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The 9th National Conference of ASNER,

The Romanian Society of Electrodiagnostic Neurophysiology

CN2017, Căciulata, Vâlcea, RomaniaOctober 13 – October 15 2017

Program & Abstract book

ASNER CN2017 Căciulata, 13-15 October 2017 – Program & Abstract book9th National Conference of the Romanian Society of Electrodiagnostic Neurophysiology

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Scientific partners:

.ROSocietatea Națională

de Neuroștiințe


Dear Friends,

It’s again October, and that means it is again time forthe national conference of Clinical Neurophysiology.We are now starting this scientific event for the 9th

time, so I suppose we are entitled to call it a tradition.Some of you have participated every year, many ofyou have attended a few times, and others arenewcomers, but all of us have one thing in common,namely our passion for neurophysiology. We haveprepared a scientific program that will contain aplenary session, and, workshops in EEG, EMG.Again, we have important guests who have acceptedour invitation for this event.

So we are expecting few days of intense scientificactivity with ample opportunity for networking and tomake new friends.

The conference was awarded 11 CME credits.

Welcome to the 9th edition of the ASNER NationalConference !

Sincerely,

Tudor Lupescu M.D. Ph.D.

ASNER President

[email protected]

http://www.asner.org

https://www.facebook.com/asner.org/

Ioana Mindruta, M.D. Ph.D.

ASNER Vice-President

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

[email protected]

Ionela Codita, M.D.

ASNER Secretary

Neurology Department of Elias UniversityEmergency Hospital, Bucharest, Romania

[email protected]

Ana-Maria Cobzaru, M.D.

ASNER Treasurer

Neurology Department, “Carol Davila” University ofMedicine 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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http://www.asner.org/

https://www.facebook.com/asner.org/


Friday, Oct 13

13.00 - 16.00: EMG Workshop (Tudor Lupescu,Reinhard Dengler)

16.00 - 16.30: Coffee Break

16.30 - 19.30: EEG Workshop (Ioana Mindruta,Troels Wesenberg Kjaer)

Mihai Malaia - Amplitude & polarity of EEG signals

Floriana Boghez – Neurophysiology in narcolepsypatients

Amalia Ene - Importanta polisomnografiei inevaluarea pacientilor cu alfa-synucleinopatii

Irina Popa - Testing epileptic seizures during video-electroencephalography for better anatomo-electro-clinical correlations

Ioan-Radu Carcalici - EEG pattern of drug resistantepilepsy

Saturday, Oct 14 – Part 1

8.30 - 9.00: Opening of the conference

Session 1 (chair: Tudor Lupescu)

9.00 - 10:00 Reinhard Dengler - State of the Art inALS: Clinic and Research

10.00 - 10.30 Tudor Lupescu - Chronic InflammatoryDemyelinating Polyneuropathy (CIDP) – a logicalapproach

10.30 - 11:00 Mihai Moldovan – Do we need nerveexcitability testing by threshold-tracking?

11.00 - 11.30 Coffee Break

Session 2 (chair: Ioana Mindruta)

11:30 - 12: 30 Troels Wesenberg Kjær, Clinical useof ultra-long-term EEG-monitoring - the cross roadbetween traditional diagnostics and health devices

12.30 - 13.00 Ioana Mindruta - Electro-clinicalpatterns and new classification in epilepsies relatedwith focal cortical dysplasia

13:00 - 13:20 Cosmin Serban, Towards aneurophysiological EEG reactivity monitor(NERMO) to assess coma severity

13.20 - 14.30 Lunch Break

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Saturday, Oct 14 – part 2

14.30 – 15.15 Masă rotundă: Boala Pompe -abordare clinică și terapeutică. Simpozionorganizat cu sprijinul Sanofi Genzyme.

Tudor Lupescu-Scurta prezentare Boala Pompe

Marian Cristian Feticu - Boala Pompe, studiu cazpacient adult

Diana Barca - Boala Pompe, studiu caz pacientpediatric

15.15 – 15:45 Masă rotunda. Amalia Ene, IonelaCodiță, Izabela Popa – Evaluarea pacientului cupolineuropatie amiloidotică transtiretinică.Simpozion organizat cu sprijinul Pfizer

15:45-16:00 Coffee Break

Session 3 (chair: Mihai Moldovan)

16:00 – 16:30 Mircea Moldovan - Clumsy hand -casepresentation

16:30 – 17:00 Nicu Draghici - Median nerveultrasound as a screening tool in carpal tunnelsyndrome overlapped with diabetic neuropathy

17:00 – 17:20 Marian Cristian Feticu - GBS or not?-A case of acute poliradiculoneuritis withunpredictable evolution and multiple co-morbidities

17:20 – 17:40 Andrei Daneasa - Parallel directelectrical stimulation and somatosensory evokedpotentials for primary sensory cortex mapping: a casestudy

17:40 – 18:00 Izabela Popa - Motor neuron diseasespectrum-a case study

18.15 – 18.45 ASNER General assembly

20:00 Galla dinner

Sunday , Oct 15

9.00 - 9.30 Simona Petrescu: ”O privire atenta asupracomplexitatii COPAXONE “. Simpozion organizatcu sprijinul TEVA România

Session 4 (chair: Ioana Mindruta)

9.30 - 10.00 Marc Guenot -Stereoelectroencephalography (SEEG) technique,results and recommendations

10.00 - 10.30 Marc P. Sindou. Surgery in the DREZ(dorsal root entry zone). From neurophysiologicalconcepts to clinical practice

10.30 – 11: 00 Andrei Brinzeu - IntraoperativeMonitorig for Spinal Cord Surgery

11:00 - 11:30 Coffee Break

Session 5 (chair: Ionela Codita)

11:30- 11:50 Bogdan Florea - Telemedicine inEpilepsy - 1 year in Romania

11:50-12:10 Dan Filip - Neurophysiologicalintraoperative monitoring in cerebral awake surgery

12:10 - 12:30 Ionela Codita - Challenging situationsduring spinal intraoperative neuromonitoring-a casereport

12:30 Closing discussions, certificates andfeedback

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This talk will deal with some of the newestdevelopments in the field of familal and sporadicALS. The modern state of genetics and of proteinaggregate formation will be presented and the overlapwith some forms of frontotemporal lobe dementia(FTLD). The actual diagnostic criteria based on therevised version of the El Escorial Criteria and theiraddendum, the so called Awaji Criteria will bedescribed. The important role of clinicalneurophysiology in the diagnosis of ALS will beespecially stressed. Although imaging, especiallyfunctional MRI, can currently not yet contribute tothe diagnosis it has a role in the understanding ofsome pathophysiological aspects and of theprogression of the disease. Riluzole is licensed forthe treatment of ALS in Europe and Edaravone isadditionally licensed in the US and Japan. Modernexperimental treatment approaches including celltransplantation or molecular biological techniqueswill be discussed. Finally a summary and an outlookat next developments will be provided.

