Beruflich Dokumente
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NEUROLOGIC INVESTIGATION
PLAIN RADIOGRAPHY
Skull Radiography
Skull radiography is not used in the routine investigation of the
common neurologic disorders. Plain radiographs have a role in the
investigation of nonaccidental injury or penetrating injury and in the
assessment of ventriculoperitoneal-shunt tubing connections.
Spinal Radiography
Spinal radiography is still performed widely as part of the primary
survey for patients with acute spinal trauma, and less often for those
suspected of having cervical or lumbar nerve root compression,
although it is incapable of providing evidence, at least directly, of any
cord or root entrapment. Lateral and anteroposterior views of the
lumbar spine allow identification of the components of the neural
10 11 12 13 14
arch, together with the shape and size of the intervertebral foramina (Fig. 1-4). Although many views of the cervical spine have been
described, anteroposterior, lateral, and oblique views suffice other
than for traumatic cases (Figs. 1-5 and 1-6). Views of the cervical
or lumbar spine in flexion and extension (Fig. 1-7) are performed
if there is a suggestion of instability of the spinefor example, after
injury. However, most spinal imaging is now performed with computed tomography (CT) or magnetic resonance imaging (MRI).
Pineal tumors
Carcinoma
Lyme disease or other antigen assays
HIV-1 infection
Toxoplasmosis
Cysticercosis
Herpes simplex
JC virus
Cryptococcus
Syphilis
Herpes zoster
Epstein-Barr virus
Arbovirus, enterovirus
CLA, Cationic leukocyte antigen; ELISA, enzyme-linked immunosorbent assay; HCG, human
chorionic gonadotropin.
CT Myelography
CT myelography is now seldom performed, but it may be necessary if
MRI is contraindicatedfor example, in a patient with a pacemaker.
The contrast can be inserted into either the lumbar or the cervical
region (Fig. 1-11). Although the latter is a more hazardous procedure, it may be necessary if there is a spinal block between the lumbar
and cervical regions (Fig. 1-12).
CT Angiography
Computed tomographyangiography (CTA) can be performed on
all multislice scanners with spiral capability and can be performed
immediately after standard CT imaging. Intravenous nonionic contrast medium is injected using a pump injector. The technique is particularly applicable for the assessment of carotid and vertebral artery
stenosis (particularly the origins of the vertebral arteries) (Fig. 1-13),
and for assessment of intracranial aneurysm morphology (Fig. 1-14).
CT Perfusion
The injection of a bolus of contrast with continuous scanning enables
the alteration of contrast with time to be plotted. Various parameters can be measured (time to peak, mean transit time, change in
contrast), which enables other parameters to be calculated (cerebral
blood flow, cerebral blood volume) using certain assumptions. These
parameters can be overlaid on a structural slice of brain for ease of
interpretation and have been validated with gold standard cerebral
blood flow measurements (using positron emission tomography
[PET]) (Fig. 1-15).
B
Fig. 1-4. Normal lumbar spine radiographs. A, Lateral. B, Anteroposterior.
B
Fig. 1-5. Normal cervical spine radiographs. A, Lateral. B, Anteroposterior.
B
Fig. 1-6. Normal cervical spine radiographs. A, Left posterior oblique. B, Right posterior oblique.
B
Fig. 1-7. Flexion (A) and extension (B) views of the cervical spine.
Internal
Common
External
Cortical sulcus
Frontal horn
Pineal
gland
Suprasellar
cistern
Sylvian
Fourth
Quadrigeminal
fissure
ventricle
cistern
Fig. 1-10. Normal noncontrasted CT scan at four levels: at the vertex (A), at the level of the frontal horns (B), at the level of the third ventricle (C), and at the level of
the pons (D).
Fig. 1-11. CT myelogram of the cord. A, Axial source data showing normal cervical cord and dorsal roots. B, Conus and filum.
