop across the elbow was decreased (29%). At day 26, distal CMAP amplitude was further decreased, but amplitude reduction in CMAPs from proximal stimulation sites were no longer evident. Modified from Uncini et al., 21. Quantitative pilomotor axon reflex test; A novel test of pilomotor function Arch Neurol Doi:1.11/archneurol (piloerection),, (axon reflex). (sudomotor) (neurogenic inflammation) (vasomotor) ,. (quantitative pilomotor axon reflex test, QPART) 1% phenylephrine 5. (silicon impression). ( 1), (lidocaine gel) ( 2), ( 3), ( 4), ( 5), ( 6). 1. phenylephrine (Figure 1) QPART (Figure 2). 3. Phenylephrine. 4. (Figure 3) , 6 (Figure 4) ) Phenylephrine. 2) Phenylephrine. 3). 4). 5),..,,. phenylephrine,. (small fiber neuropathy), QPART,. QPART. Figure 1. Phenylephrine-induced piloerection. Direct and axon reflex-mediated piloerection after iontophoresis of phenylephrine on the dorsal forearm. The inner circle delineates the region of phenylephrine application (direct response). The outer circle delineates the margins of the axon reflex-mediated response.

5 8 Journal Update 6 9 Figure 2. Attenuation of axon reflex-mediated piloerection by pretreatment with topical lidocaine gel. Silicone impression scans after phenylephrine iontophoresis of a subject without (A) and with lidocaine pretreatment (B). Hair follicle impressions are dark spots on the yellow silicone. Usefulness of distal motor latency measurement after palmar stimulation in advanced carpal tunnel syndrome J Clin Neurophysiol 212;29: (carpal tunnel syndrome, CTS) (thenar) (atrophy),. CTS (carpal tunnel release, CTR). (median nerve) CTS (abductor pollicis brevis, APB) - (distal latency) CTR.. 48 CTS APB 3-4 cm , 1.9 ms , , CTS. CTS - CTR, -. - CTS. Kimura CTS. CTS -. CTS Figure 3. Subcuteneous lidocaine injections abolish axon reflex-mediated piloerection. Piloerection spread in the surrounding region ceases at the border of the lidocaine injection region. The arrows point to lidocaine injection sites. Figure 4. Delayed onset of piloerection in the axon reflex region. Photographs of the dorsal forearm of a subject at different points after phenylephrine iontophoresis. Maximal piloerection in the direct region occurs after a mean [SD] of 13.3 [5.8] second, whereas maximal piloerection in the indirect region.

6 1 Journal Update 6 11 Electroencephalography (EEG): 뇌파 Continuous high-frequency activity in mesial temporal lobe structures Epilepsia 212;53(5): EEG high frequency oscillation (HFOs). HFOs. Frequency 8-25 Hz ripple, 25-5 Hz fast ripple, 8-2 Hz 2-5 Hz. ripple frequency. ripple montreal neurological institute 42. Stero - electroencephalography (SEEG) Harmonie monitoring system image guided system. 9 SEEG 5 Hz hardware low-pass filter sampling rate 2, Hz. SEEG bipolar montage, / 2. 2 CT MRI lesional non-lesional. ictal activity seizure onset zone non-seizure onset zone (SOZ, nsoz). 1 interspike data. 8 Hz high pass filter continuous/semi-continuous, irregular sporadic bipolar channel Continuous/semi-continuous (wake 29/96, sleep 34/96). continuous/semi-continuous. seizure onset zone lesional side. Continuous/semi-continuous, ripple, fast ripple. 8 Hz rhythmic activity.. HFOs spike seizure onset zone. continuous/semicontinuous sporadic epileptogenic zone. HFOs. A Risks and benefits of invasive epilepsy surgery workup with implanted subdural and depth electrodes Epilepsia 212;53(8): (phrmacoresistant). 8%..... * Hp (35 channels) PH (25 channels) C/SC IRR SP Am (36 channels) B SOZ (49 channels) ssoz (2 channels) C/SC IRR SP No SOZ (27 channels) C Lesion (19 channels) (intracerebral electrode), (subdural electrode) grid electrode C/SC IRR SP NoLesion (77 channels) Figure 5. Background pattern distribution during sleep according to (A) the anatomic localization of the electrodes, (B) the seizure-onset zone, and (C) the presence of a lesion. The C/SC pattern was the most common in the hippocampus (marked with *) and rare in the amygdata. The type of background pattern observed in a chnnel is not influenced by that channel belonging to the seizure-onset zone or to a lesion. Epilepsia ILAE Figure 6. Relationship between averaged wavelet entropy (WE) of the background of each channel and the rates of spikes, ripples, and fast ripples. Lower WE reflects a more rhythmic background, that is, a pattern like the C/SC pattern. Events are generally more frequent with lower WE. Epilepsia ILAE. (Fernandez et al., 1997; Kral et al.,22).