Academic appointments:

01.08.1989 Professor of Neurology, University ofBonn, Vice-Chairman Neurology,

01.12.1992 - 09, 2015 Professor of Neurology,Hannover Medical School, Director of theDepartment of Neurology and ClinicalNeurophysiology,

Other professional activities:

Current member of the executive board of the GermanSociety of Clinical Neurophysiology (DGKN);current member of the executive board of theInternational Federation of Clinical Neurophysiology(IFCN); Vice President of the German Society forNeuromuscular Diseases (DGM).

Research focus:

• clinical neurophysiology,

• neuromuscular diseases;

• motor neuron diseases

• central movement disorders

Honors and Awards:

1987 Richard-Jung-Award of the DGKN (ClinicalNeurophysiology)

2003 Appointment as foreign member of theBulgarian Academy of Sciences

2005 Prix „Theophile Gluge“ of the Royal BelgianAcademy of Sciences

2015 Honorary Member of the German Society ofClinical Neurophysiology

2016 Robert Schwab Award of the American ClinicalNeurophysiological Society (ACNS)

State of the Art in ALS: Clinic and Research

Department of Neurology, Hannover Medical School,Hannover, Germany

Reinhard Dengler, M.D.

Prof. Em. Reinhard Dengler MD.

retired Director of the Department ofNeurology, Hannover MedicalSchool (MHH); member of theAdvisory Board of MHH;

[email protected]

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Multimodal in-the-wild platform is on its way in ourclinic. The great advantage of this platform is that itallows for simultaneous registration from a range ofsensors collecting both the clinical end theelectroencephalographic data characterizing epilepticseizures.

These platforms allow for better monitoring ofepisodic events both with the purpose of optimizingprophylactic treatment of sleep disorders, epilepsyand diabetes and to build alarm systems. The datacollected will also be used to perform prediction ofepisodes based on EEG and ECG.

It is hypothesized that the empowerment associatedwith use of these devices is relevant not only invarious types of patients but also in normals whowant to control when to stay alert, have a good sleepand may be even when they perform better at certaintasks like learning and memory.

Present appointments

Chief Physician in charge of clinicalneurophysiology, Zealand University Hospital, since2014

Full professor, Institute for Clinical Medicine,University of Copenhagen, since 2016

Associate professor, DIS, Danish Institute for StudyAbroad, since 2003

External examiner, Danish medical schools and anumber of other graduate schools, since 2002

Medical consultant DGM for the national board ofhealth, since 2013

Other professional activities:

Numerous popular presentations on brain issues innational TV, radio, newspapers and magazines.

Patents:

Brain-computer interface spelling system and methodfor evaluation of brain signal quality

Clinical use of ultra-long-term EEG-monitoring -the cross road between traditional diagnostics andhealth devices

Zealand University Hospital, DK

Troels Wesenberg Kjær

Troels Wesenberg Kjær,

MD, PhD, Professor

[email protected]

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New health technology now allows for unobtrusiverecording for months and years of a range ofphysiological parameters includingelectroencephalogram

(EEG) and electrocardiogram (ECG). TraditionallyEEG-recordings are limited to hours-days rarely morethan a week. In cardiology the loop-recorder has beendeveloped to detect and save abnormal rhythms, butwithout storing intermediate data. We currently workon three different ways to obtain continuous data onthe ultra-long-time range of months to years. The talkwill discuss three different technical platforms withvarious advantages and disadvantages.

Ear-EEG comprises of up to 15 electrodes placed inan ear-plug in one or both ears. There is a centralcanal allowing for passage of sound. EEG is recordedin a matchbox-sized amplifier fixed to body orclothing.

Simultaneous ear-EEG and standard-EEG revealshigh correlation between signals in the range from 2-25 Hz. At lower and higher frequencies noise tend toappear. The ear-EEG platform has found to be usefulin sleep and epilepsy.

EEG-24/7-subQ is an implantable chip placed underthe skin behind the ear with a 11 cm long 3-leadelectrode pointing in any relevant direction in thesubcutaneous space. This device is implanted in a 10-15 min procedure and after healing of the skin there isno skin penetration. Power is supplied from anexternal 13 mm - antenna placed over the chip, whichalso receives the EEG signal. Data in the range from0.1 - 25 Hz is available in high quality and highlycorrelated to standard EEG. The electrode can beplaced almost anywhere on the skull, but when placedthe position is fixed. This allows for monitoring welldefined foci - even if small. The EEG-24/7-subQsolution has successfully been used to detect epilepticinterictal and ictal discharges, hypoglycemia andsleep.


Le Pr Marc Guénot, né en 1966, est neurochirurgiendans le service de neurochirurgie et stéréotaxiefonctionnelles de l’hôpital neurologique P.Wertheimer à Lyon, et professeur de neurochirurgie àl’Université Claude Bernard Lyon I.

Il est particulièrement impliqué, tant sur le planclinique que scientifique, dans la pratique et ledéveloppement de la chirurgie de l’épilepsie, ainsique dans les études multicentriques relatives à lapsychochirurgie.

Stereoelectroencephalography (SEEG) technique,results and recommendations

Department of Neurosurgery, Hospital for Neurologyand Neurosurgery Pierre Wertheimer, HospicesCivils de Lyon, Lyon, France; Université ClaudeBernard, University of Lyon, Lyon, France;Neuroscience Research Center of Lyon, INSERMU1028, CNRS 5292, Lyon, France.

