The 7th National Conference of ASNER,

www.asner.org

The 7th National Conference of

ASNER,The Romanian Society of

Electrodiagnostic Neurophysiology

CN2015 | Cluj-Napoca | Romania | 23-25 October 2015

AbstRACt bOOk

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ASNER CN2015 Cluj-Napoca, 23-25 October 2015 – Abstract book7th National Conference of the Romanian Society of Electrodiagnostic Neurophysiology

Scientific partners:

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Prof. Dafin F. Muresanu

President of the Romanian Society of Neurology

Professor of Neurology, Chairman Department of Neurosciences “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania

Chairman “RoNeuro” Institute for Neurological Research and Diagnostic

President of the Society for the Study of Neuroprotection and Neuroplasticity (SSNN)

Dear colleagues,

It is a great pleasure to welcome you to the 7th National Conference of The Romanian Society of Electrodiagnostic Neurophysiology (ASNER), to be held in Cluj-Napoca, October 23th - 25th, 2015. This scientific event will be hosted by “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca and “RoNeuro” Institute for Neurological Research and Diagnostic.

The Conference, endorsed by the Romanian Society of Neurology, aims to constitute a platform for exchange of newest scientific information in the field of Electrodiagnostic Neurophysiology, as well as providing ample space for teaching oriented workshops and seminars. Our scope is to share our knowledge to an audience with a vivid interest in this steadily expanding and exciting field.

A major topic will relate to the current status of Electroneurophysiology in Romania and future perspectives in science and education in the field. The meeting format, as well as the selected main topics, will certainly be of interest to a wide audience.

Special thanks must be given to Prof. Christian Krarup, Prof. Margitta Seeck and Prof. András Fogarasi for joining and sharing with us their important experience.

We are looking forward to your active participation in this educational event!

With consideration,

Prof. Dr. Dafin F. Muresanu

Conference Scientific Coordinator

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Dear Friends,

Every year since 2008, in the fall, we get together for 3 days, to share and acquire knowledge in clinical neurophysiology. We call it a National Conference, it is the 7th, but I see it also as a good opportunity for us, people with a scientific passion in this field, to meet again in a friendly manner.

We uphold our commitment to organize our conferences in clinical centres across the country, and now we are for the second time here in Cluj Napoca, a beautiful transylvanian city, which I encourouge all our non-local participants to visit, of course outside of the scientific events.

As usual, we have prepared an interesting scientific programme, with plenary sessions, that will be completed with more practical aspects – workshops in EEG & EMG, followed in the last day of our meeting by scientific and case presentations, which is a opportunity for many to share their practical activity, and for all of us to learn and gain more experience.

I wish you all a pleasant stay here in Cluj, and hope that our efforts will meet your expectations.

Sincerely,

Tudor Lupescu M.D. Ph.D.

ASNER President

[email protected]

http://www.asner.org

Ioana Mindruta, M.D. Ph.D.

ASNER Vice-President

Neurology Department, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

[email protected]

Ionela Codita, M.D. Ph.D.

ASNER Secretary

Neurology Department of Elias University Emergency Hospital, Bucharest, Romania

[email protected]

Ana-Maria Cobzaru, M.D.

ASNER Treasurer

Neurology Department, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

[email protected]

Mihai Moldovan, MD, PhD

ASNER Scientific director

Copenhagen University, Denmark and “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

[email protected]

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Friday, 23rd of October12:00-12:45 welcome cocktail

12:45-14:45 Workshop: EEG (chair: Floriana Boghez) at “T. Goina” amphitheater, Str. Gheorghe Marinescu Nr. 23

14:45-15:30 coffee break

15:30-18:00 Workshop: EMG (chair: Ana-Maria Cobzaru) at RoNeuro - Str. Mircea Eliade Nr. 37

free evening

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Saturday, 24th of October – part1Plenary Session 1 (chair: Tudor Lupescu)

9:00-9:45 Quantitative EMG for diagnosis of neuromuscular disorders (Christian Krarup, DK)

9:45-10:00 Electrodiagnosis – when? how? why? (Tudor Lupescu)

10:00-10:15 The safety factor for action potential conduction along peripheral nerve axons (Mihai Moldovan, DK)


Plenary Session 2 (chair: Ioana Mindruta)

10:30-11:10 Autoimmune epilepsies – emphasis on EEG (Margitta Seeck, SUI)

11:10-11:40 Challenges of video EEG monitoring in children (Andras Fogarasi, HG)

11:40-12:00 Misleading EEG lateralization and localization in focal epilepsy (Ioana Mindruta)


Special interest lectures

12:10-12:40 Pompe disease in the adult (Tudor Lupescu)

12:40-13:10 Evoked Potentials in Multiple Sclerosis (TBA)

Lunch 13:30-14:30

14:30-16:00 EEG – case presentations (chair: Bogdan Florea)

Infections in Status Epilepticus (Bogdan Florea)

Experience with first seizure assessment (Irina Constantinescu)

Sleep latency tests (Floriana Boghez)

Memory recall and the medial temporal lobe – a cortical stimulation study (Andrei Daneasa)

The relationship between seizure semiology and brain activity in a case of refractory frontal epilepsy (Anca Arbune)

Saturday, 24th of October – part 216:00 – 16:20 coffee break

16:20-18:00 EMG – case presentations (chair: Ionela Codita)

Aging and the gluteal compartment syndrome (Mircea Moldovan)

Limb-Girdle Dystrophies (Ana-Maria Cobzaru)

