Left Radial Nerve Research Articles

Changes in intra- and interlimb reflexes from forelimb cutaneous afferents after staggered thoracic lateral hemisections during locomotion in cats.

In quadrupeds, such as cats, cutaneous afferents from the forepaw dorsum signal external perturbations and send inputs to spinal circuits to co-ordinate the activity in muscles of all four limbs. How these cutaneous reflex pathways from forelimb afferents are reorganized after an incomplete spinal cord injury is not clear. Using a staggered thoracic lateral hemisections paradigm, we investigated changes in intralimb and interlimb reflex pathways by electrically stimulating the left and right superficial radial nerves in seven adult cats and recording reflex responses in five forelimb and ten hindlimb muscles. After the first (right T5-T6) and second (left T10-T11) hemisections, forelimb-hindlimb co-ordination was altered and weakened. After the second hemisection, cats required balance assistance to perform quadrupedal locomotion. Short-, mid- and long-latency homonymous and crossed reflex responses in forelimb muscles and their phase modulation remained largely unaffected after staggered hemisections. The occurrence of homolateral and diagonal mid- and long-latency responses in hindlimb muscles evoked with left and right superficial radial nerve stimulation was significantly reduced at the first time point after the first hemisection, but partially recovered at the second time point with left superficial radial nerve stimulation. These responses were lost or reduced after the second hemisection. When present, all reflex responses, including homolateral and diagonal, maintained their phase-dependent modulation. Therefore, our results show a considerable loss in cutaneous reflex transmission from cervical to lumbar levels after incomplete spinal cord injury, albeit with preservation of phase modulation, probably affecting functional responses to external perturbations. KEY POINTS: Cutaneous afferent inputs co-ordinate muscle activity in the four limbs during locomotion when the forepaw dorsum contacts an obstacle. Thoracic spinal cord injury disrupts communication between spinal locomotor centres located at cervical and lumbar levels, impairing balance and limb co-ordination. We investigated cutaneous reflexes from forelimb afferents during quadrupedal locomotion by electrically stimulating the superficial radial nerve bilaterally, before and after staggered lateral thoracic hemisections in cats. We showed a loss/reduction of mid- and long-latency homolateral and diagonal reflex responses in hindlimb muscles early after the first hemisection that partially recovered with left superficial radial nerve stimulation, before being reduced after the second hemisection. Targeting cutaneous reflex pathways from forelimb afferents projecting to the four limbs could help develop therapeutic approaches aimed at restoring transmission in ascending and descending spinal pathways.

Sympathoinhibition during cardiopulmonary baroreceptor loading is attenuated in older females.

The purpose of the present study was to clarify the impact of age on the sympathoinhibitory response to cardiopulmonary baroreceptor loading in females. Nine older females (mean±SD, 70±6 years) and eleven younger females (20±1 years) completed the study. A passive leg raising (PLR) test was performed wherein the participants were positioned supine (baseline, 0º), and their lower limbs were passively lifted at 10º, 20º, 30º, and 40º (3 min at each angle). Muscle sympathetic nerve activity (MSNA) was recorded via microneurography of the left radial nerve. The central venous pressure was estimated based on peripheral venous pressure (eCVP), which was monitored using a cannula in the right large antecubital vein. Baseline MSNA was higher in older females compared to younger females. MSNA burst frequency (BF) decreased during the PLR test in both older and younger females, but the magnitude of the decrease in MSNA BF was smaller in older females than in younger females (older, -3.5±1.5 vs. younger, -6.3±1.5 bursts/min at 40º from baseline, P=0.014). The eCVP increased during the PLR in both groups, and there was no difference in the changes in eCVP between the two groups (older, +1.07±0.37 vs. younger, +1.12±0.33 mmHg at 40º from baseline, P=0.941). These results suggest that inhibition of sympathetic vasomotor outflow during cardiopulmonary baroreceptor loading could be blunted with advancing age in females.

Influence of sex on sympathetic vasomotor outflow responses to passive leg raising in young individuals.

The purpose of this study was to clarify sex differences in the inhibition of sympathetic vasomotor outflow which is caused by the loading of cardiopulmonary baroreceptors. Ten young males and ten age-matched females participated. The participants underwent a passive leg raising (PLR) test wherein they were positioned supine (baseline, 0º), and their lower limbs were lifted passively at 10º, 20º, 30º, and 40º. Each angle lasted for 3min. Muscle sympathetic nerve activity (MSNA) was recorded via microneurography of the left radial nerve. Baseline MSNA was lower in females compared to males. MSNA burst frequency was decreased during the PLR in both males (- 6.2 ± 0.4 bursts/min at 40º) and females (- 6.5 ± 0.4 bursts/min at 40º), but no significant difference was detected between the two groups (P = 0.61). These results suggest that sex has minimal influence on the inhibition of sympathetic vasomotor outflow during the loading of cardiopulmonary baroreceptors in young individuals.