Marc Guénot

Marc Guénot, MD, PhD

Professor

[email protected]

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Professor Emeritus University Lyon1 ; HopitalNeurologique Lyon ,France

Centre Hospitalier Universitaire de Saint-Étienne ;Hopital Nord · Neurochirurgie, France · Saint-Étienne

Surgery in the DREZ (dorsal root entry zone) -From neurophysiological concepts to clinicalpractice

Department of Neurosurgery, Hopital NeurologiquePierre Wertheimer, University of Lyon, France

Marc P. Sindou

Marc P. Sindou. MD, PhD

Professor

[email protected]

November 2009 - Hopital Neurologique de Lyon,Neurosurgeon: Pain Surgery, Deep BrianStimulation, Surgery for Spasticity

2013 – 2015 Master’s Degree, Neuroscience,Neuroscience Research, Université Claude BernardLyon 1, France

2000 – 2006 -Doctor of Medicine (M.D.), GeneralMedicine, MD, Universitatea de Medicină șiFarmacie „Victor Babeș” din Timișoara

Intraoperative Monitorig for Spinal Cord Surgery

Neurosurgical Department, Hospital PierreWertheimer, University of Lyon.

University of Medicine and Pharmacy "VictorBabes," Timişoara, Romania.

Andrei Brinzeu

Andrei Brînzeu, MD, MSc

[email protected].


Every now and then, in our neurophysiologicalpractice we find cases with modified nerveconduction studies. Since CIDP is a treatable disease,it is sometimes a matter of “wishful thinking” to labelour patients with this diagnosis. But (1) you must besure that the values of the nerve conduction velocitiesare within the ranges of demyelinating changes, alsotaking into account the CMAP amplitudes; (2) thedistribution of these changes should be compatiblewith the diagnosis of CIDP ; (3) you must notconsider only the electroneurography changes andoverlook the clinical features that can be veryrelevant; (4) not always demyelinating changes innerve conduction velocities equals CIDP.

Tudor Lupescu obtained his medical degree from“Carol Davila” University of Medicine in Bucharest,in 1989. After 3 years of training at Colentina ClinicalHospital he became Specialist in Neurology in 1994.Since 2006 he is running the Neurology Departmental Agrippa Ionescu Hospital in Bucharest. 1998, hequalified as Consultant Neurologist. Since his earlyyears of training in Neurology, Tudor Lupescu hasshown a special interest in Clinical Neurophysiology.In 2000 he earned a Competence in ClinicalNeurophysiology (EEG, EMG, and EvokedPotentials). 1997 he was the first to use TranscranialMagnetic Stimulation in Romania. This was also thesubject of his PhD thesis presented in 2005. Since2008, Tudor Lupescu is President of ASNER –Romanian Society of ElectrodiagnosticNeurophysiology. He is also founding member andvicepresident of the Romanian Society of DiabeticNeuropathy.

Dr Tudor Lupescu is associate memberof the American Academy of Neurology, andassociate member of the American Association ofNeuromuscular and Electrodiagnostic Medicine.Between 2008 and 2014 he was also member of theNeurophysiology Subcommittee of ENS, and since2015, he is member of the NeurophysiologySubcommittee of the European Academy ofNeurology.

Chronic Inflammatory DemyelinatingPolyneuropathy (CIDP) – a logical approach

Tudor Lupescu

Tudor Dimitrie Lupescu

MD, Ph.D.

[email protected]

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Agrippa Ionescu Hospital, Bucharest

RoNeuro Institute for Neurological Research andDiagnosis


Focal cortical dysplasias (FCD) are one of the leadingetiologies for surgically remediable drug resistantepilepsies. Pathologic correlates show abnormallamination and defects of neuronal migration anddifferentiation.

Intracranial recordings of electrical activity duringpresurgical evaluation display specific patternsmainly associated with FCD type IIb. These patternsare also highly recognizable on scalp EEG recordingsas well during long term videoEEG monitoring.

The new classification distinguish 3 types of FCD’sand several subtypes in each category. Earlyrecognition of electro-clinical patterns of eachcategory will impact disease outcome and choice oftherapy.

The presentation will show relevant cases and discussthe electroencephalographic activity on surface EEGbased on patterns recorded during invasiveexploration for presurgical work up. The syndromeassociated with FCD type IIb will be the main focusof the presentation.

48-year old, neurologist, with competence inelectrophysiology and special interest in epileptology,mainly invasive presurgical exploration for epilepsysurgery, neurostimulation and brain connectivity. PhDthesis on “Sleep studies in epileptic syndromes” in2006.

Current position at the University EmergencyHospital in Bucharest in the Epilepsy and SleepMonitoring Unit and also hospital coordinator of theNational Programs for Pharmacoresistant Epilepsyand Rare Disorders.

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

Vicepresident of Romanian Society forElectrodiagnostic Neurophysiology (ASNER) since2009.

Electro-clinical patterns and new classification inepilepsies related with focal cortical dysplasia

Ioana Mindruta

Lecturer, MD, PhD

[email protected]

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1Neurology Department, University EmergencyHospital, Bucharest, Romania

2Neurology Department, Carol Davila University ofMedicine and Pharmacy, Bucharest, Romania

3Physics Department, University of Bucharest,Bucharest, Romania

4Neurosurgery Department University of Texas,Health Science Centre at Houston, TX

5Neurosurgery Department, Bagdasar-ArseniEmergency Hospital, Bucharest, Romania

6FHC Inc, Bowdoin ME, USA

Ioana Mindruta 1,2,

Andrei Barborica 3,6, Mihai Malaia1,2, Irina Popa1,2Cristian Donos3,4, Jean Ciurea 5


Conventional nerve conduction studies provideinformation about the number of conducting axons aswell as their conduction velocity along theinvestigated segment, a surrogate marker ofmyelination. In contrast, nerve excitability testing by“threshold-tracking” assess ion channel function andresting membrane potential at the site of stimulationproviding an unique insight into the diseasemechanisms.