Fig. 1-12. Reformatted thoracolumbar CT myelogram (A) and MRI (B) showing intramedullary signal change and anterior cord displacement with MRI, but with no
posterior mass seen with MRI and myelography.
for the individual charged particles to fall out of the coherent resonance induced by the radio frequency signal. T1-weighted images
produce pictures in which CSF is dark; in T2-weighted images, the
CSF appears lighter, and the contrast between gray and white matter is particularly prominent. Fluid-attenuated inversion recovery
(FLAIR) images are similar to T2 images but with suppressed CSF.
These are the three common sequences used in neurologic imaging (Fig. 1-16). One of the advantages of MR over CT (in addition
to the improved soft tissue contrast resolution) is that images can
be acquired in the sagittal, axial, or coronal (or indeed any) plane.
At higher field strengths, spatial resolution is improved for a given
acquisition time (Fig. 1-17). Three-dimensional (3D) data sets can
be reconstructed in a 3D format. A midline sagittal image displays
midline structures, including the third and fourth ventricles (Fig.
1-18). Axial images display horizontal brain slices at any level from
the vertex to the foramen magnum and can be targeted to show particular features of interest (Fig. 1-19).
Fig. 1-13. A, B: CT angiography showing origins of vertebral arteries, with calcified plaque and stenosis at the origin of the left vertebral artery.
P
Fig. 1-14. Axial (A), coronal (B), and sagittal (C) maximum-intensity projection reconstructions of an intracranial CT angiography showing anterior communicating artery
aneurysm morphology, with 3D superior oblique volume reconstructions (D and E).
Fig. 1-15. Patient with acute right hemiparesis and dysphasia. A, Normal CT (at ictus +2 hrs). B and C, CT angiography showing left middle cerebral artery occlusion.
Cerebral blood volume (CBV) (D) and time-to-peak (TTP) (E) maps show irreversible ischemia in deep white matter and gray matter, and critical ischemia in cortex.
(TTP and cerebral blood flow maps show ischemic and infarcted tissue; CBV shows infarcted tissue.) F, Follow-up CT at 48 hours shows preserved cortex with infarct
corresponding to CBV map.
Fig. 1-16. Coronal T1 (A), axial T2 (B), and axial fluid-attenuated inversion recovery (FLAIR) (C) images through normal brain.
Fig. 1-17. Coronal 3-mm T2-weighted slices through the hippocampi at 1.5T (A) and 3T (B). Note the improved resolution at 3T, with improved detail of hippocampal
substructures.
Fig. 1-18. Midline sagittal T1-weighted (A) and T2-weighted (B) images demonstrating different appearances of the same structures on different sequences.
Conventional MRI techniques (e.g., spin echo) require a considerable time (up to 15 minutes). Accordingly, faster imaging techniques
have been developedfor example, fast spin echo and gradient echo
imaging. Although many thousands of sequences are now available, the standard sequences suffice in most clinical settings. The
IV contrast media used for MRI scanning are all gadolinium based.
Shortening the T1 relaxation times of lesions enhances the imaging
discrepancy between the lesion and its surrounding tissue.
MRI is also used to visualize the spinal cord and its surrounding
structures. A midline sagittal image is supplemented by axial images
at the relevant levels. Structures demonstrated on the sagittal images
of the cervicothoracic region include the spinal cord, the vertebral
bodies, and the intervertebral discs (Fig. 1-20). Axial views, according to the level, demonstrate the vertebral body, the facet joints,
the spinal cord and nerve roots, and the epidural space (Fig. 1-21).
Images of the lumbar spine demonstrate the vertebral body and neural arches, the discs, and the contents of the spinal canal (Fig. 1-22).
MR Angiography or Venography
Signal from vessels can be obtained using many types of sequences
with MR. Most commonly, 3D time of flight (3D TOF) (Fig.