Treatment of Iatrogenic Nerve Injury After Humeral Shaft Fracture Fixation: A Case Report

Background. Iatrogenic neuropathies of the radial nerve following intramedullary nailing of the humerus are observed in 2.9% of patients. In 30% of cases, iatrogenic nerve injury is associated with distal nail locking. Questions about the timing and volume of diagnostic measures to determine the nature of nerve damage, methods of conservative and surgical treatment, and their effectiveness remain relevant.
 Aim of the study to illustrate the causes, prevention methods, diagnosis, and treatment of iatrogenic radial nerve injuries in humeral shaft fractures through a clinical example.
 Case presentation. A 30-year-old female patient was admitted with a nonunion fracture of the left humerus and iatrogenic radial nerve injury three months after the fracture was fixed with a locking nail. A revision operation was performed: removal of the nail from the left humerus; re-fixation of the left humerus with a plate; revision, neurolysis, and plastic repair of the left radial nerve using autografts from the right sural nerve. Postoperative courses of medication therapy, physiotherapy, and therapeutic exercises were conducted. At 26 months after the surgery, complete range of motion and restoration of strength in active extension of the left wrist and three phalanges, abduction of the first finger, partial extension of the first finger, and restoration of sensitivity on the outer surface of the left forearm and the back of the hand were observed.
 Conclusion. Iatrogenic radial nerve injury primarily occurs as a result of incorrect technique when introducing locking screws during intramedullary nailing of humeral shaft fractures. Delayed examination and surgical treatment of patients with injured radial nerve lead to a lack of full functional recovery, potential muscle atrophy, and impairment of their motor function. Surgical treatment aimed at restoring the radial nerve at an early stage after injury, combined with a full range of postoperative rehabilitation for a year, is the only correct treatment approach.

Recurrent Bickerstaff Encephalitis: Clinical Manifestation and Potential Treatment Options (P10-5.020)

<h3>Objective:</h3> NA <h3>Background:</h3> Bickerstaff encephalitis is a rare autoimmune disease involving the peripheral and central nervous system, most commonly presenting as a monophasic condition with ophthalmoplegia, ataxia and altered sensorium. <h3>Design/Methods:</h3> We present a rare case of Bickerstaff encephalitis with recurrent episodes along with notable EMG findings and possible therapeutic options to prevent recurrence. <h3>Results:</h3> A 47-year-old woman presented with four days of progressive bilateral ptosis and dysphagia. Her exam was notable for anosognosia, oculobulbar weakness, hyperreflexia, and ophthalmoplegia. Her hospital course was complicated by respiratory failure and autonomic instability. NCS revealed absent F-waves in the left median, ulnar, and radial nerves. MRI, lumbar puncture, malignancy screenings, autoimmune and paraneoplastic panels were all unrevealing. She was found to be ganglioside antibody negative. The patient was treated with IVIg for possible Bickerstaff encephalitis with no improvement. Nine days after completing her IVIg course, she was treated with PLEX followed by rapid recovery. She has since re-presented with dysphagia, ptosis, diplopia and ophthalmoplegia, and has been treated successfully with steroids and PLEX. To prevent further episodes, she was started on immune-modulating therapy, and had been in remission for over one year. Recently, she accidentally discontinued her immune-modulating therapy resulting in a recurrence, which was treated with another session of PLEX. <h3>Conclusions:</h3> Additional studies are needed to guide treatment of Bickerstaff encephalitis and identify which patients are likely to benefit from PLEX over IVIG. Since this disease can lead to life threatening respiratory failure and autonomic instability, immune-modulating therapy might be a reasonable preventive option in rare cases of recurrent Bickerstaff Encephalitis. Further investigation is necessary regarding effective management of this rare clinical syndrome. <b>Disclosure:</b> Dr. Amirkhanashvili has nothing to disclose. Mr. Chang has nothing to disclose. Dr. Shen has nothing to disclose. Dr. Holtzman-Hayes has nothing to disclose. Dr. Friedman has nothing to disclose. Dr. Gluck has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Janssen. Dr. Milstein has received personal compensation in the range of $5,000-$9,999 for serving as an Expert Witness for various law firms. Dr. Milstein has received publishing royalties from a publication relating to health care. Dr. Milstein has a non-compensated relationship as a Board of Directors with New York County Medical Society that is relevant to AAN interests or activities.

