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ELECTRO

ENCEPHALO
GRAPHY
:- To check the records of brain
waves, and to detect the level of
electrical activity in the brain is
called EEG
The "10-20 System" of Electrode Placement

The 10-20 System of Electrode Placement is a method used to


describe the location of scalp electrodes. These scalp
electrodes are used to record the electroencephalogram
(EEG) using a machine called an electroencephalograph. The
EEG is a record of brain activity. This record is the result of
the activity of thousands of neurons in the brain. The pattern
of activity changes with the level of a person's arousal - if a
person is relaxed, then the EEG has many slow waves; if a
person is excited, then the EEG has many fast waves. The
EEG is used to record brain activity for many purposes
including sleep research and to help in the diagnosis of brain
disorders, such as epilepsy.
One second of EEG signal
Historically four major
types of continuous
rhythmic sinusoidal
EEG waves are
recognized
(alpha, beta, delta and
theta).
•Alpha (Berger's wave):-
The frequency range from (8 Hz to 13 Hz). It is
characteristic of a relaxed, alert state of
consciousness . Alpha rhythms are best detected with
the eyes closed. Alpha attenuates with drowsiness
and open eyes, and is best seen over the occipital
(visual) cortex.
•Beta :-
The frequency range 13-30 Hz. Low amplitude beta
with multiple and varying frequencies is often
associated with active, busy or anxious thinking and
active concentration. Rhythmic beta with a dominant
set of frequencies is associated with various
pathologies and drug effects.
Delta:-

The frequency range up to 4 Hz and is often


associated with the very young and certain
encephalopathies and underlying lesions. It is seen
in stage 3 and 4 sleep.
•Theta:-
The frequency range from 4 Hz to 8 Hz and is associated
with drowsiness, childhood, adolescence and young
adulthood. This EEG frequency can sometimes be
produced by hyperventilation. Theta waves can be seen
during hypnagogic states such as trances, hypnosis, deep
day dreams, lucid dreaming and light sleep and the
preconscious state just upon waking, and just before
falling asleep.
asleep
Some examples of EEG waves.
THE BASIC PRINCIPLES OF EEG DIAGNOSIS
What abnormal results mean
 Seizure disorders (such as epilepsy or convulsions)
 Structural brain abnormality (such as a brain tumor or
brain abscess)
 Head injury, encephalitis (inflammation of the brain)
 Hemorrhage (abnormal bleeding caused by a ruptured
blood vessel)
 Cerebral infarct (tissue that is dead because of a blockage
of the blood supply)
 Sleep disorders (such as narcolepsy)

Note:-
EEG may confirm brain death in someone who is in a coma.
ATYPICAL BUT NORMAL WAVE FORMS
K Complexes occur in sleep when
arroused - thus K complexes are
seen with noises or other stimuli
especially in stage 2 sleep. The
K complex is often followed by an
arrousal response - namely a
run of theta waves of high
K Complexes amplitude. Following this the
EEG shows sleep again or the
awake state.
Lambda and POSTS are similar
morphologically, and have a
triangular shape.They occur
posteriorly and symmetrically.
POSTS stands for 'positive
occipital transients of sleep' and
occurs in stage 2 sleep.
Lambda occurs in the awake
Lambda and POSTS patient when the eyes stare at
blank surfaces. Both are normal
wave forms and can occur singly or
inlong or short runs.
V waves occur in the parasaggital
areas of the two sides and take the
form of sharp waves or even spikes
which show in the biparietal
regions(vertex) withphase reversal
at the midline in tranverse
montages or at the vertex in front-
V Waves to-back ones. They are seen
in stage 2 sleep along with spindles,
K complexes, POSTS, etc..
Mu activity is a rhythm in which the
waves have a shape
suggestive of a wicket fence with
sharp tips and rounded bases.
It may show phase reversal between
two channels. The frequency
is generally half of the fast activity
MU activity present.
Psychomotor variant is a rare
rhythm which appears to be an
harmonic of two or more basic
rhythms causing a complex
form. As can be seen it is higher
in amplitude than the surround
and the waves have a notched
appearance. It is quite
Psychomotor Variant assymetrical and is often
mistaken for paroxysmal
activity. It is benign. It is also
known as
Fourteen and six activity
is most often seen in
children and adolescents.
As seen it takes the form
of 6 Hz and 14 Hz waves
sometimes going in the
same direction(up or
down) and in others in
Fourteen and Six Rhythm opposite directions. It is
typically seen in sleep or
drowsiness and is usually
seen in monopolar
recordings.
ELECTRO
MIO
GRAPHY
Amplifier parameters Chann Sensitivity Scaling for fo fu 50 Hz notch Rctf. Ext. Auto-matic
e analysis Input offset
l
s
Spontanous 1 0,1 mV/div 0,1 mV/div 10 kHz 5 Hz x x