1-23) or 2D TOF is used (neither needs IV contrast), but contrastenhanced MR angiography (MRA) and black blood MRA are also
available if needed. MR venography (MRV) is often produced using
Fig. 1-19. A, Axial MR images showing third nerves in interpeduncular cistern. B, Left fourth nerve crossing prepontine cistern. C, Left fifth nerve exiting pons, and right
entering Meckels cave. D, Both sixth nerves entering Dorellos canal in the clivus. E, Seventh and eighth nerves in the internal auditory meat; F, Twelfth nerve and fifth
nerve leaving lateral medulla and traversing hypoglossal canals.
B
Fig. 1-20. A, B:T2-weighted sagittal MRI of cervical and upper thoracic spine.
white matter. This may have clinical uses in white matter diseases,
including multiple sclerosis, diffuse axonal injury, and dementia or
mild cognitive impairment.
MRI Tractography
In vitro, water diffuses freely in any planethat is, it is a vector, having both direction and distance. Using diffusion-weighted sequences
in multiple directions, it is possible to measure both the extent of
diffusion and its direction, which, in vivo, is not free in any plane but
is altered by the presence of myelinated white matter tracts, which
severely restricts diffusion in directions tangential to the direction of
the myelinated fibers. In MRI tractography, these vectors are overlaid
on a structural image and displayed as color maps with brightness
equivalent to increased magnitude (i.e., greater distance of diffusion),
and color can be used to encode direction (Fig. 1-25). White matter
tracts can be displayed using mathematical formulas that use various
assumptions to link neighboring voxels (Fig. 1-26).
MR Perfusion
The principles of MR perfusion are similar to those of CT perfusion coupled with an IV bolus injection of contrast agent to calculate time-to-peak (TTP), relative cerebral blood volume (rCBV),
and relative cerebral blood flow (rCBF) maps (relative because in
MR techniques the measured values are relative, as opposed to the
absolute values obtained with CT perfusion). This is useful in the
assessment of acute stroke and in imaging gliomas. Glioblastoma
multiforme typically demonstrates higher CBV than low-grade gliomas (Fig. 1-27). It is possible that a progressive elevation of CBV in
tumors is one of the earliest markers of transformation of a low-grade
glioma to a high-grade glioma. It is possible to obtain MR perfusion
data without IV contrast using arterial spin labeling techniques, but
this is not widely used.
Functional MR
Blood oxygen leveldependent (BOLD) functional MRI (fMRI)
is the most commonly used method. It measures changes in blood
flow by detecting changes in intravascular oxyhemoglobin concentration. This occurs because in activated cortex there is an increase
in blood flow, mediated by vasodilation, that exceeds the local metabolic requirement, and this results in an increase in the intravascular
oxyhemoglobin concentration (Figs. 1-28 and 1-29). This increase
can be measured, usually using gradient echo sequences. The BOLD
effect is greater at 3T than at 1.5T, so the former (if available) is
preferred.
MR Spectroscopy
The speed of precession (or spinning) of hydrogen atoms is governed by the strength of the external magnetic field. However,
when H is incorporated into chemicals, other atoms vary slightly
in local field strength. This slight variation in local magnetic field
strength (measured in parts per million) can tell us what chemical
the hydrogen atom is part of, and modern scanners allow us to
B
Fig. 1-23. A and B, Reconstructed data from 3D time of flight of circle of Willis.
Fig. 1-24. Axial postcontrast T1-weighted (A, D), diffusion-weighted (B, E), and apparent diffusion coefficient (C, F) images of abscesses (A, B, C) and metastases
(D, E, F), showing similar ring enhancement on postcontrast T1 but with characteristically restricted diffusion in bacterial abscesses.
Fig. 1-25. Diffusion tensor imaging showing color (superoinferior, blue; anteroposterior, green; right-left, red-orange) encoding of tracts (A), with texture (B), and with
anatomic overlay (C).
Interventional Techniques 13
Fig. 1-26. Fiber tracking of motor fibers from cortex into cerebral peduncle. A, AP view. B, Oblique view.