Diagnosis difficulties in acute asymmetrical paraparesis in pacient with type 2 diabetes-case report (Ionela Codita)

Benign idiopathic HiperCKemia - a case presentation (Florian Antonescu)

Generalized severe deep pain as onset of GBS (Marian Cristian Feticu)

19:00 Get together buffet dinner

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Sunday, 25th of OctoberNeurophysiology in pediatric disorders (chair: Mihaela Adela Vințan)

9:00-9:40 Suppression burst in critical patient – case presentation (Mihaela Adela Vințan)

9:40-10:00 Follow-up (clinical, EEG and cognitive) in a child with cortical dysplasia (Anca Fărcaș, Mihaela Adela Vințan)

10:00-10:20 Challenges in diagnosis of brain tumours with seizures at onset (Ludmila Darie, Mihaela Adela Vințan)

10:20-10:40 When EEG makes the difference – tics or ocular seizures (Andrea Așchilean, Mihaela Adela Vințan)


Neuromonitoring (chair: Mihai Moldovan)

11:00-11:20 CERMO: A coma EEG reactivity monitor (Mihai Moldovan)

11:20-11:40 Repetitive low-frequency magnetic stimulation in stroke in the subacute stage: clinical evaluation, prognosis, evaluating cortical excitability (Dana Răcășan)

11:40-12:00 Repetitive magnetic stimulation in neuropathic pain (Livia Popa)

12:00-12:20 Intraoperative neurophysiological monitoring of brain tumors (Dan Filip)

12:20-12:40 Introducing the epileptome-dynamic seizure onset zone connectome as revealed by single pulse electrical stimulation in stereoelectroencephalography (Dragos Mihai Maliia)

12:40-13:00 Cognitive flexibility testing during electrostimulation in patients explored with intracranian electrodes (Alexandru Rusu)

13:00-13:30 Certificates, Feedback and Closing

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Diagnosis of neuromuscular diseases using quantitative EMG

Christian Krarup

Department of Clinical Neurophysiology, Rigshospitalet, Copenhagen, Denmark

EMG is a method used to record electrical activity from muscle to distinguish weakness caused by neurogenic disease or myopathy. A needle electrode inserted in the muscle records electrical signals. The needle may be a monopolar or a concentric needle. Qualitative assessment of potentials viewed on a monitor is often used for analysis and interpretation, but this method does not allow independent verification of the findings. Alternatively, quantitative measurements may be used for diagnostic purposes.

Quantitative EMG is based on a standardized protocol that includes recordings of activity at rest and individual motor unit potentials at weak effort from 10 sites in the muscle. Furthermore, the electrical activity at maximal voluntary activity is recorded. The potentials recorded with a concentric needle are stored and measured off-line.

The number of sites with spontaneous potentials is counted to assess the amount of denervation activity. The mean duration and amplitude and the shapes of motor unit potentials are measured and compared to age-matched controls. The interference pattern of the activity at maximal voluntary effort is measured.

95% confidence limits for the different variables have been determined, and deviations that allow diagnosis of neurogenic disorders or myopathy have been determined.

Prof. Christian Krarup MD, DMSc, FRCP

[email protected]

Christian Krarup, MD DMSc FRCP, Professor of Clinical Neurophysiology and Head of the Department of Clinical Neurophysiology, the Neuroscience Centre, Rigshospitalet, Copenhagen, Denmark. MD degree, 1975; Doctorate in Medical Sciences in 1984, University of Copenhagen. 2003 honourary Fellow of Royal College of Physicians (London). Training in neurology and clinical neurophysiology at Rigshospitalet (1975-1979), at the National Hospital for Neurology and Neurosurgery, Queen Square, London (1979-1981) and the National Institute of Neurological Disorders and Stroke (1982-1984). Director of Clinical Neurophysiology at Brigham and Women’s Hospital, Boston and Assistant/Associate Professor of Neurology, Harvard Medical School. Research Associate, Massachusetts Institute of Technology (1984-1989). 1990 to present at Rigshospitalet. Research interests are in neuromuscular diseases and translational neurosciences with particular reference to nerve degeneration, regeneration and protection.

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Autoimmune epilepsies – emphasis on EEG

Margitta Seeck

Clinique de NeurologieUnité d’évaluation préchirurgicale d’épilepsieUnité d’épileptologie et d’EEGGeneva University Hospital

Over the past 10-15 years, the discovery of novel forms of encephalitis associated with antibodies to cellsurface or synaptic proteins has allowed the description of new diseases, previously ill-classified and under-treated. Since, more than 10 different forms of autoimmune encephalitis have been described, resulting to a variable degree in seizures, neuropsychological deficits, psychosis, or abnormal movements. I will review the pathogenesis, symptoms, and state-of-art treatment of the most common forms. Rapid diagnosis and treatment improves the outcome and avoids lengthy disease courses with irreversible consequences.

Prof. Margitta Seeck MD PhD

[email protected]

Margitta Seeck did her medical studies in Munich, followed by post-doc fellowships in Berlin and in Boston (Harvard University) in order to complete her studies in neurophysiology and epileptology. Back in Munich, where she finished her neurology training, she was recruited to Geneva in 1998, to found the epilepsy center Vaud-Genève for patients with difficult-to-treat epilepsy. Under her direction, the center is today established on the national and international level. In 2005, she was nominated as associated professor and promoted to full professor the 1.7. 2015. Since 2007, she is heading also the outpatient EEG and epilepsy unit overseeing more than 3000 EEGs per year, including adult and pediatric intensive care. With the support of the Swiss National Science Foundation, she leads a research group dedicated to the analysis of electrical brain signals and their localisation on the basis of high density EEG and fMRI. Other research interests include autoimmune epilepsy and behavioral aspects of epilepsy.

