QUIZ RNS
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The document describes a case of a 47-year-old woman presenting with progressive weakness over 3 months. On examination, she has fatigable neck muscles and weak leg muscles without atrophy. Repetitive nerve stimulation of the ADM muscle shows no change at rest but decrement after 20 seconds of activation. SFEMG of the orbicularis oculi is normal. She is found to have positive VGCC antibodies. The diagnosis is likely myasthenia gravis based on the clinical features and decremental response on repetitive nerve stimulation, though Lambert-Eaton myasthenic syndrome cannot be ruled out based on testing of only one muscle.
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QUIZ RNS
The patient has clinical features consistent with myasthenia gravis including fatigable neck and leg muscles as well as symptoms affecting swallowing and voice. Repetitive nerve stimulation and SFEMG testing would help confirm the diagnosis. Positive voltage-gated calcium channel antibodies also support MG. The diagnosis is myasthenia gravis (option a).
NCS routine
The document provides guidance on interpreting various neurography results. It discusses potential reasons for low amplitude compound muscle action potentials including carpal tunnel syndrome, lumbar epidural mass, technical problems, and polyneuropathy. It also discusses diagnoses for other neurography findings including possible carpal tunnel syndrome based on abnormal sensory findings in fingers 1-3 with normal motor amplitudes. Other sections discuss distinguishing between lumbar root lesions versus plexopathies and evaluating possible myasthenia gravis. The document aims to instruct on drawing conclusions from neurography studies.
NCS special
The document contains questions and answers regarding neurophysiology techniques. Some key points discussed include:
- Voluntary activity does not influence CMAP amplitude at supramaximal stimulation, except for effects of muscle shortening.
- CMAP satellites can be distinguished from extra discharges by superimposing traces after 3Hz stimulation - satellites will be stable while extra discharges will be variable.
- If CMAP amplitude is unexpectedly low with no nerve damage or PNP, steps should be taken to check stimulation strength, equipment, skin conditions, and perform activation maneuvers before considering anomalies.
- F waves are usually normal in C8 radiculopathy but may be abnormal on the affected side in an ul
NCS routine
The document contains guidance on interpreting different neurography findings. It discusses various scenarios where the CMAP amplitude is low and provides potential reasons for this, including carpal tunnel syndrome, lower extremity mononeuropathy, technical problems, and polyneuropathy. It also addresses interpreting low sensory amplitudes and abnormal sensory latencies. Different neurography patterns are presented that may indicate carpal tunnel syndrome, lumbar root lesions, plexopathies, or other diagnoses. Methods for distinguishing between these various diagnoses are suggested.
EMG routine
The document contains questions about electromyography (EMG) signals and interpretations. Key points addressed in the responses include:
1. Complex repetitive discharges (CRDs) seen on EMG are characterized by an abrupt start and stop with no waxing and waning, unlike myotonia.
2. In Guillain-Barré syndrome presenting with acute weakness, early EMG findings may show normal compound muscle action potentials and conduction velocities but reduced F-wave persistence and abnormal interference patterns, indicating conduction block.
3. Double discharges seen on EMG do not need to be identical in shape to be considered extra discharges, as the second discharge will be lower in amplitude due to the relative
Basics of rnst,vep ,baer and emg
1. The document discusses various electrophysiological tests including repetitive nerve stimulation test (RNST), visual evoked potentials (VEP), and brainstem auditory evoked responses (BAER).
2. RNST involves electrically stimulating a motor nerve repeatedly to observe changes in the compound muscle action potential. Abnormal results can indicate disorders of the neuromuscular junction like myasthenia gravis or Lambert-Eaton myasthenic syndrome.
3. VEP involves recording electrical potentials from the visual cortex in response to visual stimuli. Pattern reversal VEP using checkerboard patterns is commonly used to detect lesions of the visual pathway. P100 latency prolongation is the most reliable indicator of abnormality.