From the patients' perspective, excitability testing is asimple continuation of conventional studies. The testis commonly performed on the median nerve motorand sensory axons stimulated at wrist. A test takesabout 15 minutes and consists of a sequence ofmeasures controlled automatically by a computer: 1)charge-duration, threshold electrotonus, current-threshold and recovery cycle. Results are given as aset of numeric excitability indices derived from themeasures. Deviations from control values isinterpreted based on a increasing number of literaturereports in different pathologies. A mathematicalmodel is available to aid the interpretation.

In the recent years, there is a growing interest forperforming nerve excitability studies. Thispresentation advances a personal view on the currentutility and future of nerve excitability testing both as adiagnostic tool and as a clinical research tool.

Mihai Moldovan obtained his medical degree from“Carol Davila” University Bucharest in 1999 and PhDdegree in neurophysiology from CopenhagenUniversity in 2004 where he continues his academiccareer.

•2016, ‘P.K.Thomas’ prize of the European Academyof Neurology.

• Since 2014, elected full member in the EuropeanDana Alliance for the Brain (EDAB).

• Since 2013, serving on general council of Federationof European Neuroscience Societies (FENS) andInternational Brain Research Organization (IBRO).

• Since 2012, President of the National NeuroscienceSociety of Romania (SNN), a FENS member.

• Since 2012, editorial board member for ClinicalNeurophysiology, the official scientific journal of theInternational Federation of Clinical Neurophysiology(IFCN).

• Since 2009, Scientific director of the Romaniansociety for electrodiagnostic neurophysiology(ASNER), an IFCN member.

• Since 2009, Invited professor and research directorassociated to the Department of Physiology andFundamental Neurosciences, "Carol Davila”University of Medicine and Pharmacy, BucharestRomania;

Do we need nerve excitability testing by threshold-tracking?

1) Copenhagen University DK;

2) Carol Davila University, Bucharest, RO

Mihai Moldovan (1,2)

Mihai Moldovan

Assoc. Prof., MD, Ph.D.

[email protected]

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Within the past 2 decades, the management of spinaldeformities has changed and the neurological post-operative complications have been associated withincreased complexity, large corrections, stagedprocedures and significant blood loss.

Intraoperative neurophysiologic monitoring wasdeveloped in an effort to reduce the risks to thesensitive neural elements during spine surgery.

Neuromonitoring modalities include: SomatosensoryEvoked Potentials (SSEPs), transcranial evoked motorpotentials, free-running EMG, triggered EMG, EEG.

One controversial aspect of neuromonitoring involvesthe thresholds required to prompt intraoperativeactions by the surgeon. Some guidelines do exist forspecific neuromonitoring methods.

In order to appropriately respond to neuromonitoringalerts, it is important to understand the etiology ofpotential neurological deficits.

We present the case of a 17 years old female, withsevere neuromuscular scoliosis who was operated forthis condition using intraoperative neuromonitoring.During surgery, we recorded MEPs and unilateralSSEPs changes without apparent explanations. Thepossible sources of theses abnormalities will bediscussed. At awakening the patient reported righthemihypoesthesia. The brain MRI offers a reason forthe electrophysiological abnormalities observedduring the surgical intervention.

Ionela Codita is currently working as a SeniorNeurologist in the Neurology Department of EliasUniversity Emergency Hospital in Bucharest.

She earned a Competence in ClinicalNeurophysiology in 2005. During her practice, dr.Codita attended many courses and teaching programsin the field of Clinical Neurophysiology such as:scholarship in Neuro-physiopathology field atPoliclinical Institute of San Donato Milanese, Italy(2002-2004), “Training Course in EMG andNeurography”-Uppsala, Sweden (2009), InternationalSFEMG and QEMG Course–Kobe, Japan (2010),VIREPA distance learning courses on “EEG in thediagnosis and management of epilepsy – BasicCourse 6th edition” (September 2011- March 2012)and “EEG SCORE course-1st edition”( November2012-March 2013), the international educationalcourse “Dianalund Summer School on EEG andEpilepsy” (July 2012) and educational course:”Brainstem and Peripheral Nervous System-Neurophysiological Monitoring”- Groningen,Netherlands (Nov 2016).

She manifests interest in Peripheral Neuropathies,Motor Neuron Diseases, Myopathies andIntraoperative Neuromonitoring. Dr. Ionela Codita isa member of the Romanian Society of Neurology andshe is the Secretary of ASNER-Romanian Society forElectrodiagnostic Neurophysiology (ASNER), since2013.

Ionela Codita

MD

[email protected]

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Challenging situations during spinalintraoperative neuromonitoring-a case report

Neurology Department of Elias University EmergencyHospital, Bucharest

Ionela Codita

Alexandru Thiery, Mihai Sabin Magurean, AncaVisan Raluca Gurgu


Throughout history, the study of the hand fascinatedthe interest of multiple artists, philosophers, writers,doctors, and was invoked in different situations ofgratitude. We therefore take this opportunity topresent a rare hand dysfunction resulting from acervical spondylitis.

Among situations involving hand in pathology, the"clumsy hand“ (“mana neindemanatica") can resultfrom several different pathologies. I was described inassociation with dysarthria -through an accident at thelevel of the brainstem as well as in cases of cervicalmedulla injury without dysarthria. It is a raresyndrome characterized by uncertainty in currentactivity requiring coordination with that hand.

I present a case of impairment of hand functionality inthe context of a spondylitis with spinal cordcompression at cervical level C3-C4 in patient of 60years operated for a cervical canal stenosis.

The patient presented clumsy hand movements withataxic clinical features. The muscle strength wasnormal. The proprioceptive and cutaneous sensoryafferents were partial involved, tactile discriminationstimuli being spared. The patient was operated ofcervical spinal stenosis although the relationship withthe hand dysfunction was unclear.

Motor and sensitive neurography was normal.Sensory evoked potential elicited by stimulating themedian found an increased N11-N13 duration (thepotential originating in the lower cervical cord) ,rightmore than the left by about 1 ms. This indicated apossible spinal lesion along the cuneate fasciculus.The presence of some movement in his left handfingers wrist associated with the right handmovement - “ mirror movements" suggested animpairment of medullary interneuronal innervation atthe level of cervical C3-C4.