MAP-Analyse 1 0,1 – 0,2 mV/div 0,1 mV/div 10 kHz 5 Hz x x

Maximal-innervation 1 1 mV/div 1 mV/div 10 kHz 5 Hz x x

Aquisition- Monitor time Analysis time Trigger-mode Averager Sweeps (no. of passes) Artefact
parameters mode Detection
Spontan-aktivität 10 ms/div 10 ms/div Internal Standard --- ---

MAP-Analyse 10 ms/div 10 ms/div Internal Standard --- ---

Maximal- 100 ms/div 100 ms/div Internal Standard --- ---


innervation
An electromyogram (EMG) is a test that is used to record the
electrical activity of muscles. When muscles are active, they
produce an electrical current. This current is usually
proportional to the level of the muscle activity.
EMGs can be used to detect abnormal muscle
electrical activity that can occur in many diseases and
conditions, including muscular dystrophy, inflammation of
muscles, pinched nerves, peripheral nerve damage.
The EMG helps to distinguish between muscle
conditions in which the problem begins in the muscle and
muscle weakness due to nerve disorders. The EMG can also be
used to detect true weakness, as opposed to weakness from
reduced use because of pain or lack of motivation.
NEEDLE EMG CRANIAL MUSCLES

Frontalis Masseter Orbicularis Oculi

Trapezius

Sternocleidomast Tongue -
Orbicularis Oris oid Genioglossus
NEEDLE EMG | FOOT MUSCLES

Abductor Digiti Extensor


Quinti - Foot Abductor Hallucis Digitorum Brevis

First Dorsal
Interosseous -
Foot
NEEDLE EMG | FOREARM MUSCLES

Ancone
us
BRACHIORADIALIS EXTENSOR DIGITORUM
ANCONEUS
COMUNIS

EXTENSOR CARPI EXTENSOR INDICIS FLEXOR CARPI


RADIALIS (Lt.) RADIALIS (Rt.)
FLEXOR
FLEXOR CARPI
SUPINATOR DIGITORUM
ULNARIS
PROFUNDUS

FLEXOR POLLICIS PRONATOR TERES


LINGUS
NEEDLE EMG | HAND MUSCLES

ABDUCTOR DIGITI ABDUCTOR POLLICIS FIRST DORSAL


MINIMI (HAND) BRAVIS INTEROSSEOUS
NEEDLE EMG | LEG MUSCLES

EXTENSOR GASTROCNEMIUS EXTENSOR


ANTERIOR TIBIAL
DIGITORUM LONGUS (MEDIAL HEAD) HALLUCIS LONGUS

SOLEUS GASTROCNEMIUS PERONEAL LONGUS


NEEDLE EMG | PARASPINAL MUSCLES

Multifidus - Caudal Multifidus - Multifidus - Rostral


Insertion Perpendicular Insertion
Insertion
NEEDLE EMG | ARM AND SHOULDER MUSCLES

BICEPS BRACHLI INFRASPINATUS DELTOID DELTOID (MIDDLE)


(ANTERIOR)

