Nermin Gorkem Sirin

A quadruple examination of ictal EEG patterns in mesial temporal lobe epilepsy with hippocampal sclerosis: onset, propagation, later significant pattern, and termination.

Purpose: The purpose of this study was to analyze electrophysiological properties of four main stages of ictal patterns of patients with operated temporal lobe epilepsy related to hippocampal sclerosis. Methods: We included 48 patients with temporal lobe epilepsy–hippocampal sclerosis. Seizures were classified according to their electrophysiological properties and surgical outcomes as seizure-free and not seizure-free. The EEGs with artifacts at the beginning were analyzed separately. Results: The most frequent type of ictal onset patterns was rhythmic theta/alpha activity, which was correlated to seizure-free group, whereas “switch of lateralization” and “bitemporal asynchrony” correlated to not seizure-free group. When bilateral independent ictal propagation patterns emerged, seizures tended to predict the side of epileptogenic zone wrongly. As a later significant pattern, rhythmic theta/alpha activity lateralized the focus correctly. Seizure termination was significantly concordant with hippocampal sclerosis lateralization in the seizure-free group. Conclusion: Ictal onset pattern with rhythmic theta/alpha activity correlates well with seizure freedom. Morphology of later significant patterns was more important in determining the lateralization reliability than time of appearance. The EEGs with short artifacts at the beginning are seen to be valuable in presurgical evaluation. Lateralization of ictal termination ipsilateral to MRI indicates good prognosis after surgery. Scalp EEG monitoring helps predict epileptogenic zones and postsurgical outcomes.

A Case Report of Cerebral Venous Thrombosis in Polycythemia Vera Presenting with Intracranial and Spinal Subdural Hematoma.

Spinal subdural hematoma (SDH) is a rare condition and can be caused by several factors. Concomitant cranial and spinal SDH is even much less common. We present a 77-year-old male patient with lower back pain, paraparesis, and urinary retention following a sudden onset headache. Imaging revealed concomitant cranial and spinal SDH related to cerebral venous thrombosis (CVT) associated with hemorrhagic venous infarct. Laboratory examinations were consistent with polycythemia vera. There was no history of trauma and previous cranial surgery. Brain angiography did not reveal any evidence of arteriovenous fistula or vascular malformation. Since lower back pain occurred shortly after the headache and there was no other reasonable explanation for spinal hemorrhage, we suppose that the mechanism of spinal SDH is the migration of blood from the intracranial compartment. Therefore, this is the first report of concomitant spinal SDH and cerebral hemorrhage associated with CVT in a patient with myeloproliferative disease.

Repetitive nerve stimulation and jitter measurement with disposable concentric needle electrode in newly diagnosed myasthenia gravis patients

INTRODUCTION The aim of this study was to define the diagnostic accuracy of concentric needle (CN)-jitter in newly diagnosed myasthenia gravis (MG) patients and to compare CN-jitter with repetitive nerve stimulation. METHODS In 30 MG patients, repetitive nerve stimulation in 4 muscles (orbicularis oculi, nasalis, trapezius and abductor digiti minimi) and CN-jitter of extensor digitorum (ED) and frontalis muscles were evaluated. RESULTS Twenty-eight of 30 patients (93%) had high jitter in at least one muscle. Repetitive nerve stimulation was abnormal in 23 of the patients (77%). Eighty-six percent of the patients in whom repetitive nerve stimulation test was negative could be diagnosed with CN-jitter. The most frequent muscle showing abnormal decrement was orbicularis oculi. The results of CN-jitter were similar between patients with different serological groups. Of 13 patients with generalized weakness, all had high jitter in both muscles studied whereas of 17 patients only with ocular weakness, 15 had high jitter in at least one muscle studied. CONCLUSION Abnormal RNS was present in 77% of newly diagnosed MG patients, being less than CN-jitter (93%) but more than antibody positivity (73.3%).