Dr. Mircea Moldovan, graduate of the “Carol Davila”University Bucharest, Doctor of Medical Sciences,MD is a neurologist at the Hospital “Elias” Bucharestsince 1968. Throughout his career, he had acontinuous interest for clinical neurophysiology. Inthe 80s, his main interest was the EEG and evokedpotentials under the guidance of Prof Dr VVoiculescu. In the 90s, his interest expanded to theperipheral conduction studies and EMG. During hispioneering work in Romanian clinicalneurophysiology, Mircea Moldovan advocated thediagnostic importance of clinical neurophysiology forneurological practice through talks at nationalscientific meetings and scientific publications. Mostimportantly, however, through his wealth of practicalexperience and didactic spirit, he helped initiate inclinical neurophysiology generations of youngneurologists. During the last decade, with thetransformation of “Elias” hospital neurology into auniversity department and re-formalizing his skills inEMG (2003) and EEG (2004), Dr. Mircea Moldovandeveloped his preoccupation for clinicalneurophysiology teaching. Together with Dr. IonelaCodita he carries out practical demonstrations of post-graduate courses organized by Professor Dr. PaneaEMG. In addition, Dr. Mircea Moldovan contributedto re-launch of the clinical neurophysiology society inRomania as founding member of ASNER 2009.

Mircea Moldovan

MD, PhD

[email protected]

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Clumsy hand -case presentation; Introduction-anepisode of -medical historiography

Neurology Department of Elias University EmergencyHospital, Bucharest

Mircea Moldovan

I Codita, Horia Niculae, D Baltateanu, E Georgescu


Introduction: The awake surgery and cerebralmapping are performed in patients with low-gradebrain tumors that infiltrated functional brain areas; inthese cases, the wider the resection is, the longer thesurvival.

Objectives: Tumor resection should be quasitotal butwith the preservation of the integrity of motor orlanguage-specific areas. This is done by corticalmapping and then subcortical monitoring.

Methods: Cortical and subcortical mapping wasperformed with the bipolar stimulator starting at 1.5mA and not exceeding 6 mA. The generator emitsrectangular biphasic pulses with a duration of 1.25 msin 4-second trains at 60 Hz (Penfield technique).Subcortical motor monitoring was performed with themonopolar stimulator attached to the surgical suctiontube with cathodic stimulation, 5-pulse train ofstimuli with a duration of 0.5 ms and frequency of250 Hz, repeated every second (1 Hz).

In order to achieve a real-time appreciation ofcognitive and language functions during the tumorresection that infiltrates the eloquent brain areas, acomplex neuropsychological test was used incombination with standard cortical and subcorticalmapping. During the psychological testing concurrentwith cortical mapping were normal, damagedresponses, reversible dysfunctions in differentrequirements that tested cognitive skills.

Results: We performed neurophysiologicalintraoperative neuromonitoring in 3 patients withlow-grade brain tumors and awake surgery. Theasleep-awake-asleep anesthesia protocol was used.The first patient had a left frontal tumor with focalmotor faciobrahial seizures. Cortical mapping withphase reversal technique and direct bipolarstimulation for motor language area, continuousmonitoring of cortical and subcortical MEPs wereperformed.

Graduate Faculty of Medicine and PharmacyTg.Mureş -1995.

Certificate of complementary studies inelectromyography -dec. 2013

Educational Courses ISIN (International Society ofIntraoperative Neurophysiology) –„Spine” – Istanbul 2014; „The Essentials” – Verona2015; „Brainstem” – Groningen 2016.

Member of the European Academy of NeurologyEAN

Member of ASNER (Association of ElectrodiagnosticNeurophysiology Society in Romania)

Member of ISIN (International Society ofIntraoperative Neurophysiology)

Neurophysiological intraoperative monitoring incerebral awake surgery

Spitalul European Polisano Sibiu

Filip Dan, Matei Claudiu, Nistor Sofia, Dancu Iulia,Calvun Elena

Filip Dan, MD

[email protected]

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In the second case with a left parietal tumor we usedcortical sensory mapping and phase reversal,continuous subcortical monitoring for the area of thereceptive language and for the subcorticalinterconnection paths of the areas of the language(arcuate fasciculus, superior longitudinal fasciculus)that were at risk. The third case with right front tumorand moderate left hemiparesis benefited from corticalmotor mapping and cortical and subcortical MEPsmonitoring for preserving the corticospinal tract.

Patients did not show newly developed motor deficitsor postoperative speech disorders.

Conclusion: The glioma resections in awake surgerywith mapping technique are associated with fewerneurological deficits under the conditions of a widerresection. Unlike motor functions, speech andlanguage are variably distributed and widelyrepresented cortical, emphasizing the need formapping. Both in low-grade gliomas and in higher-grade gliomas, it was observed that extendedresection increases life expectancy. Cortical mappingand subcortical monitoring is therefore recommendedin any glioma resection located near eloquent areas asstandard .


There are differences between the approaches of thepatients with epilepsy among various areas inRomania. The EEG recording procedures, treatmentefficacy monitoring , change or interrupt decisiondiffer according to the local neurologist. Universitycenters experience contrasts with the modest servedgeographical areas considering the standardization ofthese decisions.

Creating in 2016 in Romania of a network with 6epilepsy centers linked through a server, allows theaccess of the patients at a sooner and correctdiagnosis of the form of epilepsy, closer to theirhomes. In this way could be avoided the pressure onthe university centers, which could offer a second or athird opinion, recruiting only the difficult or treatmentrefractory cases.

Telemedicine does not replace the medical way ofthinking. Telemedicine optimizes the time of themedical doctors and patients, standardizing the workprocedures.

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 andbecame senior consulting neurologist in 2012.Clinical neurophysiology fellowships in Italy –Modena and Bologna, USA – Mayo Clinic, Sweden –Uppsala doubled by the daily activity in thecomputerized EEG department of the NeurologicalClinic and many teaching courses in this arearecommend him as a passionate in neurophysiology.His domains of interest are epilepsy andneurophysiology of coma.