Group website: http://epilepsie.hug-ge.ch

The main activity of the unit is to propose surgical solution to drug resistant patient. To achieve this goal we are currently dealing with cerebral imaging techniques to localise brain functions such as MRI, PET, SPECT, ESI, fMRI, electrocorticography.

Among all functional brain imaging techniques, ESI (Electromagnetic Source Imaging) became more and more precise and useful to localize the epileptic foci. Sine many years our group demonstrated that high resolution EEG (256 channels) is promised tool to localize epileptic foci for various type of epilepsy. Multimodal imaging allow us to compare the yield of each technique (MRI, PET, SPECT, ESI, fMRI) for different group of patient (paediatric population, non lesional epilepsy).

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Challenges of video EEG monitoring in children

Andras Fogarasi

University of Pécs, Neurology Department of the Bethesda Children’s Hospital (Budapest), Hungary

Long-term video-EEG monitoring (VEM) is a key method in the diagnostics of children with therapy resistant epilepsy. VEM can be used for differential diagnosis: in case we are not sure if there is epilepsy in the background of therapy resistant seizures. Another indication is the identification of non-classified epilepsy syndromes. Finally, VEM is used for localizing the seizure onset focus during presurgical evaluation.

In this lecture I would like to show examples of all three indication. Examples of non-epileptic paroxysmal events can illustrate the pitfalls of childhood therapy resistancy. Beside interictal and ictal EEG as well as video characteristics of some epilepsy syndromes, I will show the most important lateralizing and localizing signs used in this population illustrated by interesting surgery cases from our department.

Prof. András Fogarasi MD, PhD

[email protected]

Andras Fogarasi MD, PhD received his diploma at the Semmelweis Medical University (Budapest) in 1995 and at the Bárczi College of Special Education a year later. He is specialized in pediatrics, neuropediatrics and clinical neurophysiology and received health care management diploma as well. He is a professor at the University of Pécs and head of the Neurology Department of the Bethesda Children’s Hospital (Budapest). Prof. Fogarasi has published 90 papers and gave 150 lectures in the field of child neurology and epileptology based on extended research on seizure semiology, age-dependent features of epilepsy, epilepsy surgery, electrophysiology as well as childhood psychogenic non-epileptic seizures.

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Electrodiagnosis – when? how? why?

Tudor Lupescu

Spitalul Clinic de Urgenta “Prof Dr Agrippa Ionescu”

EMG is a very complex investigation that should give us as much knowledge as possible, in cases with neuromuscular involvement. It is actually an extension of the clinical reasoning, and we should use it in such ways to gain the maximum on information. Thus, the level of the nerve lesion, the pathogenic mechanism (demyelination, axonal loss), the extent and intensity of the lesion can be evaluated by the examination of the CMAP and SNAP amplitudes, the nerve conduction velocities, by the spontaneous activity, motor unit potentials parameteres and recruitment. If we can extract these data and interpret it correctly, we can estimate prognosis, or we can indicate the timing of a surgical procedure. Some examples are given.

Pompe disease in the adult

Tudor Dimitrie Lupescu

MD, Ph.D.

[email protected]

Tudor Lupescu obtained his medical degree from “Carol Davila” University of Medicine in Bucharest, in 1989. After 3 years of training at Colentina Clinical Hospital he became Specialist in Neurology in 1994. Since 2006 he is running the Neurology Department al Agrippa Ionescu Hospital in Bucharest. 1998, he qualified as Consultant Neurologist. Since his early years of training in Neurology, Tudor Lupescu has shown a special interest in Clinical Neurophysiology. In 2000 he earned a Competence in Clinical Neurophysiology (EEG, EMG, and Evoked Potentials). 1997 he was the first to use Transcranial Magnetic Stimulation in Romania. This was also the subject of his PhD thesis presented in 2005. Since 2008, Tudor Lupescu is President of ASNER – Romanian Society of Electrodiagnostic Neurophysiology. He is also founding member and vicepresident of the the Romanian Society of Diabetic Neuropathy.

Dr Tudor Lupescu is associate member of the American Academy of Neurology, and associate member of the American Association of Neuromuscular and Electrodiagnostic Medicine. Between 2008 and 2014 he was also member of the Neurophysiology Subcommittee of ENS, and since 2015, he is member of the Neurophysiology Subcommittee of the European Academy of Neurology.

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Misleading EEG lateralization and localization in focal epilepsy

Ioana Mindruta1, Andrei Barborica2, Mihai Malaia3, Cristian Donos4, Irina Popa5, Ana Ciurea6, Jean Ciurea7

1,3,5Neurology Department, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania2,4,6University of Physics, Bucharest Romania7Bagdasar Arseni Hospital, Functional Neurosurgery Department, Bucharest Romania

One of the most important goal of EEG recordings in focal epilepsy is to find epileptiform activity and also to clearly define localisation and lateralisation for abnormal discharges. Many studies focused on explaining misleading findings in this patient population. These studies used methods of concomitant scalp and intracerebral subdural and depth recordings, correlation with MEG dipole localisation method and EEG source localisation technique.