Left–right asymmetry of the visual system in the scallop Nodipecten nodosus (Bivalvia: Pectinidae)

ABSTRACT Left–right asymmetries are consistent differences between the left and right sides and represent an intriguing feature of molluscan morphology. Interestingly, external asymmetries, such as inequivalve shells, are often coupled with lateralization in the nervous system, which often includes functional and structural specializations of the left or right sides. In the case of visual asymmetries, lateralized phenotypes frequently include left–right differences in eye position, structure and use. To investigate lateralization and visual asymmetries among bivalves, we examined the visual and nervous systems of the scallop Nodipecten nodosus. We characterized different eye morphologies in the species and determined eye-side frequencies. We also studied the anatomy of the nervous system, focusing on the parietovisceral ganglion (PVG). Our results reveal that the visual and nervous systems of the scallop N. nodosus comprise consistent left–right asymmetries: (1) a greater number of eyes on the left side, (2) increased size of the left PVG lateral lobe, (3) larger glomeruli in the left PVG lateral lobe and (4) radial pallial nerves associated with the left lateral lobe spaced more widely than the more compactly arranged pallial nerves associated with the right lateral lobe. In addition, eyes with a distinctive morphology, where the optic vesicle is rotated, are more frequent on the left side. Considering the habit of this species to rest on the right valve, we hypothesize that curved eyes might contribute to expanding the overall visual field. Even though bivalves are not typically considered in the literature on lateralization, accumulating evidence for scallops, as suggested by our results, indicates their potential to reveal novel patterns of visual asymmetry in benthic invertebrates.

Sympathetic vasomotor outflow during low-intensity leg cycling in healthy older males.

What is the central question of this study? Sympathetic vasomotor outflow is reduced during low-intensity dynamic leg exercise in younger individuals: does ageing influence the sympathoinhibitory effect during low-intensity leg cycling? What is the main finding and its importance? Muscle sympathetic nerve activity during low-intensity cycling decreased in older males, as seen in young males. It is possible that cardiopulmonary baroreflex-mediated inhibition of sympathetic vasomotor outflow during dynamic leg exercise is preserved in healthy older males. Muscle sympathetic nerve activity (MSNA) is reduced during low-intensity dynamic leg exercise in young males. It is suggested that this inhibition is mediated by loading of the cardiopulmonary baroreceptors. The purpose of this study was to clarify the impact of age on MSNA during dynamic leg exercise. Nine younger males (YM, mean±SD, 20±1years) and nine older males (OM, 72±3years) completed the study. The subjects performed two 4-min cycling exercises at 10% of their heart rate reserve using a cycle ergometer in a semirecumbent position (MSNA and estimated central venous pressure (eCVP) trials). MSNA was recorded via microneurography of the left radial nerve. The CVP was estimated based on peripheral venous pressure, which was monitored using a cannula in the right large antecubital vein. The magnitude of the increase in mean arterial blood pressure during leg cycling was larger in OM (+9.3±5.5mmHg) compared with YM (+2.8±4.7mmHg). MSNA burst frequency was decreased during cycling in both YM (-8.1±3.8bursts/min) and OM (-10.6±3.3bursts/min), but no significant difference was found between the two groups. The eCVP increased during exercise in both groups, and there was no difference in the changes in eCVP between YM (+1.1±0.4mmHg) and OM (+1.2±0.7mmHg). These data indicate that inhibition of sympathetic vasomotor outflow during low-intensity cycling appears in OM as seen in YM. It is possible that the muscle pump-induced loading of the cardiopulmonary baroreflex is preserved during cycling in healthy older males.

P046 A rare case of peripheral T cell lymphoma presenting as peripheral neuropathy &amp; myositis