Fig. 1-27. Biopsy-proven glioblastoma multiforme. Axial T2-weighted (A), postcontrast T1-weighted (B), and perfusion-weighted cerebral blood volume (CBV)
(C) MR images showing bland, nonenhancing mass with markedly raised CBV.
INTERVENTIONAL TECHNIQUES
Using the arterial (or sometimes venous) tree as an access pathway,
it is now possible to position a microcatheter almost anywhere in
the central nervous system (CNS). Endovascular techniques are now
the first-line treatment for intracranial aneurysms and for most dural
fistula. Arteriovenous malformations are now often treated endovascularly to obliteration or to reduce their size prior to surgery or stereotactic radiosurgery (gamma knife treatment).
It is possible to place stents in the middle and anterior cerebral
arteries, as well as in the internal carotid artery and the carotid bifurcation, although randomized trial data for benefit are lacking, and
these techniques are often used only in medically refractory cases.
Intraarterial clot lysis and aspiration catheters are available and
may be of benefit in the anterior intracranial circulation, but benefit
has not yet been shown in large randomized trials. In the posterior
circulation (particularly with basilar artery occlusion), the outcome
is so poor that intervention is often tried. Major dural venous sinus
occlusion can also be treated this way if there is no improvement with
IV heparin.
Fig. 1-28. Functional MRI after visual stimulation showing increased activity in visual cortex.
Radioisotope Imaging 15
C
Fig. 1-31. MR spectroscopy spectrum in (A) and out of tumor (B), showing increased choline in low-grade tumor. C, Metabolite map of choline.
RADIOISOTOPE IMAGING
Single-Photon Emission CT
Single-photon emission computed tomography (SPECT) can be
carried out with either multidetector or rotating gamma camera
systems. Using a radioactively labeled isotope, usually technetium99m labeled hexamethylpropylene amine oxide, the system allows
quantitative assessment of regional cerebral blood flow. In normal
individuals, symmetrical activity is greatest in a strip corresponding
to cortical gray matter at the periphery of the frontal, temporal, parietal, and occipital lobes. In addition, high flow is found in the region
of the thalami and basal ganglia (Fig. 1-37).
Positron Emission Tomography
Positively charged electrons (positrons) are emitted during the decay
of certain unstable nuclei. When a positron collides with an electron,
the two particles destroy each other and in doing so release energy in
ELECTROPHYSIOLOGY
Electroencephalography
For an electroencephalography (EEG) recording, 16 to 20 scalp electrodes record, amplify, and convert the basic brain rhythms into a
trace drawn on paper moving at 3 cm/sec. Bipolar recording measures
the potential difference between two electrodes. Unipolar recording
measures the difference between a single electrode and, most commonly, an average reference electrode summating potentials from the
other recorders.
The electrodes are attached to the scalp with an adhesive material as the patient sits or lies on a couch (Fig. 1-40). The recording is performed with the patients eyes closed and also with eyes
open. In addition to the resting trace, recording is carried out during
LT Carotid
LAO
RT Carotid
lateral
Visual Evoked Potentials. Stimulation of the retina by an alternating pattern of light and dark squares produces a well-defined positive potential over the occipital cortex. Typically, 100 to 200 visual
presentations are required to obtain a satisfactory averaged response.
A pattern-reversal stimulus (Fig. 1-44) is the most effective, the
response being recorded by a string of electrodes above and below
the inion together with a horizontal row along a line 5 cm above the
inion. Monopolar recordings are made with the reference electrode
placed anteriorly. Full-field stimulation produces a triphasic potential
RT Carotid
lateral
RT Carotid
lateral
Fig. 1-33. Digital subtraction angiography. Normal lateral internal carotid artery arteriogram. Arterial (A), late arterial/capillary (B), and venous (C) phases.
Electrophysiology 17
with a large positive component, preceded and followed by smaller
negative potentials (Fig. 1-45). Topographic mapping confirms the
occipital localization of the evoked response (Fig. 1-46).