7 12 Journal Update mapping , 6, 12, % 9%.. grid electrode grid strip electrode depth electrode. (p=.3), burr hole (p=.19), trepanation (p=.3), grid electrode (p=.1), (p=.14), (p=.36) %. No. of patients with DE No. of patients with SE No. of patients with GE Combinations of electrodes DE+SE GE+DE+SE DE SE+GE GE SE GE+DE (a) Complication class (n=2) 1 (n=2) 2 (n=16) 3 (n=24) (B) Grade 3 complications All patients (n=26) All epilepsy patients (n=242) Epiliepsy patients with epilepsy (n=115) Tumor patients without epilepsy (n=18) All tumor patients with and without epilepsy (n=6) No. of patients (% of all 26) 171 (65.8%) 165 (65.3%) 133 (51.2%) 72 (27.2%) 44 (16.9%) 48 (18.5%) 42 (16.2%) 4 (15.4%) 7 (2.7%) 7 (2.7%) DE, depth electrode; SE, strip electrode; GE, grid electrode. a Odds ratio was calculated for the risk to develop a relevant complication. b Fisher`s exact test. c No case of relevant complication. 13 (65.%) 3 (18.8%) 19 (79.2%) 19 (7.3%) 16 (6.6%) 14 (12.1%) 3 (16.7%) 6 (1.%) 2 (1.%) 1 (6.3%) 1 (4.2%) 1 (.4%) 1 (.4%) % Engel class 1a 6.3% Engel class 1a.... grid electrode grid strip. 99%. grid electrode strip depth electrode burr hole trepanation. Table 3. Implant electrode type sorted according to their frequency of implantation and risk for relevant complication associated with different electrode types Epidural or subdural bleeding increased ICP No. of patients with relevant complications 11/171 (6.4%) 19/165 (11.5%) 19/133 (14.3%) 4/72 (5.6%) 6/44 (13.6%) 1/48 (2.1%) 9/42 (21.4%) 4/4 (1%) /7 (%) /7 (%) Table 4. Overview of types of complication Intracerebral bleeding/ contusion Meningitis 2 (12.5%) Edema around electrode 2 (1.%) 1 (6.3%) Odds ratio (95%CI) a.42 ( ) ( ) 4.67 ( ).494 ( ) ( ).175 ( ) ( ) ( ) n.d. c n.d. c Increased ICP/brain edema 6 (37.5%) 1 (4.2%) 1 (.4%) 1 (.4%) 1 (.9%) Grade 4 and 5 complications were not observed. Among complications comprised as else are the following: grade 2, torn electrode cables (n=3) making evaluation of one implanted electrode each impossible. Subgaleal fluid collection (n=1), bleeding from skin incision (n=1), dislocation of electrode documented by CT (n=1). Grade 3, empyema leading to bone flap removal and later artificial bone flap insertion (n=1), intolerable headache (n=1), CSF-leakage requiring revision surgery (n=1). (b) risk for relevant complications (grade 3) in function of underlying tumors. All tumors patients were implanted with grids. This explains the trend toward a higher percentage of bleeding complications in this group. When patients with tumors are compared to patients with epilepsy with grids, there is no recognizable trend toward higher risk. ICP, intracranial pressure. p-value b Else 3 (15.%) 3 (18.8%) 3 (12.5%) 3 (1.2%) 3 (1.2%) 1 (.9%) 1 (1.7%) Intraoperative neurophysiologic monitoring (INM): 수술중신경생리감시 Evidence-based guideline update: Intraoperative spinal monitoring with somatosensory and Transcranial electrical motor evoked potentials Neurology 212:78: (SEP, somatosensory evoked potentials) (MEP, motor evoked potentials). 7 MEDLINE EMBASE.,,.. (AAN) class III, IV 4 class I, 8 class II. Class I 4 31% (p=.184), 16% (p=.369), 4% (p=.158), 4% (p=.148). 8 Class II 1-1% 7 (p<.5)..,,.. MEP SEP MEP SEP.. MEP, SEP. Facial nerve motor-evoked potential monitoring during microvascular decompression for hemifacial spasm J Neurol Neurosurg Psychiatry 21;81(5): (Hemifacial spasm, HFS) Lateral spread response (LSR), (microvascular decompression, MVD) LSR. (Facial nerve motor-evoked potentials, FNMEPs). FNMEP MVD MVD FNMEP LSR University of Niigata MVD FNMEP ( 25-7 ), ,, / C3 C4, Cz Corkskrew electrode ( V) orbicularis oculi, mentalis, oris