Abstract Background/Aims Peripheral T cell Lymphomas are a heterogeneous group of very aggressive and rare lymphomas in the western world accounting for 5% to 15% of non-Hodgkin lymphomas. Inflammatory myositis and nephropathy associated with hematological malignancies are extremely rare. Methods A 64-year-old gentleman presented with progressive neuropathy with pain and numbness in feet, clawing in both hands, muscle weakness and wasting. He also noticed a rash in his groin and scrotum (erythematous) and new erectile dysfunction along with Raynaud’s, dry eyes, and unintentional weight loss over a year. His paternal uncle suffered from peripheral neuropathy. He had splinter hemorrhage and telangiectasia on general examination. Neurological examination revealed clawing of hands, muscle wasting in his hands and legs in distribution of right median, ulnar, left radial, bilateral sural and bilateral peroneal nerve. Results He had normal routine blood tests (FBC, U&amp;Es and LFTS and CRP). Rheumatology work up revealed CK of 204, LDH 317, ANA 1: 640 titre, negative ENA, dsDNA, ANCA, RF, anti CCP antibodies, myositis blot, normal C3, C4, protein electrophoresis, IgG sub classes and negative para neoplastic screen including anti Ri, anti Yo and anti Hu and a negative urine dip for blood or proteins. Echocardiogram revealed small pericardial effusion. PET scan showed markedly avid lesion in ascending colon proven to be low-grade tubulovillous adenoma on biopsy. MRI of thighs showed inflammatory change consistent with myositis and nerve conduction studies has revealed mono neuritis multiplex. Peroneal nerve biopsy showed small vessel lymphocytic vasculitis followed by skin biopsy of thigh and shin consistent with features of lymphocytic vasculitis and angiocentric NK cell lymphomatous changes. On the bases of his presenting symptoms and investigations, he was treated with 60mg of oral prednisolone and pulsed cyclophosphamide at dose of 15mg /kg for 6 cycles for multisystemic inflammatory condition causing mono neuritis multiplex and myositis. His cyclophosphamide was stopped after 4 cycles as there was no response to treatment and MDT review confirmed that skin and nerve biopsies features were consistent with peripheral T cell lymphoma. Further treatment was with CH(O)P (minus vincristine) under the care of oncologists. Conclusion Peripheral T cell lymphoma (PTCL) is a rare and aggressive heterogeneous group of lymphomas. Risk factors include family history of hematological malignancies and smoking. Rashes may be the antecedent finding in about 20% to 50% of angioimmunoblastic T cell lymphoma patients, with skin manifestations ranging from urticarial lesions to nodular tumor. Patients with cutaneous T cell lymphomas often present with “chronic dermatitis” which is resistant to therapy, early-stage having a predilection for folds and non-exposed sun areas. Cancer associated inflammatory myopathies are rare syndromes occurring in 10%-30% of all malignancies and inflammatory myopathies associated with hematological malignancies are even rarer entities. Disclosure M. Ashraf: None. J. David: None.

Transient radial paralysis occurring in a Belgian White Blue bull undergoing general anaesthesia for claw amputation

A four-year-old, 973 kg Belgian White Blue bull was presented for further evaluation of a persistent right hindlimb lameness. The physical and radiographic examinations revealed osteitis of the medial second phalanx of the right hindlimb. A claw amputation was performed under general anaesthesia. The bull was premedicated with 0.17 mg/kg xylazine intramuscularly and general anaesthesia was induced with 2 mg/kg ketamine administered intravenously. During the recovery phase, the bull could not bear any weight on his left thoracic limb. Further examinations revealed left radial nerve paralysis. Treatment consists of a bolus of dexamethasone (0.05 mg/kg) intravenously in order to decrease the inflammation; fluid therapy in an attempt to improve muscle perfusion and to replace the fluid losses and cold showers to decrease the rise in temperature. After 90 minutes from the end of general anaesthesia, the radial paralysis resolved spontaneously without any major consequences.

Henry Head’s lifelong studies of cutaneous sensation

In 1900 research on cutaneous sensation was defined by histological techniques defining sensory receptors in skin, leading to undetermined conceptual problems when considered in relation to Brown-Séquard's startling finding that there were two qualitatively different afferent pathways in the spinal cord. Four modalities were considered to function as the determinants of sensory input. In 1903 Rivers and Head carried out the first interventional study of human cutaneous sensation, and analysed the return of sensation following section and immediate suture of the dorsal cutaneous branch of Head's left radial nerve. This resulted in the revolutionary idea summarised in his description of protopathic and epicritic sensory systems in peripheral sensory nerve. Although this concept was at best seen as controversial and even ridiculed by some of his many contemporaneous critics, more recently this concept has proven a fundamentally important stimulus to understanding the physiology of cutaneous sensation. His writings show him to have been capable of deeply instructive thought, based on his clinical experience and his admiration of Hughlings Jackson's teaching concerning the hierarchical organisation of brain function. First and foremost a clinician neuroscientist, his ideas were ahead of their time and not understood.