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QUIZ RNS
The patient has clinical features consistent with myasthenia gravis including fatigable neck and leg muscles as well as symptoms affecting swallowing and voice. Repetitive nerve stimulation and SFEMG testing would help confirm the diagnosis. Positive voltage-gated calcium channel antibodies also support MG. The diagnosis is myasthenia gravis (option a).
NCS routine
The document provides guidance on interpreting various neurography results. It discusses potential reasons for low amplitude compound muscle action potentials including carpal tunnel syndrome, lumbar epidural mass, technical problems, and polyneuropathy. It also discusses diagnoses for other neurography findings including possible carpal tunnel syndrome based on abnormal sensory findings in fingers 1-3 with normal motor amplitudes. Other sections discuss distinguishing between lumbar root lesions versus plexopathies and evaluating possible myasthenia gravis. The document aims to instruct on drawing conclusions from neurography studies.
NCS special
The document contains questions and answers regarding neurophysiology techniques. Some key points discussed include:
- Voluntary activity does not influence CMAP amplitude at supramaximal stimulation, except for effects of muscle shortening.
- CMAP satellites can be distinguished from extra discharges by superimposing traces after 3Hz stimulation - satellites will be stable while extra discharges will be variable.
- If CMAP amplitude is unexpectedly low with no nerve damage or PNP, steps should be taken to check stimulation strength, equipment, skin conditions, and perform activation maneuvers before considering anomalies.
- F waves are usually normal in C8 radiculopathy but may be abnormal on the affected side in an ul
NCS routine
The document contains guidance on interpreting different neurography findings. It discusses various scenarios where the CMAP amplitude is low and provides potential reasons for this, including carpal tunnel syndrome, lower extremity mononeuropathy, technical problems, and polyneuropathy. It also addresses interpreting low sensory amplitudes and abnormal sensory latencies. Different neurography patterns are presented that may indicate carpal tunnel syndrome, lumbar root lesions, plexopathies, or other diagnoses. Methods for distinguishing between these various diagnoses are suggested.
EMG routine
The document contains questions about electromyography (EMG) signals and interpretations. Key points addressed in the responses include:
1. Complex repetitive discharges (CRDs) seen on EMG are characterized by an abrupt start and stop with no waxing and waning, unlike myotonia.
2. In Guillain-Barré syndrome presenting with acute weakness, early EMG findings may show normal compound muscle action potentials and conduction velocities but reduced F-wave persistence and abnormal interference patterns, indicating conduction block.
3. Double discharges seen on EMG do not need to be identical in shape to be considered extra discharges, as the second discharge will be lower in amplitude due to the relative
Basics of rnst,vep ,baer and emg
1. The document discusses various electrophysiological tests including repetitive nerve stimulation test (RNST), visual evoked potentials (VEP), and brainstem auditory evoked responses (BAER).
2. RNST involves electrically stimulating a motor nerve repeatedly to observe changes in the compound muscle action potential. Abnormal results can indicate disorders of the neuromuscular junction like myasthenia gravis or Lambert-Eaton myasthenic syndrome.
3. VEP involves recording electrical potentials from the visual cortex in response to visual stimuli. Pattern reversal VEP using checkerboard patterns is commonly used to detect lesions of the visual pathway. P100 latency prolongation is the most reliable indicator of abnormality.
Activation Proceedures in EEG.pptx
This presentation explains the technique, interpretation and utility of commonly used activation procedures in EEG.
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Polysomnography (PSG) is the primary tool used to assess sleep. PSG involves recording the electroencephalogram (EEG), electrooculogram (EOG), electromyogram (EMG), respiratory effort, airflow, and oxygen saturation. It provides information about sleep stages and architecture, respiratory events like apneas, and movements during sleep. Portable PSG allows for more natural sleep but provides less information than laboratory PSG. Various conditions can be diagnosed using PSG findings, including sleep apnea and periodic limb movement disorder.
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- Slow RNS (3Hz) depletes quanta/acetylcholine, which can cause a >10% decrement in the compound muscle action potential amplitude. Rapid RNS (20-50Hz) prevents depletion through calcium accumulation, potentially causing increment.
