RELAPSING NEUROPATHY
ELECTRODIAGNOSIS
Dr Mohamed Ibrahim Khalil
Physical Medicine Rheumatology and Rehab ,
Alexandria Univ...
46 years old male called Sobhy Ahmed , married
, From Kafr El Dawwar Presented with:
1. Flail left upper limb
2. Weakness ...
Condition started 1 year ago by incidious oncet and
Progressive course of Weakness of the right upper limb

**The patient ...
The weakness and wasting of his right upper limb run through a
• Progressive course over a period of 3 month duration and
...
5 months ago he suffered from the same complaint with
the same pattern on his Left Upper Limb
and Presented with :
1. Flai...
Flail left Upper limb Inability to flex his left elbow
Loss of weight
Severe finger clubbing
Hand Tremors
Wasting and weakness of forearm and hand muscles
Wasting of Thenar eminence
Wasting of hypothenar eminence
Wasting of the 1st Dorsal interosseous
• The patient is conscious cooperative oriented with normal
intellectual
• Speech and articulation : Normal receptive expr...
• The patient is Heavy smoker
• Patient is not DM nor HTN nor cardiac / renal / hepatic
•
•
•
•
•
•
•

NO Bulbar Manifesta...
1.
2.
3.
4.
5.
6.
7.
8.

Paraneoplastic neuropathy
Vasculitic neuropathy
Infectious neuropathy
Immune mediated neuropathy
...
AFCL = ( F + DL ) - (2 х Proximal latency)

F wave Latency

Distal Latency

----AFCL----13.6 ms

2 х Proximal latency
AFCL = ( F + DL ) - (2 х Proximal latency)
Ulnar Nerve :

( 38.6 + 3.6 ) – ( 2 х 11.8 ) = 42.2 – 23.6 =

Median nerve :

(...
1.Diabetic Poly-Radiculoneuropathy
2.Chronic imf demylinating Polyradiculoneurop.
3.Early Guillian Barre ( Axillary loop b...
1.Non Systemic vasculitic Neuropathy
2.Paraneoplastic neuropathy
1.
2.
3.
4.
5.
6.

Neuromyotonia
Lambert Eaton syndrome
Polymyositis
Motor neuron disease
Vasculitic neuropathy
Myasthenia...
1.Lewis-Sumner Syndrome
2.Chronic relapsing Dysimmune Polyneuropathy
(CRDP )
•

The Lewis- Sumner syndrome (LSS) is a dysimmune multifocal demyelinating
sensorimotor neuropathy. It should be consider...
• Electrophysiological pattern associates a multifocal motor
demyelination with conduction blocks mostly situated in
the f...
• Sural nerve biopsy in LSS show elements consistent with
a primary demyelination, indistinguishable from that seen
in typ...
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
Relapsing polyneuropathy electrodiagnosis
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Relapsing polyneuropathy electrodiagnosis

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Relapsing polyneuropathy electrodiagnosis