Resting Muscle Sympathetic Nerve Activity Is Not Different in Symptomatic Concussed College Athletes versus Healthy Controls

Heart rate variability, primarily an indicator of cardiac parasympathetic function, has been shown to be reduced at rest and during physiological stressors (e.g., aerobic exercise, handgrip exercise, and face cooling) following a concussion, which suggests altered autonomic function. Previous work in our lab has demonstrated attenuated increases in sympathetically‐mediated increases in blood pressure due to unaltered total peripheral resistance during face cooling and the cold pressor test in symptomatic concussed college athletes (CA) compared to healthy controls (HC). These responses suggest that CA have blunted sympathetic activation. It is unknown if a direct measure of sympathetic nerve activity (e.g., muscle sympathetic nerve activity (MSNA)) is altered at rest in CA compared to HC.PURPOSEWe tested the hypothesis that MSNA at rest would be lower in CA compared to HC.METHODSSeven CA (age: 19±2 y, 4 females, 4±2 days post‐injury) and seven HC (age: 21±3 y, 3 females) completed one study visit. Heart rate (3‐lead electrocardiogram), mean arterial pressure (photoplethosmography), and MSNA (microneurography) from the left radial nerve were continuously recorded at 1 kHz for 30 s following at least 20 minutes of supine rest. MSNA burst frequency, burst incidence, and total activity were assessed using commercially available software. Cardiac output was calculated as the product of heart rate and stroke volume. Total peripheral resistance was calculated as mean arterial pressure divided by cardiac output. We used unpaired t‐tests to determine if the main outcome variables were different between groups. Values are reported as mean ± SD.RESULTSResting heart rate (CA: 58±10 vs. HC: 61±12 bpm; P = 0.31), mean arterial pressure (CA: 95±9 vs. HC: 88±10 mmHg; P = 0.11), cardiac output (CA: 6±1 vs. HC: 7±3 L/min; P = 0.31), and total peripheral resistance (CA: 16±3 vs. HC: 16±11 mmHg/L/min; P = 0.45) were not different between CA and HC. Resting MSNA was not different between CA and HC for burst frequency (CA: 27±6 vs. HC: 29±9 beats/min; P = 0.33), burst incidence (CA: 47±10 vs. HC: 46±11 bursts/100 heartbeats; P = 0.44), or total activity (CA: 4883±1520 vs. HC: 6321±1689 AU/min; P = 0.07).CONCLUSIONThese preliminary data indicate that muscle sympathetic nerve burst frequency, burst incidence, and cardiovascular variables during resting conditions are not different in symptomatic concussed college athletes compared to healthy controls. Research is warranted to determine if muscle sympathetic nerve activity is different between symptomatic concussed colleges athletes and healthy controls during a sympathoexcitatory maneuver.Support or Funding InformationSupported by the National Center for Advancing Translational Sciences of the National Institutes of Health Pilot Grants Award Program under award Number UL1TR001412.

Muscle pump-induced inhibition of sympathetic vasomotor outflow during low-intensity leg cycling is attenuated by muscle metaboreflex activation.

Muscle sympathetic nerve activity (MSNA) decreases during leg cycling at low intensity because of muscle pump-induced increases in venous return and loading of the cardiopulmonary baroreceptors. However, MSNA increases during leg cycling when exercise is above moderate intensity or for a long duration, suggesting that the sympathoinhibitory effect of the cardiopulmonary baroreflex can be overridden by a powerful sympathoexcitatory drive, such as the skeletal muscle metaboreflex. Therefore, we tested the hypothesis that high-intensity muscle metaboreflex activation attenuates muscle pump-induced inhibition of MSNA during leg cycling. MSNA (left radial nerve) was recorded during graded isolation of the muscle metaboreflex in the forearm with postexercise ischemia (PEI) after low (PEI-L)- and high (PEI-H)-intensity isometric handgrip exercise (20% and 40% maximum voluntary contraction, respectively). Leg cycling (15-20 W) was performed alone and during each PEI trial (PEI-L+Cycling, PEI-H+Cycling). Cycling alone induced a significant decrease in MSNA burst frequency (BF) and total activity (TA). MSNA BF and TA also decreased when cycling was performed during PEI-L. However, the magnitude of decrease in MSNA during PEI-L+Cycling [∆BF: -19 ± 2% (P < 0.001), ∆TA: -25 ± 4% (P < 0.001); mean ± SE] was less than that during cycling alone [∆BF: -39 ± 5% (P = 0.003), ∆TA: -45 ± 5% (P = 0.002)]. More importantly, MSNA did not decrease during cycling with PEI-H [∆BF: -1 ± 2% (P = 0.845), ∆TA: +2 ± 3% (P = 0.959)]. These results suggest that muscle pump-induced inhibition of sympathetic vasomotor outflow during low-intensity leg cycling is attenuated by muscle metaboreflex activation in an intensity-dependent manner.NEW & NOTEWORTHY There are no available data concerning the interaction between the sympathoinhibitory effect of muscle pump-induced cardiopulmonary baroreflex loading during leg cycling and the sympathoexcitatory influence of the muscle metaboreflex. In this study, muscle metaboreflex activation attenuated the inhibition of muscle sympathetic nerve activity (MSNA) during leg cycling. This may explain, in part, the response of MSNA to graded-intensity dynamic exercise in which low-intensity leg cycling inhibits MSNA whereas high-intensity exercise elicits graded sympathoexcitation.