S101. A novel automatized F-wave MUNE method: A preliminary analysis

Introduction The aim of this study was to test a novel automatized F-wave MUNE method by comparing its results with those elicited with the manual method performed in patients with amyotrophic lateral sclerosis (ALS) and healthy controls. Methods Ninety F-waves elicited with supramaximal stimuli were recorded from thenar and hypothenar muscles in 10 ALS patients and 4 healthy controls. For manual analysis, F-waves with the same amplitude, latency and shape were selected visually by the same examiner. For automatized analysis, similar signals were grouped according to latencies of negative and positive peaks and peak-to-peak amplitudes in MATLAB by using the original software developed for this study. The mean amplitudes of F-waves repeating more than once were defined as sMUPs and MUNE value for each case was calculated by dividing the CMAP amplitude by mean sMUP amplitude. Results Data of two healthy controls and 1 ALS patient were excluded from the analysis since no repeater F-waves were detected by one of the methods. sMUP and F-wave MUNE values calculated by both methods were found to be highly correlated (Spearman’s rho, p μ V and 406.55  μ V, respectively in thenar muscles and 412.53  μ V and 332.77  μ V in hypothenar muscles). Similar F-wave MUNE values were also calculated by using both methods (26.00 and 28.58, respectively in thenar muscles and 36.04 and 30.18 in hypothenar muscles). Conclusion Our automatized F-wave MUNE method seems to be promising in reflecting motor unit numbers in the hand muscles in patients with ALS and healthy controls.

T40. Comparison of MScanFit MUNE and other parameters derived from the CMAPScan in ALS patients

Introduction The aim of this study was to analyse MScanFit MUNE, D50 and step% values elicited from the CMAP scan curves of thenar and hypothenar muscles in patients with amyotrophic lateral sclerosis (ALS) and healthy controls. Methods Thirty-four ALS patients (31 definite, 1 probable and 2 possible, according to Awaji criteria) and 24 healthy controls were included. CMAP scan curves were recorded from both thenar and hypothenar muscles by applying 500 stimuli. Step% and D50 values were calculated semi-automatically and MScanFit MUNE was calculated by using the freeware version of Qtrac software. Results Mean MScanFit MUNE and D50 values were lower and step% values were higher significantly in patients (48.8, 25.0, 32.5 in thenar muscles and 66.5, 28.9, 17.0 in hypothenar muscles, respectively) as compared to healthy controls (112.5, 45.6, 4.0 in thenar muscles and 124.5, 46.6, 1.1 in hypothenar muscles; p p Conclusion Step% and MScanFit MUNE are parameters correlated with each other and they are sensitive tools in revealing the severities and the courses of the electrophysiological abnormalities in ALS.

F52. Repeater F-waves: Electrophysiologic manifestations of upper or lower motor neuron involvement?

Introduction The aim of this study is to compare repeater F-wave parameters with CMAP amplitudes recorded from the hand muscles (as indicators of the amount of lower motor neuron [LMN] loss) and with the triple stimulation technique (TST) ratios in the same muscles (as indicators of upper motor neuron [UMN] involvement) in 19 patients with amyotrophic lateral sclerosis (ALS). Methods Ninety F-waves were recorded from thenar and hypothenar muscles by supramaximal stimuli applied to the relevant nerves at the wrist level. Repeater F-waves (F rep ) were visually defined as those presented with the same amplitude, latency and shapes. Repeater neuron (RN) index, F rep index, persistances of F-waves, F/M amplitude ratio and the neurophysiologic index (NI) were calculated. By depending our laboratory normals, TST ratio values lower than 82% and 86% were accepted as abnormal showing UMN involvement in thenar and hypothenar muscles respectively. Results TST ratios were abnormal in 13 thenar and 11 hypothenar muscles. None of the F rep parameters showed any significant relationship with the abnormal TST ratios, except the lower F rep index in thenar muscles, in patients with UMN involvement according to low TST ratios. However, there was a strong negative correlation with the CMAP amplitudes and F rep index and RN index values in hypothenar muscle (Spearman’s rho, p Conclusion These findings imply that repeater F waves might be a manifestation of LMN loss more than being a result of UMN involvement.