Volume conduction of field potentials, dipole strength and orientation as well as direct fast propagation were incriminated in different types of conditions. Temporal lobe epilepsy was the localization that has been studied extensively and shown that mesial structures related spiking is not visible on scalp EEG. Moreover contralateral spiking could be related to a severe damage of the hippocampus called “burnt out hippocampus” (Fujimoto A., 2006). It is also known that parasagittal location of seizures generators is frequently associated with false lateralization at least for the interictal epileptiform discharges. Several literature reports shown that also insulo-perisylvian cortex epilepsies could reflect on scalp EEG with misleading findings.

In conclusion false lateralisation and localization of scalp EEG abnormal discharges is a well known phenomenon in focal epilepsy. To avoid misjudgements in our clinical cases the EEG information is recommended to be integrated with clinical and imaging data.

Fujimoto A, Masuda H, Homma J, Sasagawa M, Kameyama S. False lateralization of mesial temporal lobe epilepsy by non-invasive neurophysiological examinations. Neurol Med Chir (Tokyo) 2006;46:518–21.

Epilepsy: Case presentations

Ioana Mindruta

Lecturer, MD, PhD

[email protected]

46-year old, neurologist, with competence in electrophysiology and special interest in epileptology, mainly presurgical exploration for epilepsy surgery. PhD thesis on “Sleep studies in epileptic syndromes” in 2006.

Current position at the University Emergency Hospital in Bucharest in the Epilepsy and Sleep Monitoring Unit and also hospital coordinator of the National Programs for Pharmacoresistant Epilepsy and Rare Disorders.

Academic affiliation - lecturer in neurology at the University of Medicine and Pharmacy “Carol Davila” of Bucharest.

Vicepresident of Romanian Association for Clinical Electrodiagnosis (ASNER) since 2009 and member in the board of Romanian Society of Neurology since 2013.

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The safety factor for action potential conduction along peripheral nerve axons

Mihai Moldovan1,2

S) Copenhagen University DK; 2) Carol Davila University, Bucharest, RO

Myelinated peripheral axons are biological structures specialized in energy-efficient conduction of action potentials. Axonal conduction involves a complicated voltage-gated ion channel machinery comprised of several types of Na+ channels (mediating the inward depolarizing currents), K+ channels (mediating the outward rectifying currents) and hyperpolarization-activated cyclic nucleotide-gated channels(mediating the inward rectifying currents), as well as energy-dependent pumping mechanisms required to maintain the ionic concentration gradients across the membranes. Additionally, the spatial distribution of these channels is tightly controlled by axon-Schwann cell interactions.

It is increasingly recognized that during the progression of many neuropathies a reduction in the safety factor for conduction causes a functional, thus potentially reversible, conduction failure before the initiation of the irreversible axonal degeneration cascade. This raises hope for developing new therapeutic strategies for improvement of peripheral nerve function.

CERMO: A coma EEG reactivity monitor

Mihai Moldovan1,2

S) Copenhagen University DK; 2) Carol Davila University, Bucharest, RO

We present the functioning principle, construction and ongoing research using a novel coma monitor based on EEG reactivity to external stimuli.

The project is supported by grants of the Romanian National Authority for Scientific Research, CNCS — UEFISCDI, project number PN-II-ID-PCE-2011-3-0847 and PN-II-PT-PCCA-2011-3.2-1290.

Mihai Moldovan

Assoc. Prof., MD, Ph.D.

[email protected]

Mihai Moldovan obtained his medical degree from “Carol Davila” University Bucharest. He obtained his PhD degree in neurophysiology from Copenhagen University in 2004 where he continues his scientific career as associate professor with prof. Christian Krarup. His research is focused on distinguishing the contribution of voltage-gated ion channel dysfunction to pathophysiology of neurodegenerative disorders, with particular emphasis on peripheral nerve excitability testing. While based in Copenhagen, Mihai Moldovan continued to collaborate with prof .Leon Zagrean at “Carol Davila” University, Department of Physiology and Neuroscience. In 2011, he founded the COMAEEG.RO international network, bringing together Romanian neuroscientists, clinicians and engineers dedicated to improving the monitoring of the comatose brain excitability. Mihai Moldovan has scientific duties in several international organizations including International Brain Research Organization (IBRO) and the European Federation of Neuroscience Societies (FENS). He is also founder and acting president of the National Neuroscience Society of Romania (SNN) and founder of the Romanian Society of Electrodiagnostic Neurophysiology (ASNER) for which he now serves as scientific director.

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Diagnosis difficulties in acute asymmetrical paraparesis in pacient with type 2 diabetes-case report

Ionela Codita,

Simona Petrescu, Raluca Simona Gurgu, Cristina Aura Panea

Neurology Department of Elias University Emergency Hospital, Bucharest

We present a case of 64-year-old female, with history of type 2 diabetes , admitted in our Neurological Department due to abnormal gait ( paraparesis and dysmetria ) as well as ascending lower limbs paresthesia , started 3 weeks prior to the admission, with progressive evolution.

Neurological exam revealed asymmetric paraparesis, more on the right, with distal lower limbs vibratory anesthesia, distal upper limbs hypoesthesia , right dermatomal L1-L5 hypoestesia , tetra-ataxia, absent deep tendon reflexes in the lower limbs.

The electrophysiologic abnormalities didn’t fulfill electrodiagnostic criteria for peripheral nerve demyelination .

Imagistic findings of CNS ( brain and spinal cord ): minimal hydromyelia of the inferior thoracic spinal cord and CSF analysis revealed increased proteins level and moderate pleocytosis. HTLV1 antibodies were present.