- RNS helps distinguish pre- from post-synaptic disorders based on changes with exercise, fatigue and rapid stimulation patterns. It is useful for diagnosing myasthenia gravis and other neuromuscular transmission disorders.
4. Practical aspects
Neurography is often the first test performed to evaluate peripheral nerve function. It focuses on answering the clinical question and follows strict methodological standards. The second step is typically EMG to further assess muscle and nerve function. Successive diagnostic steps depend on the findings and may include repetitive nerve stimulation, SFEMG, and macro EMG. Precise technique and attention to signal quality are important for optimally performing and interpreting neurography and EMG studies.
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This document provides information about repetitive nerve stimulation (RNS) testing, including:
1) RNS is used to evaluate neuromuscular junction disorders like myasthenia gravis by assessing changes in the compound muscle action potential with repetitive nerve stimulation.
2) In myasthenia gravis, the safety factor is reduced due to fewer acetylcholine receptors, so some endplate potentials may not reach threshold, causing a decremental response on RNS.
3) The protocol for RNS involves stimulating multiple nerves at rest and after exercise to look for an abnormal decremental or incremental response that indicates impaired neuromuscular transmission.
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REPETITIVE NERVE STIMULATION (RNS)
- Repetitive nerve stimulation (RNS) involves electrically stimulating a nerve multiple times to assess neuromuscular transmission. It evaluates the safety factor and response to exercise at the neuromuscular junction.
- Slow RNS (3Hz) depletes quanta/acetylcholine, which can cause a >10% decrement in the compound muscle action potential amplitude. Rapid RNS (20-50Hz) prevents depletion through calcium accumulation, potentially causing increment.
- RNS helps distinguish pre- from post-synaptic disorders based on changes with exercise, fatigue and rapid stimulation patterns. It is useful for diagnosing myasthenia gravis and other neuromuscular transmission disorders.
4. Practical aspects
Neurography is often the first test performed to evaluate peripheral nerve function. It focuses on answering the clinical question and follows strict methodological standards. The second step is typically EMG to further assess muscle and nerve function. Successive diagnostic steps depend on the findings and may include repetitive nerve stimulation, SFEMG, and macro EMG. Precise technique and attention to signal quality are important for optimally performing and interpreting neurography and EMG studies.
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This document summarizes the examination of the motor and sensory systems. It describes how to examine muscle bulk, tone, power, and involuntary movements. It also outlines how to test various sensory modalities like pain, touch, temperature, proprioception, vibration, and cortical sensations. Key points examined include muscle wasting, tone (loss or increase), power grading, reflexes, coordination, dermatomes, and signs for proprioception. Assessment methods are provided for each test with normal and abnormal findings.
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This document contains 6 case studies with impressions of different neuromuscular disorders:
1. A 22-year-old woman with a postsynaptic neuromuscular junction transmission disorder shown by repetitive nerve stimulation testing.
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Cortical stimulation and mapping is used to localize functional areas of the brain before epilepsy surgery. There are two main methods - intraoperative using probes during surgery, and extraoperative using grids or strips placed on the brain surface. Central sulcus mapping uses stimulation of the median nerve and recording across the central sulcus to identify the motor cortex. Cortical stimulation parameters include bipolar pulses at 50-60Hz for language and motor mapping to elicit responses without afterdischarges. Two patient case studies demonstrate invasive EEG using grids and strips to further define the ictal onset zone and guide resection in relation to eloquent areas.
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The Faradic Galvanic (FG) test assesses lower motor neuron problems by stimulating muscles with different electric currents. A brief tetanic contraction indicates intact innervation, while a sluggish response suggests denervation. The test involves using faradic current to search for motor points and elicit fast contractions in innervated muscles. Galvanic current then produces slow contractions in denervated muscles. However, the FG test is inaccurate and unreliable, correctly interpreting muscle reactions in only 50% of cases.