Telemedicine in Epilepsy - 1 year in Romania

Centrul de Epilepsie si Monitorizare EEG Cluj-Napoca, Cluj-Napoca, Romania

Florea Bogdan

Bogdan FLOREA MD

[email protected]

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Introduction

Carpal tunnel syndrome (CTS) is the most commonentrapment neuropathies and represents thecompression of the median nerve at the level of thewrist. Diabetic polyneuropathy (DPN) is one of themost common complications of diabetes melitus(DM) with a hight prevalence between 23% - 54%.Because the DPN symptoms can mimic a CTS, itsdiagnosis in patients with diabetes may berecognized with difficulty and delayed. Currently,there is no gold standard in the diagnosis of CTS indiabetic patients.

Methods

We included 28 consecutive patients with DPNdivided into two groups: Cases (with CTS) andControls (without CTS). The clinical suspicion ofCTS and DPN was established by standardelectroneurography techniques. An experiencedexaminer was blinded for the EMG diagnosis andperformed all the median nerve ultrasounds. The crosssectional area (CSA) was calculated by tracing twotimes the nerve at different sites: (a) at the wrist abovethe flexor retinaculum and (b) 6 cm proximal to thislevel at the mid – forearm.

Results:

This study was conducted to demonstrate if themedian nerve ultrasound is useful in the diagnosis ofCTS superimposed on DP. We found a significantdifference between the two groups of patients usingthese two methods.

Conclusion

Ultrasound is complementary to electroneurographicexamination and can be used with confidence in thediagnosis of CTS in the patients with overlappingdiabetic polyneuropathy.

Este medic specialist neurolog din octombrie 2014 șia absolvit Facultatea de Medicină și Farmacie “IuliuHațieganu”, Cluj Napoca, în anul 2010. În timpulrezidențiatului, și-a completat pregătirea profesionalăcu mai multe stagii în Franța, iar in prezent, estedoctorand la Facultatea de Medicină și Farmacie“Iuliu Hațieganu”. Tema de cercetare aleasă este“Eficiența și inocuitatea stimulării farmacologice aneuroplasticității în neuropatie diabetică”. În cadrulaceleiași instituții este membru în Consiliul pentruStudiile Universitare de Doctorat (CSUD).

Este medic specialist neurolog la Institutul RoNeurosi asistent cercetător în cadrul Institutului IMOGEN,proiect derulat de Spitalul Județean de Urgență ClujNapoca. De asemenea, este implicat, în calitate deinvestigator, în desfășurarea studiilor clinice Extend siProCid.

Principalele arii de interes sunt studiul și diagnosticulneuropatiilor periferice.

Median nerve ultrasound as a screening tool incarpal tunnel syndrome overlapped with diabeticneuropathy

INSTITUTUL IMOGEN. INSTITUTUL RONEURO,Cluj Napoca, Romania

Nicu Draghici

Tudor Lupescu, Maria Balea, Dafin F. Muresanu

Nicu Draghici, MD

[email protected]

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More than 30% of patients with epilepsy are drug-resistant; around 50% of these patients could undergoepilepsy surgery in an attempt to control seizures. Inthese cases, a detailed work-up including seizuresemiology analysis should be done in order to localizethe epileptogenic zone.

Seizure semiology is an expression of activation anddisinhibition of cerebral areas and thus providesinformation about which cerebral areas are “involved”during the ictal discharge. Objective data on seizuresemiology are provided by video-electroencephalography (VEEG). This is a neuro-electrophysiological tool that, using surface orintracranial electrodes enables us to record seizureswhile monitoring ictal semiology and electrical signalat the same time. Hence, we can perform anatomo-electro-clinical correlations and delineate the amountof cortex that has to be resected so that the patientcould have a chance to be seizure-free.

Our workshop aims to explain the importance oftesting seizures by interacting with the patient duringthe ictal and post-ictal period. This allows us todetermine possible clinical manifestations thatotherwise would remain unknown. For example,during a left temporal lobe seizure it is necessary toevaluate language abilities, to identify any deficit,determine what type of impairment does the patientpresent and at which time of the seizure it appears.Furthermore, together with ictal scalp and/orintracranial EEG signals we can define the epilepticnetwork and tailor resection without generating adeficit.

Testing epileptic seizures during video-electroencephalography for better anatomo-electro-clinical correlations

Spitalul Universitar de Urgenta Bucuresti, Bucuresti,Romania

[email protected]

Ioana Mindruta, Mihai Dragos Maliia, AndreiBarborica, Cristian Donos, Andrei Daneasa, AncaArbune, Jean Ciurea

Narcolepsy is a chronic neurologic disorder definedby a tetrad of symptoms: excessive daytimesleepiness, cataplexy, hypnagogic hallucinations andsleep paralysis. It affects approximately 0.05% of thegeneral population and it is associated withsubstantial morbidity and an impaired quality of life.The full clinical picture may develop years after theassessment of somnolence and, in the mean time, untilcataplexy (which is almost pathognomonic) comes insight, the neurophysiologic testing could help thediagnosing and analyzing the most convenienttreatment for these patients. Sleep studies are anessential part of the evaluation of patients withpossible narcolepsy. The combination of an overnightpolysomnography (PSG) followed by a multiple sleeplatency test (MSLT) can provide strongly suggestiveevidence of narcolepsy while excluding other sleepdisorders. A sleep latency below 8 min and at leasttwo sleep-onset REM periods (diurnal or nocturnal)almost certifies narcolepsy. A sleep and wake EEGrecording differentiates between narcolepsy andepilepsy, a frequent clinical problem especially inchildren/adolescents where the cataplexy may bepartial/segmentary, often confused with seizure.Besides that, the night EEG remains the main tool tocontinue to study the microstructure of sleep in thesepatients with almost permanent disrupted night-timesleep and sleep comorbidities (REM sleep-behaviordisorder, periodic limb movements, sleep apnea,insomnia, nightmares).

Neurophysiology in narcolepsy patients

Clinica Academica, Bucuresti, Romania

[email protected]

Floriana Boghez

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Introducere. Tulburarile de comportament in timpulsomnului REM (RBD – “REM sleep behaviourdisorder”) reprezinta parasomnii caracterizate deabsenta atoniei in timpul REM, asociata cu miscaricomplexe. RBD se asociaza in mare masura cu alfa-sinucleinopatii, fiind foarte frecvent intalnit in atrofiamultisistem si boala Parkinson (BP), atat in perioadaprodromala, cat si pe parcursul evolutiei bolii.