Delayed nerve repair with epineural microsutures in traumatic radial nerve palsy: a case report

Introduction: Traumatic radial nerve palsy is a condition that need surgical management. Patients who neglect their symptoms or under diagnosed on examination, cause delays to their surgery treatment. Direct nerve repair with epineural microsutures is still the gold standart of surgical treatment for severe axonotmesis and neurotmesis injuries. In this article, we reported a case of nerve repair with epineural microsutures in traumatic radial nerve palsy.Case presentation: A 14-year-old male complained cramps, tingling, and numbness of his left arm and he was unable to extend his left wrist and fingers after he got a left arm injury 3 months ago. The electromyography (EMG) shown that left radial nerve lesion at left radial sulcus. Direct nerve repair is performed by epineural microsutures. Â Two weeks after surgery, we found improvement on the sensory process, but no improvement on the motoric process.Conclusion: Direct nerve repair with epineural microsutures is an effective treatment for radial nerve injury, but the timing for surgery influencing the result of operation.

P87-T Rapid recovery of motor and sensory conduction block in multifocal motor neuropathy

Background Multifocal motor neuropathy (MMN) almost purely involves motor nerve. About 20% MMN patients develop minor sensory symptoms in the course of disease. Material and method We reported a 62-year-old male who developed a slowly progressive asymmetrical limb weakness for five years. Motor nerve conduction studies showed definite CB in left median and ulnar nerves, and probable CB in right tibial nerve. Although the patient complained of no sensory symptom, sensory never conduction studies showed absent sensory nerve action potential (SNAP) for bilateral medial plantar and fibular nerves, left sural nerve and reduced amplitude for left median, ulnar and radial nerves. Conduction velocities were otherwise normal. One month after receiving intravenous immunoglobulin (IVIg), his weakness alleviated apparently. A substantial increase in motor amplitude recorded with stimulation at the PF indicated a partial reversal of CB. The SNAP amplitude of left median, ulnar and radial nerves increased more than 50% and the return of bilateral fibular nerve potentials provided evidence of reversible conduction failure in sensory nerves. We reviewed related literature for this performance. Result Three previously published studies reported such a decrease of SNAP amplitude in MMN patients. Such features suggest a more prominent axonal damage more than demyelination. The hyperpolarization of axolemma, resulting from axonal Na+/K+ pump inhibition at the lesion site and overactivity at the adjacent site may constitutes the prominent mechanism of CB. Conclusion Amplitude reduction of SNAP combined with motor CB, which recovered rapidly after IVIg, may suggest axonal damage rather than demyelination.

P75-F Evaluation of deterioration in sensory nerve conduction studies in Amyotrophic Lateral Sclerosis

Background Many neurophysiological and pathological studies showed sensory abnormalities in ALS patients as a part of multisystem disease. In this study, we assessed progression of sensory changes in ALS patients, using nerve conduction studies (sNCS) in two consecutive visits. Material and methods sNCSs were evaluated based on amplitudes and velocities of bilateral dorsal sural (DS), medial plantar, superficial peroneal (SP), sural and left radial sensory nerves. In addition a global Total Sensory Score (TSens) was determined using the amplitudes of these nerves. Results Although, for both visits, TSens was smaller in patients (p = 0.04 and P = 0.01, for consecutive visits) then controls, there was no significant change between two visits of the patients (P = 0.19). ALS patients had significantly smaller amplitudes and slower velocities for bilateral DS, and left radial nerves for both visits. TSens was reduced in 7 (63.3%) but increased in 4 (36.6%) ALS patients. Conclusions Although, ALS patients showed considerable changes in NCS, sensory denervation is probably slowly progressive. The patients with improved sNCS were attributed to possible changes in sensory nerve excitability following corrective measures, e.g. administration of parenteral gastrostomy or high caloric diet.