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1) RNS is used to evaluate neuromuscular junction disorders like myasthenia gravis by assessing changes in the compound muscle action potential with repetitive nerve stimulation.
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3) The protocol for RNS involves stimulating multiple nerves at rest and after exercise to look for an abnormal decremental or incremental response that indicates impaired neuromuscular transmission.
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A 21-year-old man presented with slowly progressive proximal muscle weakness and pain over 1 month. Neurography was normal. EMG showed myopathic motor unit potentials, interference patterns, and fibrillations. Ultrasound revealed hyperechogenicity and increased vascularization in the deltoid muscle. A muscle biopsy showed fiber diameter variation but no grouping. The likely diagnosis is polymyositis or dermatomyositis given the clinical presentation, normal neurography, myopathic EMG, and muscle biopsy findings.
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Electrodiagnosis can help diagnose Guillain-Barré syndrome (GBS) within the first week, when other tests may be normal. An absent H-reflex combined with abnormal F-waves and upper extremity sensory nerve action potentials, with normal sural nerve responses, suggests early GBS. From days 1-4, an absent H-reflex is most common abnormal finding. By days 5-7, 50-75% of patients show these characteristic electrodiagnostic features. Over time, motor nerve responses become more abnormal with low amplitudes, prolonged distal latencies, and slowed conduction velocities. Outcomes correlate with preserved motor nerve amplitudes—lower amplitudes indicate slower recovery.
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This document provides an overview of normal EEG patterns in adults. It begins with a brief history of EEG and then describes the basic electrical activity generated by the brain and how EEG recordings work. It outlines the normal frequency bands seen in EEG - delta, theta, alpha, beta and gamma. Specific normal EEG patterns like the alpha rhythm, vertex waves, sleep spindles and K-complexes are described. It also discusses benign variants and activation procedures. In summary, the document serves as a reference for the typical EEG patterns seen in healthy, awake and sleeping adults.
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This document outlines the components and process of performing a motor examination. It describes examining muscle mass, tone, power, coordination, gait, and reflexes. Deep tendon reflexes are tested using a reflex hammer at sites including the biceps, triceps, patella, and Achilles tendons. Abnormal reflex responses include spasticity, rigidity, and hypotonia. Motor strength is graded on a scale from 0 to 5. The plantar reflex test assesses upper motor neuron function.
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The document discusses various EMG findings including: fibrillation potentials and positive sharp waves that are generated in the axon or individual muscle fibers with irregular firing rhythm and always signify axonal pathology; findings expected in demyelinating neuropathies with conduction block such as reduced MUP amplitudes and interference pattern; what complex repetitive discharges represent; and EMG findings in acute weakness such as Guillain-Barré syndrome where early on there would be normal CMAPs and CVs with reduced interference pattern. It also addresses discrepancies that can occur on EMG and the diagnostic methods of choice for various conditions.
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The document discusses characteristics of ideal muscle relaxants for day surgery/day anesthesia including fast onset and offset, lack of residual block, lack of side effects, predictable duration, and safety. It evaluates various muscle relaxants and their profiles in terms of these characteristics. It also discusses evaluation of residual neuromuscular block and implications of a study showing visual disturbances in volunteers even at TOF ratios thought to indicate full recovery. Ensuring patients have fully recovered motor function before discharge is important in day surgery settings.
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The document summarizes testing of the autonomic nervous system. It discusses the two main components of the autonomic nervous system - the sympathetic and parasympathetic nervous systems. It then describes several specific tests used to evaluate autonomic function, including heart rate response to deep breathing, Valsalva ratio, and sympathetic skin response. The document provides details on the protocols, normal responses, and clinical significance of these autonomic function tests.
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This document discusses neuromuscular transmission testing, including repetitive nerve stimulation (RNS) protocols and analysis. It describes RNS protocols to evaluate myasthenia gravis and other neuromuscular disorders. Key points covered include RNS parameters to analyze like initial amplitude, decrement, and post-activation facilitation/exhaustion. It also discusses RNS considerations like muscle selection, temperature, and fixation effects. Normal RNS results and examples of abnormal findings in myasthenia gravis and congenital myasthenia are presented.