  1. 1. RELAPSING NEUROPATHY ELECTRODIAGNOSIS Dr Mohamed Ibrahim Khalil Physical Medicine Rheumatology and Rehab , Alexandria University , Egypt Reverie-forever@hotmail.com
  2. 2. 46 years old male called Sobhy Ahmed , married , From Kafr El Dawwar Presented with: 1. Flail left upper limb 2. Weakness ,wasting and Numbness of both upper and lower limbs 3. Gait instability , Heaviness of both Lower Limbs
  3. 3. Condition started 1 year ago by incidious oncet and Progressive course of Weakness of the right upper limb **The patient neither can comb his hair nor button his shirt **No Diurnal variation **Associated with Dull aching Pain around the am radiating distally relived by analgesics , (no ppt factors) ** Associated with numbness in his right hand and forearm The Patient Sought medical advice . Xray , CT and MRI Cervical spine was done Revealing : C5-6 Posterolateral Disc Bulge
  4. 4. The weakness and wasting of his right upper limb run through a • Progressive course over a period of 3 month duration and his right upper limb become flail with inability to flex his elbow and associated with severe wasting and weakness in his right hand and forearm muscles • Stationary course for 2 months • Then regressive course upon neurotonics and Physical therapy (the patient attains Partial recovery , regaining some ability to flex his right elbow )
  5. 5. 5 months ago he suffered from the same complaint with the same pattern on his Left Upper Limb and Presented with : 1. Flail left Upper limb Inability to flex his left elbow 2. Wasting and weakness of hand and forearm muscles 3. Gait instability associated with Heaviness of both lower limbs 4. Loss of weight 5. Numbness of the Both upper and lower limbs 6. Pain at his both shoulder , elbow and ankle The patient was admited to El Hadara University Hospital
  6. 6. Flail left Upper limb Inability to flex his left elbow Loss of weight
  7. 7. Severe finger clubbing Hand Tremors Wasting and weakness of forearm and hand muscles
  8. 8. Wasting of Thenar eminence Wasting of hypothenar eminence
  9. 9. Wasting of the 1st Dorsal interosseous
  10. 10. • The patient is conscious cooperative oriented with normal intellectual • Speech and articulation : Normal receptive expressing, naming , writing and reading • Cranial Nerve examination showed ?Tongue fasciculation • Motor examination: Tone : Hypotonia all over Reflexes : Areflexia all over Extensor planter : unequivocal bilaterally Coordination : cannot be assessed due to weakness Gait : instability , inability to walk on heel or tip of the toes
  11. 11. • The patient is Heavy smoker • Patient is not DM nor HTN nor cardiac / renal / hepatic • • • • • • • NO Bulbar Manifestation No sphincteric complaint No Cognitive impairment NO specific drug or sensitivity No Relevant Cutaneous Manifestation No history of previous operation NO family history of similar condition(-ve consanguinity )
  12. 12. 1. 2. 3. 4. 5. 6. 7. 8. Paraneoplastic neuropathy Vasculitic neuropathy Infectious neuropathy Immune mediated neuropathy Motor neuron disease Multifocal Motor neuropathy Inclusion body Myositis Lewis-sumner syndrome
  13. 13. AFCL = ( F + DL ) - (2 х Proximal latency) F wave Latency Distal Latency ----AFCL----13.6 ms 2 х Proximal latency
  14. 14. AFCL = ( F + DL ) - (2 х Proximal latency) Ulnar Nerve : ( 38.6 + 3.6 ) – ( 2 х 11.8 ) = 42.2 – 23.6 = Median nerve : ( 42.4 + 4.7 ) – (2 х 12.7) = 47.1 – 25.4 = 18.6 ms 21.7 ms
  15. 15. 1.Diabetic Poly-Radiculoneuropathy 2.Chronic imf demylinating Polyradiculoneurop. 3.Early Guillian Barre ( Axillary loop block) 4.Severe demylinating peripheral neuropathy 5.Demylinating Brachial Plexopathy(Br. Neuritis) NB: Axonal Lesion never lead to abnormal Delay in Fwave mylinating In severe axonal neuropathy or plexopathy  F wave is Lost Single motor Radiculopathy never cause abnormal f wave except if the lesion is severest
  16. 16. 1.Non Systemic vasculitic Neuropathy 2.Paraneoplastic neuropathy
  17. 17. 1. 2. 3. 4. 5. 6. Neuromyotonia Lambert Eaton syndrome Polymyositis Motor neuron disease Vasculitic neuropathy Myasthenia Gravis
  18. 18. 1.Lewis-Sumner Syndrome 2.Chronic relapsing Dysimmune Polyneuropathy (CRDP )
  19. 19. • The Lewis- Sumner syndrome (LSS) is a dysimmune multifocal demyelinating sensorimotor neuropathy. It should be considered as a clinical asymmetrical variant (CIDP). • Patients with LSS usually present with an asymmetrical involvement of the upper limb with distal sensorimotor deficit in median or ulnar territories. 1. A purely sensory onset with numbness and paresthesia or pain in median or ulnar territory is observed 30% of cases. 2. A lower limb onset is present in 30% of patients with a distal and asymmetrical sensorimotor deficit. 3. Amyotrophy and cranial nerve involvement may be observed in 50% and 20% of patients, • LSS could mimick a nerve entrapment or a vasculitis. The course is progressive or remitting.
  20. 20. • Electrophysiological pattern associates a multifocal motor demyelination with conduction blocks mostly situated in the forearm. • Contrarily to CIDP, other conduction anomalies (reduction of truncal motor nerve velocities, prolonged distal latencies or prolonged F waves) occur rarely outside the blocked nerve territory. • Sensory conduction shows a multifocal sensory involvement.
  21. 21. • Sural nerve biopsy in LSS show elements consistent with a primary demyelination, indistinguishable from that seen in typical CIDP. However nervous biopsy is not necessary to establish the diagnosis ( unlike vasculitis ) . • Serum anti-GM1 antibodies are negative and CSF protein content is usually normal or mildly elevated with a mean value of 0.7 g/l. LSS is characterized by a responsiveness to IVIg and steroids. • For LSS patients, a treatment similar to that of CIDP, Plasma exchanges are not recommended in LSS.

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