Although in a pacient with diabetes mellitus the clinical picture and evolution suggest acute polyradiculoneuropathy, the paraclinic, electrophysiologic tests and CSF analysis lead to another diagnosis.

The case is presented in order to discuss the electrophysiologic assessment of acute paraparesis in pacients with diabetes mellitus.

Ionela Codita

MD, PhD

[email protected]

Ionela Codita is currently working as a Senior Neurologist in the Neurology Department of Elias University Emergency Hospital in Bucharest. She has graduated “Carol Davila” University of Medicine and Pharmacy in 1995 and became a specialist in Neurology in 2000.

She earned a Competence in Clinical Neurophysiology in 2005. During her practice, dr. Codita attended many courses and teaching programs in the field of Clinical Neurophysiology such as: scholarship in Neurophysiopathology field at Policlinical Institute of San Donato Milanese, Italy (2002-2004), training Course in EMG and Neurography Uppsala , Sweden (2009), International SFEMG and QEMG Course –Kobe, Japan (2010), VIREPA distance learning courses on “EEG in the diagnosis and management of epilepsy – Basic Course 6th edition” (September 2011- March 2012) and “EEG SCORE course-1st edition”( November 2012-March 2013), the international educational course “Dianalund Summer School on EEG and Epilepsy” (July 2012).

She also manifests interest in Epilepsy, Motor Neuron Diseases and Movement Disorders. Dr. Ionela Codita is a member of the Romanian Society of Neurology, affiliated to the ENFS (European Federation of Neurological Societies) and to the WFN (World Federation of Neurology) and since May 2013 she is the secretary of ASNER-The Romanian Society of Electrodiagnostic Neurophysiology.

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Experience with first seizure assessment

Irina Constantinescu1,2, Antonia Nita2, D.I. Cuciureanu1,2

1. “Prof. N. Oblu” Clinical Emergency Hospital, Iasi

2. University of Medicine and Pharmacy “Grigore T. Popa” Iasi

The high prevalence of patients admited to the emergency departments with a first episode of consciousness loss is well established. Although there are studies assessing acute management in patients experiencing consciousness loss, there is still need for more data on clinical and paraclinical characteristics of these patients. The aim of the present work was to evaluate EEG abnormalities during routine EEG recording in adult patients with a first episode of consciousness loss in our emergency hospital, by performing a retrospective observational study over 9 months. The results show an increased number of standard EEG recordings without abnormalities in patients with non-syncopal episode. We comment on the associated pathologies and imagery findings. Our data points out the need for specific multidisciplinary protocols to evaluate a first episode of consciousness loss, including long-term EEG recordings, in order to allow prompt and efficient diagnosis management of this common presenting complaint in the emergency departments.

Irina Constantinescu

Assistant Professor, MD, PhD

[email protected]

Current positions

Specialist in Neurology, Emergency Hospital “Prof.N. Oblu” Iasi

Assistant Professor in Neurology, Neurological department, University of Medicine and Pharmacy “Grigore T. Popa” Iasi,

Post-doctoral fellow, POSDRU program, University of Medicine and Pharmacy “Grigore T. Popa” Iasi, June 2014

Education

PhD in Neuroscience, University of Geneva, Switzerland. Thesis: “Influence of sleep-wake states on human memory and underlying neural plasticity: insights from EEG recordings and parasomnia”. Thesis advisors: Prof. S. Schwartz and Prof. M. Seeck, March 2011.

MD, University of Medicine and Pharmacy “Grigore.T.Popa” Iasi, Romania. Thesis: “Silent Cerebral Infarct - clinical study on a representative group of patients from the Neurological Department, Rehabilitation Hospital, Iasi”. Thesis advisor: Prof. C.D. Popescu, September 2005.

Competences

Certificate in Electroencephalography, Swiss Society of Clinical Neurophysiology, Geneva, Switzerland, November 2013

Certificate in “Sleep and its pathology”, Inter-University Diploma, University Pierre et Marie Curie Paris VI, Paris, France, October 2007

Awards:

Prize for the best PhD thesis of the Faculty of Medicine, University of Geneva, awarded June, 2012

Biaggi de Blasys Award 2011 for the best doctoral thesis in Neuroscience defended at the Universities of Geneva or Lausanne, or the EPFL, Switzerland, awarded March, 2012

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Infections in Status Epilepticus

Bogdan Florea1, Lucia Herbel2, Adina Danci3, Daniela Dreghiciu4, Helga Demeny5, Cristian Popovici5, Iuliu Scurtu5

1. Centrul Medical Regina Maria, Cluj-Napoca, Romania, 2. Spitalul Clinic de Boli Infectioase , Cluj-Napoca; 3.Spitalul Militar “Dr. Constantin Papilian”, Cluj-Napoca; 4.UPU Spitalul Clinic de Urgenta de Copii ,Cluj-Napoca; 5.Facultatea de Medicina Veterinara ,USAMV Cluj-Napoca

Both in humans and animals, after stated the status epilepticus (SE) diagnostic, appropriate supporting care is of vital importance and often request intensive care unit (ICU) admission and ventilation.

Infections could complicate SE and must be taken into account when estimate the risk of ICU admission and outcome.

In humans, recent studies demonstrated an association between infections and poor outcome of SE in a cohort of severely ill patients with high mortality due to hypoxic-ischemic encephalopathy (Sutter 2012, Rossetti 2014) Could infections be as common in a cohort of patients with SE of less severe aetiology?

