Investigational basis of clinical neurophysiology. Edina Timea Varga MD, PhD Department of Neurology, University of Szeged 27th October 2015
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1 Investigational basis of clinical neurophysiology Edina Timea Varga MD, PhD Department of Neurology, University of Szeged 27th October 2015
2 What is clinical neurophysiology?
3 ? What is clinical neurophysiology?
4 Clinical neurophysiology Specialty Extension of neurology + special lab examinations To study central nervous system (CNS) peripheral nervous system (PNS) autonomic nervous system (ANS) To treat PD - Parkinson s disease: DBS deep brain stimulation Epilepsy: DBS/VNS vagal nerve stimulation/operation Tumors, lesions: resective surgery Spinal cord lesions, etc
5
6 Clinical neurophysiology EEG electroencephalography EP evoked potentials: visual/acustic/somatosensory/magnetic/cognitive EMG - electromyography ENG/NCS electroneurography/nerve conduction study RNS - repetitive nerve stimulation Sleep studies: PSG polysomnopgraphy, Autonomic nervous system: sympathetic skin respone test, RR-interval,
7 axon membrane
8 axon membrane Resting potential
9 axon membrane Resting potential -70 uv
10 axon membrane Na + /K + pump: 3 Na + out, while K + in
11 axon membrane Na + /K + pump: 3 Na + out, while K + in depolarisation
12 axon membrane Na + /K + pump: 3 Na + out, while K + in depolarisation
13 axon membrane depolarisation
14 axon membrane depolarisation
15 axon membrane repolarisation
16 axon membrane repolarisation
17 axon membrane return to resting potential
18 axon membrane return to resting potential
19 axon membrane return to resting potential
20 axon membrane return to resting potential
21 axon membrane return to resting potential
22 membrane potentail (mv) Action potential can be visualized on an oscilloscope oscilloscope Purves et al. Life The Science of Biology IVth Edition 1995.
23 membrane potentail (mv) pair of electrodes Action potential can be visualized on an oscilloscope oscilloscope Purves et al. Life The Science of Biology IVth Edition 1995.
24 membrane potentail (mv) pair of electrodes Action potential can be visualized on an oscilloscope oscilloscope the electrodes detect an AP as a voltage change across the axonal membrane this signal is amplified and fed into the osilloscope a beam of eelctrones sweeps across the screen in a set periode of time Purves et al. Life The Science of Biology IVth Edition 1995.
25 membrane potentail (mv) Action potential can be visualized on an oscilloscope oscilloscope Alternating electric charges on two plates makes electrone beam sweep across screen Amplified signal from axon moves electron beam &. When inside on axon is +, beams move. When inside of axon is -, beam moves. Purves et al. Life The Science of Biology IVth Edition 1995.
26 membrane potentail (mv) Action potential can be visualized on an oscilloscope oscilloscope Alternating electric charges on two plates makes electrone beam sweep across screen Amplified signal from axon moves electron beam &. When inside on axon is +, beams move. When inside of axon is -, beam moves. Purves et al. Life The Science of Biology IVth Edition 1995.
27
28 research daily routine
29 Transcranial direct current stimulation - historical background A.C. 43. Scribonius Largus 1755, Charles Le Roy 1855, Duchenne de Boulogne Electric torpedo fish Pain relief and eliciting phosphene L Electrisation Localisee Pascual-Leone&Wagner Ann Rev Biomed Eng 2007; 9:
30 Transcranial direct current stimulation Spontaneous neuronal discharge can be modulated by direct current in a polarity-dependent way cathodal stimulation basic neuronal activity anodal stimulation Terzuolo&Bullock Proc NAS USA 1956; 42: Creutzfeldt et al; Exp Neurology 1962; 5:
31 Bindman et al; Nature 1962; 196: Priori et al; Neuroreport 1998; 9: Nitsche&Paulus J Pysiol 2000; 527(3): Transcranial direct current stimulation Cathodal stimulation hyperpolarisation of neuronal membranes decreases cortical excitability Anodal stimulation depolarisation increased cortical excitability The effect depends on: Current intensity Current density Stimulus duration Anatomical structures After-effect (AE) depends on: Current intensity Stimulus duration
32 M1 V1
33 CSWS continuous slow waves of sleep idiopathic childhood epilepsy continuous epileptiform discharges during sleep neurocognitive decline behavioural dysfunctions epileptic seizures limited therapeutic approaches The aim of the study to detect the possible therapeutic effect of cathodal tdcs on the epileptiform EEG discharges (BESA) neuropsychological tests (if positive effect on EEG) Stimulator: Neuro Conn GmbH, Ilmenau, Germany Materials and methods Subjects: CSWS patients (age>5 years) were recruited (10/4) tdcs: cathodal tdcs (1.0 ma, 20 min) over the focus current density: 30 µa/ cm2 electrodes: 0,9% NaCl (35 cm2) control stimulation = sham stimulation The effect of tdcs was measured on EEG, by quantifying the percentage of non- REM sleep containing spike-and-slow-waves. M S-de-Boer Epilepsia Varga et al. Epilepsy Res 2011.