LEVATOR SCAPULA Pectoralis Major - Pectoralis Major -


Clavicular Sternocostal
RHOMBOID (MAJOR) RHOMBOID (MINOR) SUPRASPINATUS

TRICEPS BRACHII TRICEPS BRACHII


SERRATUS ANTERIOR
(LONG HEAD) (Lateral head)
NEEDLE EMG | THIGH AND PELVIS MUSCLES

ABDUCTOR BICEPS GLUTEUS GULUTEUS LLIACUS


LONGUS FEMERIS MEXIMUS MEDIUS

Semimembranosus Semitendinosus VASTUS VASTUS


LATERALIS MEDIALIS
NERVE
CONDUCTION
VELOCITY
:- To check the
electrical activity of
nerves
Amplifier Channels Sensitivity Scaling for fo fu 50 Hz Rctf. Ext. Input
parameters analysis notch Input

Motoric 1 2 mV/div 2 mV/div 3 kHz 5 Hz x


NCV

Sensory 1 10 µV/div 5 µV/div 3 kHz 20 Hz x x


NCV

Mot. Sens. 2 2 mV/div 2 mV/div 3 kHz 20 Hz


NCV X
10 µV/div 5 µV/div 3 kHz 20 Hz
Myastheni 1 2 mV/div 2 mV/div 3 kHz 20 Hz
a
Aquisition- Monitor time Analysis time Trigger-mode Averager Sweeps Artefact
parameters (no. of
mode Detection
passes)
Motoric NCV 20 ms/div 2 ms/div internal standard 20 ----

Sensory NCV 10 ms/div 2 ms/div internal standard 20 ----

Mot. Sens. 20 ms/div 2 ms/div internal standard 20 1,0 ms


NCV
Myastenia 20 ms/div 2 ms/div internal standard ---- 2,0
ms
Stimulation- Stim. Stim. Mode Duration Stimulation Traces
parameters Ferquency current step

Motorische 1,0 Hz Single puls 200 µs automatic 3


NLG
Sensible NLG 3,0 Hz Single puls 200 µs automatic 2
Mot. Sens. 2,0 Hz Single puls 200 µs automatic 2
NLG
Myasthenia 3,0 Hz Single puls 200 µs automatic 10 automatic
trace advance
Reflex
Amplifier Channels Sensitivity Scaling for fo fu 50 Hz Rctf. Ext. Auto-
param analysis notch Inpu matic
eters t offset

Blink reflex 2 100 µV/div 100 µV/div 3 kHz 20 Hz x

H-Reflex 1 1 mV/div 1 mV/div 3 kHz 20 Hz x

F-Wave 1 200 µV/div 200 µV/div 10 kHz 5 Hz x

Aquisition- Monitor Analysis time Trigger- Averager Sweeps (no. of Artefact


parameters time mode mode passes) Detection
Blink reflex 20 ms/div 10 ms/div internal Standard --- ---

H-Reflex 20 ms/div 10 ms/div internal Standard --- ---

F-Wave 5 ms/div 5 ms/div internal Standard 10 ---


Stimulation- Stim. Stim. Mode Duration Stimulation Traces
parameters Ferquency current step
Blink reflex 0,5 Hz Single puls 200 µs 0,5 mA 2
H-Reflex 0,5 Hz Single puls 500 µs Automatic 10 automatic trace
advance
F-Wave 1,0 Hz Single puls 100 µs Automatic 10 automatic trace
advance
Nerve conduction studies have been
found to be medically necessary for the
following indications ?
 Carpal tunnel syndrome  Nerve root compression
 Diabetic neuropathy  Neuritis
 Disorders of peripheral  Neuromuscular conditions
nervous system  Pain in limb
 Disturbance of skin sensation  Plexopathy
 Fasciculation  Spinal cord injury
 Joint pain  Swelling and cramps
 Muscle weakness  Trauma to nerves.
 Myopathy  Myositis
Major nerves of ULs
(Upper Limbs) are:-
MEDIAN MOTOR / APB
Distance = 5cm

Stim Points:
Elbow / Wrist
MEDIAN SENSORY / Index Stim Points:
Distance = 8cm Elbow / Wrist
ULNAR MOTOR / ADM
Distance = 5cm