Drafting an observational study, we included all human patients with a diagnosis of SE during 2013–2015 in different ICU departments in Cluj-Napoca. Patients with hypoxic-ischemic encephalopathy were excluded. The animal patients (6 dogs) with SE were admitted in the University Veterinary Clinic.Results: The human group contains 34 patients. The mortality was <3% and 73,5 % of the patients were discharged home after resolution of the SE. The most common etiologies were uncontrolled epilepsy (32%) and brain tumors (17.6%). 21 patients acquired the infections during their hospital stay. The infections were associated with intubation, longer duration of SE and a poor outcome.

The animal group contains 6 dogs. The mortality was >80% and was linked to the long time interval between the seizure start and EEG referral plus therapeutic decision.

Infections are an important factor in the equation of SE management.

Dr. Bogdan FLOREA

[email protected]

Dr. Bogdan FLOREA: UMF “Iuliu Hatieganu” Cluj-Napoca, Imogen Research Center

Bogdan Florea graduated the “Iuliu Hatieganu” University of Medicine in Cluj-Napoca in 1997 and became senior consulting neurologist in 2012. Clinical neurophysiology fellowships in Italy – Modena and Bologna, USA – Mayo Clinic, Sweden – Uppsala doubled by the daily activity in the computerized EEG department of the Neurological Clinic and many teaching courses in this area recommend him as a passionate in neurophysiology. His domains of interest are epilepsy and neurophysiology of coma.

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Limb-Girdle Dystrophies

Ana-Maria Cobzaru

Neurology Department, Neurology Department, University Hospital of Bucharest, Romania

The “LG” pattern of weakness is the one that most clinicians think of for myopathies. The true limb-girdle muscular dystrophies are rare. They need to be differentiated by acquired myopathies (drug-induced, endocrine myopathies, inflammatory myopathies), myasthenic syndromes and other hereditary myopathies.There is an extensive genetic heterogeneity (22 different forms: 8 AD and 14 AR) and a high clinical variability making diagnostic approach more complicated.The most common adult-onset muscular dystrophies with limb-girdle phenotype are: Becker muscular dystrophy (dystrophin), LGMD 2A (calpain 3), LGMD 2I (fukutin-related protein), LGMD 2L (anoctamin 5).

Sleep latency tests

Floriana Boghez*, Ioana Mindruta

*Clinica Academica, Bucharest, Romania

Excessive daytime sleepiness represents the increased and abnormal tendency to fall asleep during daytime periods and activities when the patient is supposed to be alert and vigilant. It is a frequent symptom and consequence of many sleep disorders. Sleep latencies tests are objective methods to appreciate the degree of diurnal somnolence or the capacity to stay awake in certain conditions. These tests are generally performed during daytime and together with other clinical evaluations (sleepiness scales, cognitive tests, attention tests) or paraclinical exams (polysomnography, actigraphy) can quantify the degree of sleepiness and its impact on activity and quality of life.

Ana-Maria Cobzaru

MD

[email protected]

Neurologist with competence in electrophysiology and special interest in clinical neurophysiology working in the University Emergency Hospital in Bucharest as general neurologist and in private sector as neurophysiologist.

Floriana Boghez

MD

[email protected]

Neurologist with competence in electrophysiology and special interest in clinical neurophysiology working in the Clinica Academica.

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Aging and the gluteal compartment syndrome

Mircea Moldovan,Ionela Codita

Neurology Department of Elias University Emergency Hospital, Bucharest

The population over 60 years will see an increasing trend from 3.1 million in 2004 to 5 million in 2050.

Knowledge of electrophysiological parameters chronobiology is needed to understand electromyographic examination. Limiting physiological mobility and associated comorbidities increase in home accidents. Among these is the gluteal entrapment syndrome

PJ 76 with limited autonomy woke up on the toilet -without knowledge on how he got to the bathroom and when he was seated. When he stood up he noticed a motor deficit of the distal left leg.

The persistence of motor deficit at 7 months later, let to EMG examination.

. There was a motor deficit 0/5 and 2/5 BMRC motor in the territory of n sciaticus: tibialis and gastrocnemius atrophy; absent Achilles reflex; without back pain or sphincter abnormalities. Proximal leg muscle strength was 4/5.

The NCS exam showed no response at stimulation of the peroneal and tibial nerves on the left side. EMG in m Tib ant, biceps short end, peroneal, gastrocnemius and gluteus medius showed severe denervation. Vasus medialis was normal.

In context of anamnesis, clinical and lesion ENMG appreciated as a sciatic Buttock year outlining an entrapment syndrome.

Prevention is adapting to conditions of life imposed by disabilities.

Mircea Moldovan

MD, PhD

[email protected]

Dr. Mircea Moldovan, graduate of the “Carol Davila” University Bucharest, Doctor of Medical Sciences, MD is a neurologist at the Hospital “Elias” Bucharest since 1968. Throughout his career, he had a continuous interest for clinical neurophysiology. In the 80s, his main interest was the EEG and evoked potentials under the guidance of Prof Dr V Voiculescu. In the 90s, his interest expanded to the peripheral conduction studies and EMG. During his pioneering work in Romanian clinical neurophysiology, Mircea Moldovan advocated the diagnostic importance of clinical neurophysiology for neurological practice through talks at national scientific meetings and scientific publications. Most importantly, however, through his wealth of practical experience and didactic spirit, he helped initiate in clinical neurophysiology generations of young neurologists. During the last decade, with the transformation of “Elias” hospital neurology into a university department and re-formalizing his skills in EMG (2003) and EEG (2004), Dr. Mircea Moldovan developed his preoccupation for clinical neurophysiology teaching. Together with Dr. Ionela Codita he carries out practical demonstrations of post-graduate courses organized by Professor Dr. Panea EMG. In addition, Dr. Mircea Moldovan contributed to re-launch of the clinical neurophysiology society in Romania as founding member of ASNER 2009.