Material si metode. Studiul a inclus 17 pacienti cuboli neurodegenerative, 10 cu boala Parkinson (PD)si 7 cu atrofie multisistem (AMS), care au efectuatpolisomnografie in ultimele 18 luni in clinica noastra.Au fost analizate date clinice privind timpul de ladebutul bolii, statusul cognitiv (MMSE, testulceasului), dispozitia depresiva (scorul BDI),comorbiditati si rezultatele polisomnografiei (timpultotal de somn (TST), cuantificarea stadiilor de somn,prezenta REM, a RBD, a apneei si a miscarilorperiodice ale membrelor - PLM).

Rezultate1. Majoritatea pacientilor din lotul studiatau fost barbati (70.58%), iar comorbiditatile cel maifrecvent intalnite au fost depresia (47%),dislipidemia(47%), ateromatoza carotidiana (41%),hipertensiunea arteriala (29%) si hipotensiuneaortostatica(23%). Din punct de vedere clinic,grupurile cu BP si cu AMS au fost similare, cuexceptia timpului de la debut, care a fost semnificativstatistic mai mare la cei cu BP (6.14 ± 5.46 vs 1.93 ±0.838, p=0.042).

In urma analizei univariate a datelor de lapolisomnografie, RBD a fost intalnit cu o frecventa de58.82%, PLM 47.05%, apneea in somn 70.85% (predomina apnea obstructive). Prezenta RBD s-aasociat cu scor mai mic la testul ceasului (8.1 ± 2.1 vs10, p=0.04), cu durata mai lunga a TST (281 ± 49.8min vs 81 ± 36.2 min, p=0.028) si cu eficienta maibuna a somnului (66.8 ± 14.1 vs 35.6 ± 17.8,p=0.012).

Importanta polisomnografiei in evaluareapacientilor cu alfa-synucleinopatii

1) Clinica de Neurologie, SpitalulUniversitar deUrgenta Bucuresti, Romania ; 2) Universitatea deMedicina si Farmacie “Carol Davila”, Bucuresti,Romania

[email protected]

Amalia Ene,

Oana Obrisca 1), Mihai D. Maliia 1), Irina Popa 1),Johanna Berthier 2), Ioana Mandruta 1, 2)

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Rezultate2 Nu au fost diferente semnificativestatistic intre cele 2 grupuri de pacienti in ceea cepriveste frecventa tulburarilor de somn. Datoritacoexistentei frecvente a RBD cu apneea in somn, doar8 pacienti (47.05%) au primit tratament cuclonazepam.

Concluzii. Asocierea RBD cu scor mai mic la testulceasului este sugestiva pentru deteriorarea cognitivamai importanta a pacientilor cu RBD fara de cei faratulburare de somn, fapt deja confirmat la pacientii cuBP in studii anterioare. Intrucat lotul de pacienti a fostmic, iar majoritatea pacientilor inclusi nu au avut odurata lunga de evolutie a bolii, nu s-au evidentiatasocieri intre RBD si tulburari vegetative.

Researcher and Senior Neurologist in the Neurology Department of the University Emergency Hospital in Bucharest with training in Neurophysiology,and participation at numerous courses of EMG. She is

also the Coordinator of the National Program for Deep Brain Stimulation in Parkinson’s Disease and she was and is involved in several clinical trials in Parkinson’s Disease and peripheral neuropathies. She has a vast experience in movement disorders and peripheral neuropathies, proven by many scientific papers and presentations.


Introduction: Patients with intractable epilepsy, whoare candidates for resective surgery, undergo anextensive presurgical workup. Duringstereoelectroencephalografic (SEEG) monitoring,direct electrical stimulation (DES) is used to map theeloquent cortex. Occasionally, supplementarymethods like intracranially recorded evoked potentialscan be used to complement DES exploration. In thefollowing case somatosensory evoked potentials(SSEP) were used in order to better map the primarysomatosensory cortex (S1).

Case presentation: We present the case of a 39-year-old male with intractable epilepsy, who underwentpresurgical workup in our center. Seizure onset was at13 years of age. Semiology consisted of a sensationdescribed as a shiver in the left leg, followed byclonic movements at this level and eventually loss ofcontact. Magnetic resonance imaging did not revealan epileptogenic lesion. The patient was exploredwith intracranial electrodes, which, among others,sampled the medial aspect of the postcentral gyrusand the structures surrounding it – the cingulatecortex, primary motor cortex, parietal cortex,premotor and supplementary motor area. During DESof the S1, accompanying the sensory phenomenareported by the patient were motor manifestations,even at low current intensities. Therefore it wasimpossible to accurately delineate the functionalcortex that needed to be spared during resection.Consequently we used SSEPs, obtained bystimulating the right fibular and tibialis nerves andrecording the evoked potentials intracranially. In thismanner we were able to identify the genuinesomatosensory cortex and to perform radiofrequencythermocoagulation without creating a neurologicaldeficit.

Conclusion: Somatosensory evoked potentials can beused during stereoelectroencephalographicmonitoring for S1 mapping, in addition to directelectrical stimulation. This method is most usefulwhen DES yields ambiguous results.