Abnormal responses, particularly with respect to latency, have
been identified, most commonly in patients with multiple sclerosis
(MS). Many other neurologic disorders (e.g., Friedreichs ataxia and
Parkinsons disease) can affect latency, although to a lesser degree
than in MS.
Alteration of both waveform and latency can occur with compression of the visual pathway at any site.
by applying a click stimulus via earphones. The clicks, applied unilaterally, are repeated at a frequency of 10 Hz. A masking noise is used
contralaterally. Click intensity is set at about 70 dB above the hearing
threshold. The response to 1000 to 2000 clicks is summated using
electrodes over the earlobe and vertex (Fig. 1-47). The brainstem components are separated into waves I to VII (Fig. 1-48). Measurements
Vertebral
townes
RT
Vertebral
Lateral
B
Fig. 1-35. Digital subtraction angiography. Normal frontal (A) and lateral (B) vertebral arteriograms.
Fig. 1-36. A and B, Digital subtraction angiography, two views. Radicular injection demonstrating filling of anterior spinal artery from artery of Adamkiewicz.
be obtained from the soleus muscle after stimulation of the tibial nerve.
Stimulation of afferent fibers in the tibial nerve triggers a reflex response
in the motor nerves to the soleus via the spinal cord (Fig. 1-57).
The F Wave. The F wave requires a more potent stimulus than the
sensory action potential is satisfactorily recorded by a surface electrode (Fig. 1-54). Conventionally, about 30 repetitive stimulations
are used, with the responses being averaged.
Conduction velocity in the fast conducting fibers in the nerve can
be expressed as a distal latency or as an actual velocity. Conduction
velocity declines with age and slows with a fall in limb temperature.
Cooling increases compound muscle action potential amplitude.
cies is used in the evaluation of the neuromuscular junction. In normal individuals, a small decrement can occur in the size of the muscle
evoked potential when the nerve is stimulated at 10 Hz or less. At
faster rates of stimulation (10 to 50 per second), a small increment is
sometimes seen initially, and the compound action potential subsequently remains stable.
Electrophysiology 19
OEF
CMRO2
PH
K1
CBV
SNOW 3
Fig. 1-38. Cerebral blood flow (CBF), cerebral oxygen metabolism (CMRO2), oxygen extraction fraction (OEF), cerebral blood volume (CBV), and pH in patient 7 hours
after an acute stroke. The OEF image displays a central zone of reduced oxygen extraction, with enhanced extraction at its periphery.
CM 8.2
CM 6.8
CM 5.4
CM 4.0
CM 2.6
CM 1.2
Fig. 1-39. PET images of a normal subject injected with 18F-labeled N-methylspiperone, demonstrating intense uptake of tracer in the basal ganglia.
B
Fig. 1-40. Electroencephalographic electrode placements. Lateral (A) and anterior (B) views.
7
8
3
4
15
14
9
13
12
11
10
11
12
13
14
15
16
10
1 second
1 second
Fig. 1-41. Normal 16-channel EEG. The electrode placements are shown on the left (position 6).
5.3
v
FpZ
FZ
CZ
2.6
PZ
01
1.3
0Z
02
0
Fig. 1-42. Topographic electroencephalography demonstrating the distribution of
alpha rhythm in a normal subject. A frequency analysis for alpha rhythm is shown
on the left. It reaches its maximal amplitude (red) over the occipital electrodes (O2
and Oz).
ELECTROMYOGRAPHY
Most sampling of muscle for analysis of motor unit activity is done
with a concentric needle electrode (Fig. 1-59). In the relaxed state,
no spontaneous activity can be recorded from healthy muscle except
in the region of the motor endplate. As the needle is inserted, a brief
burst of electrical activity occurs (insertional activity), and it becomes
prolonged in a variety of neuropathic and myopathic disorders.