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Benign idiopathic HiperCKemia - a case presentation

Florian AntonescuTaisia Andreea Tiron (Sp. Sf. Ioan), Alexandra Bastian (Sp. Colentina)

Institutul National de Neurologie si Boli Neurovasculare, Bucuresti, Romania

OBJECTIVE: We shall be presenting the case of a 79 year old man investigated in our clinics for a persistent elevation of creatinkinase levels, lacking any obvious signs of myopathy or other predisposing factors. We shall also discuss the main diagnostic and therapeutic aspects of benign idiopathic hiperCKemia.

METHODE: The patient was referred to us under the suspicion of myopathy, his CK levels being abnormally high since at least six months before (initially 1539 UI/l). The clinical examination was unremarkable, with the exception of absent osteotendinous reflexes. EMG examinations revealed an active distal axonal sensory-motor polyneuropathy, but without any findings to suggest myopathy. The inflammation and infectious markers (HIV, viral hepatitis, Treponema p. or Trichinella sp.) have been negative. The PSA and freePSA in the normal range. A thoraco-abdominal CT scan was unremarkable with the exception of a bilateral adrenal hyperplasia. An endocrinological evaluation found normal thyroid and adrenal function. The fasting glycemia was normal, but an oral tolerance test was strongly positive. The next step was a muscular biopsy, which did not find any signs of myopathy, but confirmed a slight neurogenic pattern, in line with the neuropathy seen on the EMG. The patient was followed closely, with checkups at every three months, the CK levels fluctuated but remained mostly high (341 to 1856 UI/l, with a mean value of 810 UI/l). There was no tendency of clinical or electrophysiological deterioration.

CONCLUSIONS: The clinical, electrophysiological and histopathological data, have led us to a diagnosis of Axonal distal polyneuropathy (probably diabetic) and Idiopathic benign hyperCKemia. This last entity is relatively rare (prevalence of 0,7%), but it is important, as it requires a complex differential diagnosis and generates considerable anxiety in the patient. The “idiopathic” aspect is almost certainly hiding multiple subclinical anomalies, most of them probably genetic. The clinical course is benign and the patients do not require close follow up. Some of the patients have an increased risk of malignant hyperthermia and they need to be informed regarding this.

Intraoperative neurophysiological monitoring of brain tumors

Dan FilipClaudiu Matei

Spitalul Clinic Județean de Urgență, Sibiu, Romania

We summarize the experience from our center in intraoperative neurophysiological monitoring. This include patients operated for central and insular tumors. The methods employed for monitoring were somatosensory evoked potential and phase reversal, motor pathway monitoring with motor evoked potentials obtained by transcranial and direct cortical electrical stimulation. We also used the subcortical mapping for the safety and radicality of the tumor resection. Intraoperative neurophysiological monitoring of the functional integrity of the cortical sensory and motor areas and pathways is not invasive and does not interfere with the ongoing surgical procedure. It gives immediate feedback about functional impairment of the monitored structure. In some cases, this feedback provides the opportunity to rectify this impairment.

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Memory recall and the medial temporal lobe – a cortical stimulation study

Andrei Daneasa

Popa I, Arbune A, Mindruta I

Sectia Neurologie, Spitalul Universitar de Urgenta Bucuresti, Bucuresti, Romania

Objective: The aim of this study is to investigate the implication of the individual mesial temporal structures, namely the amygdala, the hippocampus, the parahippocampal gyrus and the entorhinal cortex in the production of mnemonic phenomena. Historically the hippocampus was considered to be the main cerebral structure responsible for memory processes, lately the medial temporal lobe (MTL) has been regarded as a whole functional unit, whereas the anatomic subcomponents listed above do not have clear individualized functions.

Method: 28 patients with intractable epilepsy undergoing presurgical workup with stereo-electroencephalographic (SEEG) monitoring were included in the study. Each patient had intracranial electrodes placed in the MTL structure. Electrical stimulations where performed and elicited symptoms where recorded. For the purpose of this study we only focused on mnemonic phenomena (recall, déjà vu/ déjà vécu).

Results: Out of 28 subjects, 9 experienced mnemonic phenomena during electric stimulation. Proportionally, parahippocampal and entorhinal stimulations generated these phenomena more frequently than hippocampal and amygdaloid body stimulation. In regards to memory recall specifically, the same trend can be observed. Stimulation of the amygdala did not produce memory recall.

Conclusion: The results of this study suggest that the parahippocampal gyrus and the enthorinal cortex have a greater implication than other MTL structures in the generation of mnemonic phenomena in general and memory recall in particular.

The relationship between seizure semiology and brain activity in a case of refractory frontal epilepsy

Anca Adriana Arbune

Daneasa A., Popa I., Mindruta I.

Spitalul Universitar de Urgenta Bucuresti, Bucuresti, Romania

Introduction: Epileptic seizure semiology plays a great role in determining the seizure onset zone (SOZ), but it is often imprecise. The supplementary motor area (SMA) has a wide variety of manifestations, with rapid involvement of the contralateral side, making its identification as SOZ difficult.