Stim Points:
Above Elbow / Below Elbow / Wrist
ULNAR Stim Points:
SENSORY / Vth Elbow / Wrist
Distance = 8cm
RADIAL SENSORY / Dors Hnd Stim Points:
Distance = 10cm Forearm
Major nerves of LLs
(Lower Limbs) are:-
PERONEAL MOTOR / EDB
Distance = 7cm

Stim Points:
Above/Below-Fibular Head/Ankle
PERONEAL SENSORY Stim Points:
Distance = 14cm Dist / Prox
POSTERIOR TIBIAL MOTOR
Distance = 14cm

Stim Points: Pop Fossa / Ankle


SURAL SENSORY / Beh Mall Leg
Distance = 14cm
H-Reflex (Soleus)
H-Reflex Potentials
NERVE ENTRAPMENT GUIDE
PERONEAL NEUROPATHY
WHAT IS INVOLVED
Peroneal Nerve

LOCATION
 Most frequently at the Head of the Fibula

 Could be just above or below it involving the Common


Peroneal Nerve or the Deep or Superficial
branches selectively
COMMON SYMPTOMS
 Foot drop

 Patient unable to pull foot or toes up

 Usually unilateral, could be bilateral

 No associated pain

 Main complaint is tripping, falling

 Occasional leg/top of foot numbness

 Symptoms always present, no night/day preference


RADIAL NEUROPATHY
(WRIST DROP)

WHAT IS INVOLVED
Radial Nerve

LOCATION
 Most frequently at the Spiral Groove of the humerus
 Could be at the Axilla (Saturday Night palsy)

 Or in the Forearm (Posterior Interosseous Syndrome)


COMMON SYMPTOMS

 Wrist drop, Patient unable to extend wrist or fingers up

 Almost always unilateral

 No associated pain

 Occasional forearm/hand/thumb numbness

 Symptoms always present no night/day preference


NERVE SHOULDER / ARM /
HAND PROBLEMS
/TARSAL TUNNEL SYNDROME
WHAT IS INVOLVED

Posterior Tibial Nerve

LOCATION
Posterior Tibial nerve entrapment at the Tarsal
Tunnel in the foot at the level of the medial malleolous
COMMON SYMPTOMS
 Foot, Ankle, Sole pain/burning and aching

 Worse at night

 Occasional numbness/tingling sole of foot

 No muscle weakness

 Usually unilateral

 Difficulty walking because of pain and discomfort


with shoes

 Positive Tinel (tingling upon tapping nerve) sign


behind the medial malleolous
SHOULDER / ARM /HAND PROBLEMS
/ULNAR NEUROPATHY

WHAT IS INVOLVED

Ulnar Nerve

LOCATION

Most frequently at the Elbow from leaning on it or trauma


COMMON SYMPTOMS

 Weak hand, dropping objects, difficulty turning keys,


ignition, doorknobs

 Numbness/tingling fourth, fifth fingers

 Wasting of the interosseii muscles

 Occasional elbow soreness

 Symptoms not related to night/daytime

 Frequently on both sides


SHOULDER / ARM / HAND PROBLEMS
/CARPALTUNNEL SYNDROME

WHAT IS INVOLVED

Median Nerve at the wrist

LOCATION

The Carpal Tunnel, at the wrist


COMMON SYMPTOMS
 Worse in the dominant hand

 Dropping objects

 Numbness tingling, hand/wrist ----> Thumb, Index


and/or Middle finger

 May radiate up the arm, occasionally to the shoulder

 Symptoms primarily at night. Patient wakes up and


shake their hands to obtain relief

 Frequently bilateral, although may only be symptomatic


on one side
• VEP

• BAEP
• SSEP
VISUAL
EVOKED
POTANTIAL
:- To check the
electrical activity of
optic (eyes) nerve.
Amplifier Channels Sensitivity Scaling for fo fu 50 Hz notch Rctf. Ext. Auto-
parameters analysis Input matic
offset
1 20 µV/div 2 µV/div 100 Hz 0,5 Hz x x