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This document discusses the electrophysiological evaluation of tremors, myoclonus, and dystonia. It provides details on:
1) The neurophysiological characteristics of tremors, myoclonus, and dystonia that can be assessed electrophysiologically, including tremor frequency, muscle firing patterns, EEG correlates, and more.
2) Specific electrophysiological techniques used to evaluate these conditions like accelerometry, electromyography, jerk-locked back averaging, and others.
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10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
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QUIZ RNS
- 1. Quiz RNS
- 2. 57EMG: Myasthenia? Patient with bilat ptosis but no arm or leg weakness. RNS in nasalis and deltoid normal. SFEMG in orb oculi and frontalis normal. 1. Ocular MG 2. Generalized MG 3. Myopathy 4. Bell palsy Normal SFEMg findings are strong indications that symptoms are NOT MG. In this case, it may be a myopathy, often with very little of jitter abnormalities
- 3. 57EMG: Myasthenia? Patient with bilat ptosis but no arm or leg weakness. RNS in nasalis and deltoid normal. SFEMG in orb oculi and frontalis normal. 1. Ocular MG 2. Generalized MG 3. Myopathy 4. Bell palsy Normal SFEMg findings are strong indications that symptoms are NOT MG. In this case, it may be a myopathy, often with very little of jitter abnormalities
- 4. Which is the optimal time for maximal voluntary activation in RNS tests in MG and LEM respectively? 1
- 5. Which is the optimal time for maximal voluntary activation in RNS tests in MG and LEM respectively? 45-60 sec to provoke MG exhaustion 10 sec to see LEM facilitation 1
- 6. RNS • Is the head moving when you perform correctly RNS from trapezius muscle (stim behind the sternocleid muscles)? NO, move stim • Is it normal to have some degree of “biting” when you perform RNS of the nasalis muscle? If not, what to do? No, direct stim of masseter muscle, move stim 1
- 7. RNS • Is the head moving when you perform correctly RNS from trapezius muscle (stim behind the sternocleid muscles)? NO, move stim • Is it normal to have some degree of “biting” when you perform RNS of the nasalis muscle? If not, what to do? No, direct stim of masseter muscle, move stim 1
- 8. Q 43. Tests of LEM? The important finding is strong facilitation (> 60% amplitude increase) This is accomplished by 1. 10 sec voluntary activation or 2. Stim 20 (-50) Hz for 1 sec. Note, the facilitation should be assessed from the amplitude obtained after first single stimulus after the train. (during the train the muscle is shortening, which changes the amplitude by up to 40%) 8
- 9. Q 43. Tests of LEM The important finding is strong facilitation (> 60% amplitude increase) This is accomplished by 1. 10 sec voluntary activation or 2. Stim 20 (-50) Hz for 1 sec. Note, the facilitation should be assessed from the amplitude obtained after first single stimulus immediately after the train. (during the train the muscle is shortening, which changes the amplitude by up to 43%) 9
- 10. 1 Which muscles are tested?
- 12. 47 year old lady HISTORY AND FINDINGS • previously healthy • since 3 months increasingly weak • can walk 200 m, subjectively weaker right side • last month in wheelchair • hoarse, swallowing difficulties • orthostatic hypotension • obstipated CLINICAL: • fatigable neck muscles • weak leg muscles • no atrophy of facial muscles • areflexia Q3
- 14. Repetitive nerve stimulation: m. ADM sin Q3 rest rest 0 after 20 sec act 60 sec after act 3 min afdter act
- 15. SFEMG: m. orbicularis oculi Q3
- 16. CT thorax – normal VGCC antibodies – positive Diagnosis? a. MG b. LEM c. axonal neuropati d. AMAN e. post polio syndrom Comment: Not all muscles show the typical facilitation. No data from other muscles 20 sec may be too long, prefer 10 sec Do not exclude LEM from normal study of ONE muscle 47 year old lady