Case description: Female, 15 years old, diagnosed with focal refractory epilepsy and moderate mental retard. Seizure onset was at 4 months old, with a frequency of 3-4 seizures per week, currently occurring approximately once per month. The seizures are described as head and eyes version to the right, sometimes clonus of the mouth, followed by the tonic contraction and flexion of the right arm progressing into generalized convulsions. CT and MRI scans showed no abnormalities. PET scan revealed a hypometabolic area in the fronto-temporal left lobe. Scalp EEG identified epileptiform discharges in the frontal regions. Intracranial SEEG electrodes implantation with 13 electrodes was decided, due to seizure manifestation and uncertain SOZ. The SEEG data recorded during spontaneous seizures, 1Hz and 50 Hz stimulations and SPES delineated a potential surgical resection region.

Discussions: The patient experienced more seizures during hospitalization, with varying semiology (head and eyes version to either side, brief loss of awareness) as seen on video and confirmed on a more careful interview. The SEEG recordings were surprising, showing the same SOZs (left SMA and FEF) and pattern of activation for all the types of seizures. Taking into account the SEEG findings, a neurosurgical resection plan of the left SMA and FEF is in progress.

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Introducing the epileptome-dynamic seizure onset zone connectome as revealed by single pulse electrical stimulation in stereoelectroencephalography

Dragos Mihai Maliia

Donos C, Barborica A, Popa I, Ene M, Ciurea J, Mindruta I.

Spitalul Universitar de Urgenta Bucuresti, Sectia Neurologie, Bucuresti, Romania

Purpose: Design a protocol for probing the plastic nature of the epileptic networks.

Methods: We selected 5 patients with pharmaco-resistant epilepsy that were explored in the SEEG method. Single pulse electrical stimulations (biphasic, 3ms, 0.25-5mA) were applied to adjacent contacts. We calculated the early responses in the 10-110ms interval and considered only connections between contacts having a RMS value within the 3rd quartile of all the responses in an individual patient, correlated with the stimulation current (Spearman’s rho> 0.5, p <0.05).

Sublobar anatomical structures projecting to SOZ (inbound connections), as well as SOZ’s projections to other structures (outbound connections) were systematically assessed and named generically “epileptome”.

SOZ contacts were also stimulated in various relevant clinical situations (4 patients-postictally, 2 patients – N2 sleep, 1 patient-off medication) and compared to baseline, to understand the dynamics of the outbound analysis.

Results: In general the postictal period revealed a decrease in connectivity strength, a loss of some of the SOZ connections and a complex alteration of baseline intra-SOZ dependencies. Sleep had a dichotomical effect, in one patient producing an average increase with 28% of connectivity strength while in the other a 9% decrease. Tapering of AED medication caused both a quantitative (a global increase in connectivity, average 8%) and a qualitative (adding of the mesial temporal structures) modification to the patient’s epileptome.

Conclusions: Intra-individually the epileptic focus engages in an evolving network configuration that can be accurately described.

Generalized severe deep pain as onset of GBS

Marian Cristian Feticu

Simina Dumitrache

Spitalul Militar de Urgenta”Regina Maria”- Brasov,

Brasov, Romania

A 73 year old women with obesity and recent diagnosis of diabetes melitus was presented for generalized severe deep pain started 7 days prior admission. Ambulatory treatment with NSAID, dexamethasone, tramadollum and low dose of gabapentinum was unsuccessful. 2 days after admission she presented progressive motor deficit. Electroneurography shows demyelinating features. Are this demyelinating features chronic, not-related to acute disease or are signs of GBS?

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Cognitive flexibility testing during electrostimulation in patients explored with intracranian electrodes

Alexandru Rusu

I.Popa, I.Mîndruţă

Departamentul de Neurologie, Laboratorul de Epilepsie şi Somn, Spitalul Universitar de Urgenţă Bucureşti, Bucuresti, Romania

Introduction: Cognitive function testing during electrostimulation is used to establish the function of the explored cerebral structure in patients with farmacoresistant epilepsy who are explored with intracranian electrodes as presurgical evaluation. Cognitive flexibility is one of the executive functions that these patients are tested for.

Case presentation: There have been selected 8 cases of patients with farmacoresistant epilepsy, 6 males and 2 females, aged between 25 and 51. The implantation plan was conceived according to the seizure semiology, ictal scalp EEG recording, and imaging exams, and included exploratory intracranian electrodes for the cerebral structures that are involved in the executive function of cognitive flexibility: prefrontal cortex, anterior cingulate cortex, and posterior parietal cortex.

The executive function of cognitive flexibility was tested using the following neuropsychological tests: Odd one Out, Stroop Test, Object Reasoning, Wisconsin Card Sorting Test. Initially, the patients were tested without being electrostimulated, in order to get used to the test, and to determine their average score, after which they took the test again while being stimulated. The electrostimulation, with a protocol of 1 Hz and 50 Hz (pulse width: 3 ms) and 0.25-3 mA intensity, generated significant alterations of the patient’s score, demonstrating the role of the explored cerebral structures in the executive function of cognitive flexibility.

Conclusion: In adition to proving the involvement of the explored cerebral structures in the executive function of cognitive flexibility, electrostimulations showed a high potential for cognitive enhancement of this function.

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We would like to thank our sponsors and partners:

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www.ssnn.ro‘‘RoNeuro’’

Institute for Neurological Research and Diagnostic,Cluj-Napoca, Romania

Tel.: 0374 46.22.22

str. Mircea Eliade nr. 37, 400364 Cluj-Napoca, RomâniaFax: 0374.461.674; Email: [email protected]

www.roneuro.ro

Documents

The 7th National Conference of ASNER,