Parallel direct electrical stimulation andsomatosensory evoked potentials for primarysensory cortex mapping: a case study

Spitalul Universitar de Urgenta Bucuresti, Bucuresti,Romania

[email protected]

Andrei Daneasa

I. Popa, M.D. Mălîia, A. Arbune, A.M. Cobzaru, IMîndruță

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Acute polyradiculoneuritis is a disease with clinicaland paraclinical presentation well defined but with avariable and inaccurate described etiologic context.We would like to present the case of a 52 years oldpatient whose presentation, clinical and paraclinicalevolution and response to therapy are typical for acutepolyradiculoneuritis Guillain-Barre but the context ofthe other illnesses and his long term evolution havedone major difficulties in solving the case. Thosedifficulties were increased by patient trend to requiremedical aid only in acute disease and to neglect hischronic illnesses. If after the acute phase evolutionhas been favorable with very good motor recovery ,remaining kept under control diabetes mellitus andelucidated the cause of a persistent leukocytosis in theabsence of a feverish syndrome, the long termevolution was unfavorable with the emergence of asevere migratory lumbar pain culminating with theinstallation of an acute paraplegia 3 months late fromthe initial episode. The cause of the second episode ofpalsy has been an vertebral abscess withStaphylococcus aureus sensitive to antibiotic, germidentified in uroculture performed at initial admission.The source of infection was going to be revealingmuch later after a long period and difficult recovery.Infection with Staphylococcus aureus could be thetrigger factor for the initial acute polyradiculoneuritisat the initial presentation.

GBS or not?-A case of acute polyradiculoneuritiswith unpredictable evolution and multiple co-morbidities

Sp. Militar de Urgenta" Regina Maria" -Brasov,Brasov, Romania

[email protected]

Marian Cristian Feticu

Dr Simina Dumitrache-Anton, medic primar ATI, Dr.Makk Raluca -medic specialist neurolog


Cabinet de Neurologie Dr Izabela Popa, Timisoara,Romania

[email protected]

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1Department of Neurology, Emergency Hospital,Sibiu2 Departament of Neurology, University EmergencyHospital Bucharest

[email protected]

Motor neuron disease spectrum-a case study

Izabela Popa

Although motor neuron disease (MND) is usually astraightforward diagnosis on clinical basis, everyclinician has concern about missing a potentialdisorder with MND-like presentation. This oftenimplies many investigations thus prolonging time todiagnose the condition.

For patients with focal early presentation thediagnostic algorithm is changing and the differentialdiagnostics are taken into consideration first.

The main goal of antiepileptic treatment is completeseizures remission, with no side effects ofanticonvulsants. However, in 30-35% of cases, thisoutcome is not achieved because seizures are resistantto anticonvulsant treatment.

Identifying epileptic patients at higherrisk of drug resistance, as soon as possible, isparticularly important in epilepsy management.Various predictors of drug resistant epilepsy havebeen identified, but accurate prediction is still aproblem, and EEG patterns play a limited role in thisprocess. Moreover, in the population with establisheddrug resistance epilepsy, no typical EEG patterns areclearly related to pharmaco-resistance in adults.

Prolonged video-EEG recording is thegold standard for exploring patients in this stage, andshould be indicated as early as possible, usually afterthe failure of first monotherapy. Interictalepileptiform discharges with a systematiclateralization and well confined to a lobardistribution, will be the best indicator that the patientswith drug resistant epilepsy could benefit from asurgical perspective.

Carcalici Ioan-Radu 1,

Irina Popa2, Maliia Dragos Mihai2, Mîndruță Ioana

EEG pattern of drug resistant epilepsy


There is a growing clinical need to improve themonitoring of the comatose brain. EEG-basedmethods are typically aimed at quantifying thepathologic slowing of continuous EEG. Nevertheless,during deep comatose states, the EEG becomesdiscontinuous - referred to as burst-suppression (BS).We developed a novel technology that can be used toquantify both the continuous EEG and BS alike. Inbrief, we classify the multi-channel EEG intoalternating states with similar topographic frequencydistribution. We then identify a default EEG class,that is transiently reduced during a 1-minutestimulation epoch as compared to 1-minute pre-stimulation and post-stimulation epochs. The relativechange in default EEG class fraction is referred to asDefault EEG Reactivity (DER) – patent pending.Here we present experimental and clinical studiesunder different stimulation paradigms indicating thatDER impairment reflects coma severity. We thereforefeel encouraged to develop a hardwareneurophysiological EEG reactivity monitor(NERMO) to facilitate long term DER tracking.

Towards a neurophysiological EEG reactivitymonitor (NERMO) to track coma severity

1 Physics Department, University of Bucharest,Romania

2 Termobit Prod SRL, Bucharest, Romania

3 FHC Inc, Bowdoin, ME, USA

4 Neurology Department, University EmergencyHospital, Bucharest, Romania

5 Department of Neurosurgery, Bagdasar-ArseniEmergency Hospital, Bucharest, Romania.

6 Division of Physiology and Neuroscience, "CarolDavila" University of Medicine and Pharmacy,Bucharest, Romania;

7 Department of Neuroscience, Panum, University ofCopenhagen, Copenhagen, Denmark

[email protected]

Cosmin-Andrei Șerban1,2,3,

Costi Pistol1,2, Andrei Barborică1,2,3, Adina-MariaRoceanu4, Ioana Raluca Mîndruță4, Jan Ciurea5, Ana-Maria Zăgrean6, Leon Zăgrean6 and MihaiMoldovan2,6,7

The EEG trace is a graphical depiction of variouselectromagnetical processes existing at the scalplevel, only some reflecting true cerebral activity. Toproperly obtain a neurophysiological diagnosis onehas to have a basic understanding of the signals’properties and of the recording methodology.

The polarity and different montages are especiallyrelevant for inferring the location of the electricalsource and thus classifying the epilepsy syndromes. Aneurophysiologist has to have the versatility ofchanging and adapting the parameters of variousclassical EEG-montages in front of an EEG anomalyin order to maximize the amount of informationobtained. Based on these it is encouraged to createpersonalized montages tailored on the various clinicalscenarios encountered in the clinical practice.

The sampling rate and the proper filtering areessential in recording and analyzing the physiologicaland pathological brain waves. Here we will detail theNyquist-Shannon theorem and the aliasingphenomenon that are so important in recording thefrequencies of interest. The last part of thepresentation will be focused around the properties ofthe rhythms recorded in humanelectroencephalography and their diagnostic yield,with an emphasis of recent developments in the field.

Biophysical aspects in EEG signal analysis:polarity, montages, sampling, amplitude andfrequency.

Neurology Department, University EmergencyHospital, Bucharest, Romania

[email protected]

Mihai Dragos MALIIA,

Irina Popa, Andrei Daneasa, Anca Arbune, CristiDonos, Andrei Barborica, Ioana Mindruta

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