T78. CMAP scan and scanning EMG in the same muscle: Two cases with post-polio muscular atrophy

Introduction Post-polio muscular atrophy (PPMA) is characterized by new onset or increased weakness in patients with prior poliomyelitis after a stable period of time. Loss of highly reinnervated motor units during ageing has been accused for the development of this syndrome which is also known as “unstable-polio”. These patients have less number of motor units that can be estimated by conventional electrophysiological methods. By showing the large steps, CMAP scan provides information about the amount of collateral reinnervation in the construction of total muscle response (CMAP). As well as the number of motor units, their territory is also an object of curiosity. It is possible to record bioelectrical activity of motor unit lengthwise by scanning EMG and depict the temporal and spatial features of motor unit action potential (MUAP). This presentation aims to combine the findings in CMAP scan with scanning EMG and draw attention to reinnervation status of 2 PPMA patients whose tibialis anterior (TA) muscles were affected in different degrees. Methods Two patients aged 39and 41 years were included. Patient 1 had PPMA for 8 years and his TA muscle strength was 3-/5, whereas Patient 2 showed PPMA findings for 1 year and his TA strength was 4/5. CMAP scan of TA muscle on recently affected side was performed with a commercially available software. In scanning EMG, MU territories were scanned with a concentric needle electrode (CNE) which is attached to a stepper motor. Another CNE is used for sweep triggering with the rate of selected motor units’ firing frequency. Acquired signals were processed by the dedicated software designed by the authors. Results CMAP scan of Patient 1 revealed a 1.65 mV CMAP constituting of 4 very large steps and Patient 2 revealed a 5.5 mV CMAP containing a few smaller steps. In scanning EMG, both patients’ motor units showed increased voltage in different parts corresponding to dense areas arisen from collateral reinnervation. Interestingly, the patient with more pronounced weakness for a longer period revealed both huge steps in his CMAP scan and also showed electrically silent areas in his scanned motor units. On the other hand, the patient with stronger TA muscle did not show very large steps or silent areas in his CMAP scan and MU scan, respectively. Conclusion Loss of dense motor units leads to PPMA. However, in PPMA patients with severe weakness which is depicted by less number of motor units and presence of huge steps in CMAP scan, loss of fractions in motor unit territory might be a principal contributing factor which can only be demonstrated by scanning EMG.

O156 A functional connectivity analysis of patients with temporal lobe epilepsy with different propagation patterns

Objective To analyze the functional connectivity (FC) of temporal lobe and related areas in patients with temporal lobe epilepsy (TLE) showing unilateral lateralized ictal discharges (uniTLE) and unusual ictal propagation patterns (UiP) defined as ‘switch-of lateralization’ and ‘bilateral asynchrony’ in scalp EEG. Methods Twelve TLE patients with UiP (6 with left and 6 with right seizure-onset) and 13 patients with uniTLE (7 with left and 6 with right seizure-onset) and 13 healthy controls (HC) underwent resting state functional MRI. ROI-to-ROI FC analyses were carried out between homologous insula, hippocampi, parahippocampal gyri, amygdala, superior temporal and middle temporal gyri. Results All TLE patients showed reduced overall FC compared to HC, where univariate comparisons revealed that the connectivities were significantly reduced between right and left insula, parahippocampal and superior temporal gyri. MANOVA among the 3 groups revealed that the uniTLE patients displayed a lower FC between the homologous parahippocampal gyri, while patients with UiP had lower FC between the homologous insula, parahippocampal and superior temporal gyri when compared with the HC. Furthermore, TLE patients with UiP showed significantly lower FC between the bilateral insula when compared with uniTLE patients. Discussion While the reduction level of the resting-state FC between the homologous temporal lobe structures may depend on neural loss, a network change to protect contralateral temporal areas might also play role in further reduced FC in TLE with UiP. This might support the presence of independent epileptogenic zones bilaterally rather than a propagation from the contralateral hemisphere.