P17-S Repeated compression radial neuropathies caused by rope bondage

Rope bondage or shibari represents voluntary binding of a person with a rope and can lead to compression injury to peripheral nerves. We present a case of the radial nerve injury in suspension. A 29-year-old woman with a BMI of 17.5 was tied up with a 6-mm jute rope and suspended by the upper limbs, torso and hips for 25 min. The rope was placed in the middle third of the brachium. On removing the rope, she had a left wrist and a finger drop with decreased posterolateral hand sensation. Radial nerve conduction studies was performed on day 48. Compound muscle action potential was recorded from extensor digitorum communis. Conduction velocity was reduced to 19 m/s in the spiral groove segment, conduction block was 95.3%. Sensory conduction studies were normal. Clinical improvement began after 3 months with complete improvement after 5 months. Seventeen months after the recovery, this patient re-compressed both radial nerves after a similar suspension lasting about 8 min. The improvement began after one week and completed after 4 weeks. The third compression episode, that occurred three years after the first compression, lasted five minutes with clinical recovery in two minutes later. Nerve conduction studies demonstrated normal motor and sensory conduction velocities in radial, median, ulnar, peroneal, tibial and sural nerves. A high-resolution ultrasound examination showed a slight increase in the cross-sectional area of the left radial nerve in the spiral groove compared to the opposite side. Conclusion Rope bondage often causes injury to the radial nerve.

Compartment syndrome in the forearm related to carbon monoxide intoxication: case report

Introduction: Carbon monoxide (CO) poisoning is one of the most common forms of intoxication around the world. One of the complications associated with CO exposure is direct toxicity to the skeletal muscles. Though compartment syndrome induced by CO intoxication is rare, it is a well-known complication. In this study, we present a case of CO poisoning in a patient who developed compartment syndrome in his forearm. Case report: A 22-year-old man was found unconscious in a motel where a briquette had burned. He was later diagnosed with rhabdomyolysis associated with CO poison- ing. After he regained consciousness, he experienced difficulty in moving his left arm, with sensory impairment in the same arm. He was diagnosed with compartment syndrome, and an emergency fasciotomy was performed. One month later, electromyography was performed which revealed left median, ulnar, radial and musculocutaneous nerve palsy. Discussion: Compartment syndrome induced by CO intoxication is rare but is a well-known complication. Compartment syndrome is a limb-threatening and life- threatening condition. If untreated, the pressure in the muscle may rise, which can lead to tissue necrosis. Generally, nerve paralysis does not occur in CO poisoning. In our case, it occurred as median, ulnar, radial and musculocutaneous nerve palsy. Conclusion: Side effects of CO poisoning can be extant, especially for those who are unconscious since they cannot express pain, numbness, and motor weakness. It is important to not overlook compartment syndrome, to double-check whether there is swelling, change in skin color, or skin firmness in extremities, and to observe the patient closely.

P 38 Vestibular Schwannoma associated with hypertrophic neuropathy – An unusual manifestation of NF2 or not?

We report a case of generalized hypertrophic neuropathy, which was first noted with pressure palsy after surgery of a vestibular nerve schwannoma. A 46-year-old caucasian female presented with incomplete left radial nerve palsy and incomplete left ulnar nerve palsy with loss of muscle mass between the thumb and forefinger and additional slight hypaesthesia oft he fingertips dig. 1–2. Two weeks ago she underwent surgery for a left vestibular nerve schwannoma (see picture 1). One year before neurosurgery carpal tunnel syndrome was diagnosed bilaterally. In the first interview no family history of nerve diseases was reported. Neurography of median, ulnar, tibial and peroneal nerves showed very slow nerve conduction velocities (NCV) less than 30 m/s and diminished compound motor action potentials (CMAP) with prolonged duration. Electromyography showed no signs of acute denervation. High resolution nerve sonography (HRUS) showed markedly enlarged fascicles resulting in up to 6-fold nerve cross sectional areas (see picture 2, ulnar nerve oft he right upper arm) without vascularisation. This was present in all examined nerves in different expression. Family history was complemented by the patient: Her father suffered on a “disease of muscles” (has died at the age of 45 years) and her sister, too. No signs of neurofibromatosis (1 or 2) were reported. Genetic testing on mutations typically in neurofibromatosis 1 and 2 and schwannomatosis (“NF 3”) was negative. Because of demyelinating neuropathy (suspicious Charcot-Marie-Tooth disease) duplication of PMP22 gene was examined, but it was negative. At last heterozygous MPZ-Mutation was detected. This accounts for CMT1B neuropathy. The diagnosis of CMT1B is in accordance to the neurographic and sonographic findings of peripheral nerves. The focal enlargement of some fascicles is observed in schwannomas or neurofibromas, but usually they shows vascularisation, which was not present in this case. To date an association of CMT with vestibular schwannoma is not reported in the literature. Kwon et al. (2009) described a family with CMT1A caused by duplication of the PMP22 gene. Two family members had schwannomas of the spinal cord and median nerve. The authors argue that the co-occurrence of CMT1A and schwannomas in this family would be the result of independent events, but one could not completely ignore the possibility that the coincidence of two diseases might be due to a shared genetic background. Despite the missing association of CMT with vestibular schwannoma in the literature hearing loss seems not to be rare in CMT. Sanmaneechai et al. (2015) referred to patients with CMT disease caused by MPZ gene mutations. 21 of 103 patients had hearing loss, but tests like MRI or BAER (brainstem auditory evoked response) are not given in the paper. Grider et al. (2015) found in 25 CMT patients that BAER waveforms were robust even in the absence of acoustic reflexes, except for two patients with CMT1B who had abnormal BAER recordings that were not consistent with hearing thresholds. These observations supports for the neural nature of the hearing loss in CMT1B and should improve further investigations with MRI in those patients.