34 daily routine
35 EEG - electroencephalography
36 localisation odd number left side even number right side F frontal P parietal T temporal O occipital C central Fp frontopolar z - zero (vertex): Fz, Cz, Pz) A auricula International 10/20 system
37
38 Electrodes a-b-c : superficial (Ag/AgCl) d - clip Fisch & Spehlmann e needle electrode f nasopharyngealis needle electrode
39 Common reference
40 Double banana
41 Normal (adult) background activity
42 Amplitude redution for eye opening
43 Hyperventilation normal reaction (8 years) 4 Hz, ampl. 500 uv
44 Muscle artifact
45 Myoclonus (gen. spike and slow wave)
46 Myoclonus (gen. spike and slow wave)
47 Myoclonus (gen. spike and slow wave)
48 Left temporal (interictal) slow wave and spike
49 Generalized spike and slow wave activity IGE idiopathic generalized epilepsy
50 Nerve conduction studies (NCS) motor NCS sensory NCS Purves et al. Life The Science of Biology IVth Edition
51 Nerve conduction studies (NCS) motor NCS sensory NCS
52 voltage (uv) Nerve conduction studies (NCS) motor NCS time (ms) sensory NCS
53 amplitude amplitude Nerve conduction studies (NCS) motor NCS latency duration sensory NCS latency duration
54 AIM??
55 axonal /demyelinating injury focal/genearlised amplitude=axonal loss condiction velocity=demyelinisation latency=demyelinisation localisation
56 Carpal tunnel syndrome
57 Carpal tunnel syndrome
58 Medial and lateral plantar nerve
59 Medial and lateral plantar nerve superficial electrodes sensory nerve conduction
60 Motor nerve conduction study registration with superficial electrode registration with needle electrode
61 Near nerve technique tarsal tunnel syndrome Morton s metatarsalgia
62 Ulnar nerve neuropathy
63 Ulnar nerve neuropathy Near nerve technique
64 Ulnar nerve neuropathy Near nerve technique
65 Ulnar nerve neuropathy closer to the nerve higher detectable answer more precise information Near nerve technique
66 EMG - electromyography
67
68
69 AIM??
70 neurogen/myogen lesion acute/chronic reinnervation amplitude, duration, polyphasy myogenic amplitude, duration, polyphasy neurogenic prescence of abnormal resting activity reinnervation potentials
71 Investigation of neuromucular junction Indication: Myasthenia gravis Lambert-Eaton Myasthenic Syndrome
72 RNS - repetitive nerve stimulation sensitivity: Ocular MG= 50%, Generalised MG= 75% Single fiber EMG: sensitivity: 95% Stalberg, Uppsala Nandedkar
73 EVOKED POTENTIALS VEP visually evoked potentials (S)SEP (somato)sensory evoked potentials MEP motor evoked potentials BAEP (alias: ABR, BERA) brainstem auditory evoked potentials
74 VEP - visually evoked potentials
75 SEP somatosensory evoked potentials
76 SEP somatosensory evoked potentials: median nerve Erb Cv Fz-A1 C4-A1 P4-A1 C4-Fz P4-Fz
77 SEP somatosensory evoked potentials: median nerve
78 SEP somatosensory evoked potentials: median nerve missing cortical answer in an MS patient
79 SEP somatosensory evoked potentials: tibial nerve F.pop. L1 Cz-A1 Pz-A1 Cz-A2 Pz-A2 Cz-Fz Pz-Fz
80 SEP somatosensory evoked potentials: tibial nerve missing cortical answer in an MS patient
81 MEP - motor evoked potentials
82 BAEP - brainstem evoked potentials I. wave: N. VIII. III. wave: cochlear nucleus, oliva superior IV-V. wave: lemniscus lateraliscolliculus inferior IPL interpeak latency: I-III, III-IV.
83 Clinical neurophysiology in the treatment
84 Operative treatment of epilepsy - lesionectomy
85 Treatment of epilepsy (e.g e.g.).) DBS -deep brain stimulation hippocampectomy VNS vagal nerve stimulation
86 research daily routine future
87
88 ?
89 Thank you for your attention
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