Atypical Presentation of Medullary Syndrome in a Young Woman

Wallenburg syndrome occurs due to damage to lateral segment of the medulla. Medial medullarysyndrome occurs due to damage to upper portion of the medulla. I report a case of a 30 years old woman diagnosed with medullary syndrome[both medial & lateral features] in absence of CT scan findings sent to the department of Physiology for electrophysiological tests like nerve conduction studies, blink reflex, brainstem auditory evoked potential (BERA) & visual evoked potential (VEP). She had loss of sensations on the ipsilateral half of face (right), hemisensory loss on contralateral trunk & extremities, headache, contralateral hemiparesis (left), ipsilateral lingual paresis with atrophy, fibrillations with contralateral positive Babinski’s sign. The electrophysiological tests showed decrease in conduction velocity of right facial nerve, left tibial & peroneal nerves with decreased amplitude. The nerve conduction studies of median nerve (both motor & sensory) were normal. In blink reflex, latency of R2 ipsilateral & R2 contralateral of supraorbital nerves were increased on right side. There were increasedlatencies of waves II, III, IV & V of BERA & increased P100 latencies in VEP.The results of the electrophysiological tests of the patient showed that she had features of both medial & lateral medullary syndrome suggesting a lesion of both upper & middle medulla. The CT scan in this case was normal but conduction of MRI & CT guided angiography of posterior cerebral & vertebral arteries could have further localized the lesion causing this mixed symptomology

Comparative Analysis Of Various Electrophysiological Methods For The Diagnosis Of Carpal Tunnel Syndrome

BACKGROUND:Patients with Mild Carpal tunnel syndrome (CTS) may not be picked up by routine nerve conduction methods. So, this study was performed to identify the most sensitive way to detect mild to moderate Carpal tunnel syndrome and to evaluate the sensitivity of different methods for diagnosis of carpal tunnel syndrome.MATERIALAND METHOD: We included sixty clinically confirmed CTS patients in our study. We recorded the clinical characteristics and laboratory features in a proforma. We also included sixty healthy age and sex-matched asymptomatic individuals as controls in our study. We excluded patients with underlying peripheral neuropathy. We included Median distal motor latency, Median distal sensory latency, Median-versus-ulnar 2nd Lumbrical-interossei comparison study, Median-versus-ulnar wrist-to-digit four comparison study, Median -versus- Radial thumb sensory study, Median-versus-ulnar motor distal latency difference, and Median-versus-ulnar sensory latency difference tests in our study.RESULTS:Out of sixty patients, female: male ratio was 2.3:1, and the mean age was 44.28±11.41 years. The mean symptom duration was 0.76±0.03 years. Out of 42 females, 38(90.4%) were engaged in daily household activities. In patients group median nerve distal motor latency was 5.024±2.05 ms, whereas sensory latency was 3.53±0.75 ms. We found maximum sensitivity in Median-versus-ulnar wrist-to-digit four comparison study (90.19%). In Median-versus-Radial thumb sensory study sensitivity was 88.23%, followed by Median-versus-ulnar 2nd Lumbrical- interossei comparison study (86.27%). We found lowest sensitivity (72.55%) in Median distal motor latency test.CONCLUSION:Electrophysiological tests including Median-versus-ulnar wrist-to-fourth digit comparison study, and comparative study of Median-versus-ulnar 2nd Lumbrical- interossei should be included to diagnose mild CTS patients with normal Median distal motor latency, and median distal sensory latency tests

Importance of atropine challenge test in the current era of electrophysiology.

Mobitz II block is misunderstood more than any other abnormality of rhythm or conduction”. The concept of 2:1 AV block remains poorly understood by many physicians even after so many years of advancement in the field of electrophysiology. It cannot be classified into type I or type II second-degree AV block because there is only one PR interval to examine before the blocked P wave A 46 year male admitted with chief complaints of effort intolerance and non anginal chest pain of fifteen days duration. His resting ECG revealed 2:1 conduction of P wave, before and after non conducted P wave PR interval was constant and of normal duration. So in order to define the site of block we performed the atropine challenge test as the patient was not able to walk. On administration of atropine ECG revealed worsening of AV block in a 3:1 to 4:1 conduction of P wave with narrow complex QRS. This finding suggesting the block is in bundle of his or branches. This patient underwent Electrophysiological study. Electro physiological tracings showed normal PR interval, QRS duration, with 2:1 AV block. The non conducted P wave was blocked at the level of distal His bundle. This case illustrated the importance of localisation of site of block in 2:1 AV block in order to manage the case appropriately. Both vagal manoeuvres and exercise can help in localising the site of block, which will be confirmed by electrophysiology study.

Utilidad de ePEAT en determinar candidatura para implante coclear en pacientes pediátricos con malformaciones de oído interno: comunicación preliminar / Use of ePEAT to determine candidacy for cochlear implant in pediatric patients with inner ear malformations: preliminary communication

En candidatos a implante coclear con malformaciones del oído interno donde se encuentra un nervio coclear anormal, los estudios tradicionales y las imágenes muchas veces no pueden dar respuesta definitiva acerca de la funcionalidad y presencia del nervio coclear. Para esto ayudarían los estudios de electrofisiología. Se presentan tres casos clínicos de pacientes con malformaciones del oído interno que fueron evaluados con ePEAT para ayudar a determinar su candidatura a implante coclear. Los estudios electrofisiológicos no reemplazan a los estudios tradicionales de evaluación auditiva ni a los estudios por imágenes, sino que los complementan. Los casos presentados, demuestran que en casos de malformaciones de oído interno o CAI muy estrecho, en que se cuestiona seriamente la existencia de un nervio coclear funcional, y en casos de neuropatía auditiva, se hace necesario evaluar la función de la cóclea separadamente de la del nervio auditivo y la función del tronco. Para esto se utilizamos los ePEAT. Los ePEAT entregan información valiosísima ya que nos permite conocer las reales capacidades de los pacientes para transmitir un estímulo auditivo hacia el sistema nervioso central, definiendo mejor las expectativas con el uso implante, asistiéndonos en nuestra toma de decisiones.

In cochlear implant candidates with inner ear malformations, where there is an abnormal cochlear nerve, traditional studies and images cannot often provide definitive answers about the functionality and presence of the cochlear nerve. In these cases, electrophysiology studies can be used. We present 3 cases of patients with inner ear malformations who were evaluated with ePEAT to determine their candidacy for a cochlear implant. Electrophysiological studies do not replace traditional hearing screening studies or imaging studies, but complement them. The cases presented in this study demonstrate that in patients with inner ear malformations or very narrow internal auditory canal, where we question the existence of a functional cochlear nerve, and in cases of auditory neuropathy, it is necessary to evaluate the cochlear function separately from the auditory nerve and from the brainstem. In these cases we use ePEAT. ePEAT give us valuable information about the real abilities of patients to transmit an auditory stimulus to the central nervous system, which help us to define expectations with cochlear implant use, assisting us in our decision-making.