8 14 Journal Update 6 15 muscle FNMEP. LSR orbicularis oculi mentalis muscle. MVD (,,,, ). baseline ( ) final ( ) FNMEP, 3 Final-to baseline FNMEPs ratio. 연구 LSR LSR. LSR 23 LSR. (1) LSR (-) MVD LSR (2) LSR (+) LSR LSR 7. 1, LSR. FNMEP, Oribicularis oculi muscles MVD final FNMEP baseline. ( p<.1 p<.5). orbicularis oculi muscle FNMEP ratio ( %) (p<.1, mentalis muscle %, orbicularis oris muscle %; figure 1). LSR orbicularis oculi muscle FNMEP (figure 2). LSR (+) LSR(-) orbicularis oculi muscle FNMEP amplitude ratio. MVD orbicularis oculi muscles FNMEP. MVD LSR FNMEP. MVD LSR FNMEP LSR. (synkinesis) LSR MVD FNMEP. Impact of changes in intraoperative somatosensory evoked potentials on stroke rates after clipping of intracranial aneurysms Neurosurgery 212;7: ( S S E P, somatosensory evoked potentials),. SSEP 663 (691 ) SSEP Johns Hopkins Hosital Johns Hopkins Bayview Medical Center SSEP 663 (691 ). SSEP CT MRI (58.3%), 288 (41.7%). 372 (53.8%) SSEP 5% 25%.. 연구 (74.8%). (anterior circulation) (posterior circulation) (97.%) 12 (3.%) (96.2%) 11 (3.8%). Glasgow Coma scale 13 ( ; 3~5 ) Hunt and Hess scale 2 ( ; 1~5). (43 ) SSEP SSEP 2%, SSEP 8%. (288 ) SSEP 29. SSEP 12%, SSEP 42%. SSEP : (positive predictive value) 3%; (negative predictive value) 94%; (sensitivity) 25%; (specificity) 95%. SSEP. SSEP 8% SSEP 58%. SSEP (intraoperative assessment). SSEP SSEP., SSEP. Figure 1. Scatter plots comparing final-to-baseline amplitude ratios of facial nerve motor-evoked potentials (FNMEPs) among three muscles (Oculi, orbicularis oculi muscle; Mentalis, mentalis muscle; Oris, orbicularis oris muscle). The FNMEP ratio obtained from Oculi ( %) was significantly lower than the other two groups ( % for Mentalis and % for Oris; p<.1), Error bars represent the mean SD of the mean. Figure 2. Intraoperative lateral spread response (LSR: upper) and FNMEP (lower) recordings (patient 15: table 1) LSR from the mentalis muscle completely disappeared after microvascular decompression (MVD). Simultaneously, FNMEP amplitude obtained from the orbicularis oculi muscle decreased to 3.7% of that before MVD.

9 16 Journal Update 6 17 Transcranial Doppler (TCD): 경두개초음파 / (Table 1).,. vascular, laboratory, cardiologic work-up. patent foramen ovale closure. High-risk asymptomatic carotid stenosis: Ulceration on 3D ultrasound vs TCD microemboli Neurology 211;77: %,... 3D. 6% (peak velocity 17 /s ) D ( ) ( 8.51). 11 (4%) 3, 11 (6%). 25 (1%) 3. 3, 3 (18% vs 2%; p=.3). 3 2%, 2% (p=.3)..8%.. 3D 2 (1%). 3 2%, 9%,, 9%. 3D 3 1%.. Association between the amount of rightto-left shunt and infarct patterns in patients with cryptogenic embolic stroke: a transcranial Doppler study International Journal of Stroke DOI: /j x (Paradoxical embolism) (cryptogenic embolic stroke). (right-to-left shunt). 157 (Figure 1).. (microemboli <2 vs. 2, spontaneous vs. after Valsalva maneuver only). 96 (61.1%).. (p=.19). (<1 cm) (66 7% vs. 45 9%), (8%) (Figure 2). Framingham stroke risk strategy Figure 1. Patient selection. DWI, diffusion-weighted imaging; TCD, transcranial Doppler; RLS, right-to-left shunt. Figure 2. Contour images of the mean values of affected areas in the cryptogenic embolic stroke. (a) no RLS group, (b) mild RLS group, and (c) massive RLS group. RLS, right-to-left shunt.

10 18 Journal Update 6 19 The influence of anterior cerebral artery flow diversion measured by transcranial Doppler on acute infarct volume and clinical outcome in anterior circulation stroke International Journal of Stroke DOI: /j x 연구 53. CT angiography (p<.1), (p<.1) 24 (p<.1). (modified Rankin Score -2) (odds ratio = 27.5, p<.1). Journal Update, (Anterior cerebral artery flow diversion) DSA (digital subtraction angiography) (leptomeningeal collateral flow). (penumbra). 6. 3%,.. CT angiography. cerebral blood volume mean transit time CT perfusion thresholds., 24 MRI. CT angiography, 9...,,., 24 9.,. 발행인 발행처 T / F 인쇄처 T / F 상임집필진 ( 교육위원회 ) 위원장 대한임상신경생리학회 Journal Update 6 호 위원 NCS &EMG, EEG EP TCD Polysomnography INM

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