Abnormal spontaneous activity includes fibrillation potentials,
positive sharp waves, and fasciculation potentials. Fibrillation potentials are biphasic or triphasic and arise from single, or a small number
of, muscle fibers. They are particularly associated with denervation of
muscle (Fig. 1-60, A). Positive sharp waves have a similar connotation (see Fig. 1-60, B).
Fasciculation potentials are larger and readily visible to the naked
eye. They are believed to represent the spontaneous contraction of
fibers belonging to a single motor unit. They can be found in normal
muscle but are particularly associated with motor neuron disease (see
Fig. 1-60, C).
Electromyography 21
MAGNETOENCEPHALOGRAM
A
C
Fig. 1-44. The visual stimulus used for visual evoked responses.
Fig. 1-43. Magnetoencephalogram (MEG). A, Schematic of a squid (superconductive quantum interference device) magnetometer, which is connected to a detection coil and immersed in liquid helium. The magnetometer is positioned close
to the patients head. The output is in voltage proportional to the magnetic field
detected. B, Magnetic spikes were measured at more than 20 sensor positions
located 2 cm apart. In this patient, one similar, unaveraged magnetic spike, out of
a total of four spike types, was displayed over the right temporal region. C, Dots
represent the locations where the magnetic measurements were made. From the
distribution of the amplitude of the same magnetic spike, sampling the signal at the
spike peak, an isofield contour map was made and the equivalent current source
was calculated for this particular field pattern. D, Each of four dots in the temporal
tip represents a different spike type. Electrocorticography (ECoG) showed epileptiform activity in the shaded area of the right temporal lobe, which was surgically
removed. In this case, the MEG results matched well with the ECoG findings.
Ch1
2V
Ch1
2V
Ch2
2V
Ch2
2V
Ch3
2V
Ch3
2V
Ch4
2V
Ch4
2V
Ch5
2V
Ch5
2V
msec
msec
Fig. 1-45. Normal visual evoked potential. Averaging techniques allow the evoked potential to be distinguished from any random background activity.
BIOPSY
Muscle Biopsy
Muscle biopsy can be performed by needle or as an open procedure. The former is less invasive and allows multiple samples to be
obtained; the latter allows better assessment of tissue architecture and
is more sensitive for the detection of focal processes such as inflammation. In normal muscle, the fibers lie in close relationship to one
another, with one or more peripheral nuclei. Some variability of fiber
size occurs in normal subjects (Fig. 1-62).
Staining techniques allow separation of muscle into different fiber
types. Myofibrillar adenosine triphosphatase (ATPase) at pH 9.4
produces a dark-staining reaction in type II (fast-reacting) fibers and
a light reaction in type I fibers (Fig. 1-63). With nicotinamide dinucleotide tetrazolium reductase (NADH-tr), the reverse staining reaction is found, with some differential staining among type II fibers.
The distribution of fiber type varies from muscle to muscle. An
increased proportion of one fiber type, or a selective atrophy, is a
recognized consequence of certain muscle disorders.
Nerve Biopsy
Nerve biopsy is sometimes of value when attempting to clarify the
diagnosis or classification of certain peripheral nerve disorders. The
sural nerve is usually chosen, largely because it is very commonly
affected by the peripheral neuropathies, and also because its sacrifice
is of little consequence to most patients. It is of sufficient size to allow
a number of fascicles, each around 3 to 4 cm in length, to be dissected
free from the main trunk (Fig. 1-64). Part of the material is used for
the preparation of teased fibers and part for the preparation of transverse and longitudinal sections.
The teased fiber preparation demonstrates the nodes of Ranvier
and the Schwann cells (Fig. 1-65). The internodal length and its
variability can be calculated, along with the thickness of the myelin
sheath. In transverse section, the nerve fibers appear as circles, the
size of which is determined by the thickness of the myelin sheath.