Aquisition- Monitor Analysis Trigger- Averager Sweeps (no. of Artefact Artefact


parameters time time mode mode passes) treshold Detection

20 50 ms/div Internal Standard 50 95 ---


ms/div

Stimulation- Stim. Ferquency Stim. Type Stim. Field Size Patter Stim. Contrast Trace
parameters n Mode s

1 Hz Pattern Full Standard Check Invert light 3


BRAIN
AUDITORY
EVOKED
POTENTIAL
:- To check the
electrical activity of
hearing nerves.
Amplifier Channels Sensitivity Scaling for fo fu 50 Hz Rctf. Ext. Auto-matic
parameters analysis notch Input offset

1 10 µV/div 200 nV/div 3 kHz 100 Hz x

Aquisition- Monitor Analysis time Trigger- Averager Sweeps (no. Artefact Artefact
parameters time mode mode of passes) treshold Detection

20 ms/div 1 ms/div Internal Standard 2000 15 500 µs

Stimulation- Stim. Stim. Stim. Field Polarity Volume stimulus Volume noise Contrast
parameters Ferquency Type

15 Hz Click 200 µs alternated 70 dB relativ 40 dB, relativ 4


SOMATO
SENSORY
EVOKED
POTENTIAL
Somatosensory Evoked Potential (SSEP) is a test showing the
electrical signals of sensation going from the body to the brain.
The signals show whether the nerves that connect to the spinal
cord are able to send and receive sensory information like pain,
temperature, and touch. When ordering electrical tests to
diagnose spine problems, SSEP is combined with an
electromyogram (EMG), a test of how well the nerve roots leaving
the spine are working.
An SSEP indicates whether the spinal cord or
nerves are being pinched. It is helpful in determining how much
the nerve is being damaged. SSEP is used to double check
whether the sensory part of the nerve is working correctly.
Amplifier Channels Sensitivity Scaling for fo fu 50 Hz notch Rctf. Ext. Auto-
parameters analysis Input matic
offset
SEP N. tibialis 2 10 µV/div 2 µV/div 1 kHz 2 Hz x x
SEP N. medianus 1 10 µV/div 2 µV/div 1 kHz 2 Hz

Aquisition- Monitor Analysis time Trigger- Averager Sweeps (no. Artefact Aquisitionparame
parameters time mode mode of passes) Detection ters
SEP N. tibialis 20 ms/div 10 ms/div Internal Standard 400 --- ---
SEP N. medianus 20 ms/div 10 ms/div Internal Standard 200

Stimulation- Stim. Stim. Mode Duration Stimulation Traces


parameters Ferquency current step
SEP N. tibialis 3 Hz Single puls 200 µs Automatic 4
SEP N. medianus 3 Hz Single puls 200 µs Automatic 2
REPETITIVE
NERVE
STIMULATION
RNS TEST IS USED FOR
MYASTHENIA GRAVIS:
DIAGNOSTIC TESTS

Decremental response to RNS in Myasthenia Gravis


MYASTHENIA GRAVIS

Cogan
Tensilon test: Before (left); After (right)
Repetitive Nerve Stimulation
NERVE CONDUCTION QUICK
SET-UPS | BLINK / FACIAL

H-Reflex (Soleus) H-Reflex Potentials


Transcranial Doppler (TCD) ultrasound is a non-invasive
method to estimate the blood flow velocities in the large
intracranial vessels of the circle of Willis. Using established
TCD techniques, sections of the internal carotid artery
(ICA), middle cerebral artery (MCA), anterior carotid
artery (ACA), posterior cerebellar artery (PCA) and the
basilar and periorbital arteries can be examined. TCD
typically uses a 2 MHz pulse ultrasound which produces a
velocity spectrum throughout the cardiac cycle.
• MCA:- Middle Cerebral Artery
• ACA:- Anterior Cerebral Artery
• PCA:- Posterior Cerebral Artery
• Vertebral Artery
• Basilar Artery
• Vertebral Artery
• Basilar Artery