Postterapijske komplikacije kod karcinoma dojke i uloga rehabilitacije u funkcionalnom oporavku - prikaz slučaja

Introduction. The most common functional complications after the treatment of breast cancer are reduction of range of motion in the shoulder joint (incidence of 10 to 73%), lymphedema of the arm (10-30%) and nerve damage of the arm or damage of brachial plexus (1.8-4.9%). Multiple complications rarely occur and they are usually of mild to moderate forms. Case report. VV (woman), born in 1965 was exposed to quadrantectomy of the left breast with axillary dissection in 2003 (histopathology: ductal carcinoma; 4 removed lymph nodes, 1 of which with a secondary deposit). After the surgical intervention, the patient underwent chemotherapy (CMF protocol VI cycles) and radiation therapy (50 Gy/12 cycles). Four months after the therapy completion, lymphedema of the left arm was developed, and few months later brachial plexus injury as well. First visit to physiatrist was five years later, with a significant reduction of range of motion in the left arm and severe lymphedema (maximum difference to 7.5 cm). EMNG trial indicated a moderate lesion of left median nerve and ulnar nerve and mild to moderate lesion of left radial nerve injury; DASH score was 107. After repeated physical treatments (since 2009), the last control in October 2016 showed that the functional status was significantly improved: reduction of range of motion was present in flexion and abduction only, lymphedema was reduced (maximum difference of 5.5 cm); DASH score was 48, while EMNG indicated a lesion of the median nerve and ulnar nerve in lower level, with signs of recovery. Conclusion. The implementation of an early rehabilitation program for the patients who were surgically treated for breast cancer is necessary in order to prevent functional complications and to enable continuous monitoring of the patients, while in the case with already developed complications, physical therapy should be initiated regardless of the period in which the functional limitations occurred.

Leprous ganglionitis and myelitis.

A 27-year-old Brazilian woman presented with a 7-month history of progressive pain, tingling, numbness, and weakness of the left upper limb, and paroxysmal dysesthesia affecting the left foot. On examination, there were erythematous, anesthetic patches of skin overlying the metacarpophalangeal joints and on the palmar surfaces of the hands (figure e-1 at [Neurology.org/nn][1]). There was congenital, bilateral campylodactyly and new flexion deformity of the fingers of the left hand with an incomplete range of passive extension. The intrinsic muscles of the left hand were wasted, particularly the thenar eminence and the dorsal interossei. Fasciculations were not observed. There was marked tenderness in the antecubital fossa and at the wrist, and the left superficial radial nerve was palpable. There was severe weakness of intrinsic finger movements, wrist flexion, and extension. Left upper limb reflexes were brisk and painful to percuss but tone, power, and reflexes including plantar responses were otherwise normal. Sensation to pinprick was reduced throughout the left hand with loss of temperature, vibration, and proprioceptive sensation distal to the wrist. Acknowledgment: The authors are grateful to the patient for her permission to publish the case report. They also acknowledge the support and expertise of Professor Diana Lockwood (London School of Hygiene and Tropical Health) whose advice regarding treatment and management has been greatly valued. C.M.R. is supported by the Burden Neurological Institute. [1]: /lookup/doi/10.1212/NXI.0000000000000236