Groups of fibers are bound together by an encircling connective tissue (the perineurium) (Fig. 1-66), forming a fasciculus. In turn, the
fasciculi are bound together in a further layer of connective tissue,
the epineurium. Blood vessels run within the epineurium and then
divide to supply capillary branches to the individual fibers and their
surrounding endoneurium (Fig. 1-67).
10.6
v
FpZ
FZ
CZ
PZ
.67
0.00
.45
5.3
.79 .22
.24
.11 .00
.68 .27
.38
.87 .68
0
01
1.00 2.03
3.03
3.39 3.26
0Z
5.60
6.98
6.94
A
5.3
02
10.6
Fig. 1-46. Topographic mapping of visual evoked potential. The P2 potential is
shown pointing upward on the left side of the figure and has a maximal amplitude
(red on the right-hand side) at the O2 and Oz channels.
B
Fig. 1-47. Electrode placement (A) and headphones in position (B) for measurement of auditory evoked responses.
Biopsy 23
0
9 msec
2
Ch1 + 2
0.5 V
Fig. 1-48. Normal brainstem evoked potentials using a 70-dB stimulus. Waves VI
and VII are often ill defined and have not been demonstrated here.
B
Fig. 1-49. Electrode placement for somatosensory evoked potentials. Lateral
(A) and posterior (B) views.
N20
5 V
2.5 V
N13/14
N11
N9
7 ms
Fig. 1-50. Early somatosensory evoked potentials N9 and N11.
7 ms
Fig. 1-51. Somatosensory evoked potentials N13, N14, and N20.
THENAR contracted
4 mV
19.6 ms
BICEPS BRACHII
Stim.
View from above:
Coil at vertex
5 ms
EMG recorded
on right
Fig. 1-53. Electrodes attached to the little finger with the recording electrode
over the ulnar nerve at the wrist.
Wrist
Sural
5 mV
Elbow
10 V
Median
Ulnar
1 ms
Fig. 1-54. Normal sural, median, and ulnar sensory action potentials.
Erbs point
5 ms
Fig. 1-55. Ulnar motor conduction studies. Stimulating the nerve at the wrist, at
the elbow, and at Erbs point.
Biopsy 25
Conduction velocity
R common peroneal
nerve 47 m/sec
2 mV
Conduction velocity
R post. Tibial nerve
46 m/sec
Stimulus M
artifact wave
5 ms
Fig. 1-56. Measurement of motor conduction velocity in the right common peroneal and right posterior tibial nerves.
H
wave
5 mV
Fig. 1-57. As the stimulus strength increases (from higher to lower), the H reflex
diminishes and the M response appears.
5 mV
5 ms
Fig. 1-58. F wave. A succession of responses recorded from abductor pollicis
brevis after stimulation of the median nerve at the wrist.
100 V
100 mS
200 V
100 mS
JITTER
200 V
100 mS
200 V
0.5 mS
Fig. 1-60. Electromyographic findings. A, Fibrillation potentials. B, Positive sharp
waves. C, Fasciculation potentials. D, Normal interference pattern.
200s
1ms
Fig. 1-61. In normal subjects, the slight variability of delay in conduction at the
neuromuscular junctions of two fibers belonging to the same motor unit can be
recorded.
Fig. 1-62. Normal muscle cells are approximately hexagonal in shape. The bluestaining nuclei are visible beneath the cell membrane (H&E 600).
Fig. 1-63. Normal muscle.Type 1 (slow-reactive) fibers are lightly stained and type
II (fast-reactive) fibers are darkly stained (ATPase [at pH 9.4]; 600).
Biopsy 27
Endoneurium
Blood vessel
A
Connective tisue
Perineurium
Axon
Myelin sheath
Fig. 1-66. Transverse section of normal peripheral nerve. A, H&E 40. B, Methylene blue, azure 2, basic fuchsin; 100.
Longitudinally
arrayed fibers
Blood vessel
Fig. 1-67. Longitudinal section of normal peripheral nerve (Luxol fast blue/Nissl;
40).