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Kouyoumdjian JA, Paiva GP, Stålberg E. Concentric Needle Jitter in 97 Myasthenia Gravis Patients. Front Neurol 2020; 11:600680. [PMID: 33281737 PMCID: PMC7691317 DOI: 10.3389/fneur.2020.600680] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 10/13/2020] [Indexed: 11/24/2022] Open
Abstract
Objectives: To estimate the jitter parameters (single-fiber electromyography) in myasthenia gravis patients mostly by electrical activation in Frontalis, Orbicularis Oculi, and Extensor Digitorum muscles using a concentric needle electrode. Methods: Between 2009 and 2019, a total of 97 myasthenia gravis patients, 52 male, and mean age 54 years were included. Results: Any abnormal jitter parameter in individual muscles was 90.5% (Frontalis), 88.5% (Orbicularis Oculi), and 86.6% (Extensor Digitorum). Any jitter parameter combining Orbicularis Oculi and Frontalis muscle was abnormal in 100% for the ocular, and in 92.9% for the generalized myasthenia gravis. The most abnormal muscle was Orbicularis Oculi for the generalized, and Frontalis for the ocular myasthenia gravis. The decrement was abnormal in 78.4%, 85.9% for the generalized, and 25% for the ocular myasthenia gravis. The mean jitter ranged from 14.2 to 86 μs (mean 33.3 μs) for the ocular myasthenia gravis and from 14.4 to 220.4 μs (mean 66.3 μs) for the generalized myasthenia gravis. The antibody titers tested positive in 86.6%, 91.8% for the generalized, and 50% for the ocular myasthenia gravis. Thymectomy was done in 48.5%, thymoma was found in 19.6%, and myasthenic crisis occurred by 21.6%. Conclusion: The jitter parameters achieved a 100% abnormality in ocular myasthenia gravis if both the Orbicularis Oculi and Frontalis muscles were tested. There was a high jitter abnormality in generalized myasthenia gravis cases with one muscle tested, with about a 2% increase in sensitivity when a second is added. Concentric needle electrode jitter had high sensitivity similar to the single fiber electrode (93.8%), followed by antibody titers (86.6%), and abnormal decrement (78.4%).
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Affiliation(s)
- João Aris Kouyoumdjian
- Laboratório Investigação Neuromuscular, Faculdade Estadual Medicina São José do Rio Preto, São Paulo, Brazil
| | - Gabriel Pina Paiva
- Laboratório Investigação Neuromuscular, Faculdade Estadual Medicina São José do Rio Preto, São Paulo, Brazil
| | - Erik Stålberg
- Department of Clinical Neurophysiology, Institute of Neurosciences, Uppsala University, Uppsala, Sweden
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Caldas VM, Heise CO, Kouyoumdjian JA, Zambon AA, Silva AMS, Estephan EDP, Zanoteli E. Electrophysiological study of neuromuscular junction in congenital myasthenic syndromes, congenital myopathies, and chronic progressive external ophthalmoplegia. Neuromuscul Disord 2020; 30:897-903. [PMID: 33121830 DOI: 10.1016/j.nmd.2020.10.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/05/2020] [Accepted: 10/07/2020] [Indexed: 11/19/2022]
Abstract
This study was designed to analyze the sensitivity, specificity, and accuracy of jitter parameters combined with repetitive nerve stimulation (RNS) in congenital myasthenic syndrome (CMS), chronic progressive external ophthalmoplegia (CPEO), and congenital myopathies (CM). Jitter was obtained with a concentric needle electrode during voluntary activation of the Orbicularis Oculi muscle in CMS (n = 21), CPEO (n = 20), and CM (n = 18) patients and in controls (n = 14). RNS (3 Hz) was performed in six different muscles for all patients (Abductor Digiti Minimi, Tibialis Anterior, upper Trapezius, Deltoideus, Orbicularis Oculi, and Nasalis). RNS was abnormal in 90.5% of CMS patients and in only one CM patient. Jitter was abnormal in 95.2% of CMS, 20% of CPEO, and 11.1% of CM patients. No patient with CPEO or CM presented a mean jitter higher than 53.6 µs or more than 30% abnormal individual jitter (> 45 µs). No patient with CPEO or CM and mild abnormal jitter values presented an abnormal decrement. Jitter and RNS assessment are valuable tools for diagnosing neuromuscular transmission abnormalities in CMS patients. A mean jitter value above 53.6 µs or the presence of more than 30% abnormal individual jitter (> 45 µs) strongly suggests CMS compared with CPEO and CM.
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Affiliation(s)
- Vitor Marques Caldas
- Department of Neurology, Faculdade de Medicina da Universidade de São Paulo (FMUSP), Av. Dr. Enéas Carvalho Aguiar 255, 05403-900 São Paulo SP, Brazil
| | - Carlos Otto Heise
- Department of Neurology, Faculdade de Medicina da Universidade de São Paulo (FMUSP), Av. Dr. Enéas Carvalho Aguiar 255, 05403-900 São Paulo SP, Brazil
| | - João Aris Kouyoumdjian
- Laboratório de Investigação Neuromuscular, Faculdade Estadual de Medicina de São Jose do Rio Preto (FAMERP), São Jose do Rio Preto, SP, Brazil
| | - Antônio Alberto Zambon
- Department of Neurology, Faculdade de Medicina da Universidade de São Paulo (FMUSP), Av. Dr. Enéas Carvalho Aguiar 255, 05403-900 São Paulo SP, Brazil
| | - André Macedo Serafim Silva
- Department of Neurology, Faculdade de Medicina da Universidade de São Paulo (FMUSP), Av. Dr. Enéas Carvalho Aguiar 255, 05403-900 São Paulo SP, Brazil
| | - Eduardo de Paula Estephan
- Department of Neurology, Faculdade de Medicina da Universidade de São Paulo (FMUSP), Av. Dr. Enéas Carvalho Aguiar 255, 05403-900 São Paulo SP, Brazil; Department of Medicine, Faculdade Santa Marcelina, São Paulo, Brazil
| | - Edmar Zanoteli
- Department of Neurology, Faculdade de Medicina da Universidade de São Paulo (FMUSP), Av. Dr. Enéas Carvalho Aguiar 255, 05403-900 São Paulo SP, Brazil.
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Bhatia S, Quinlan H, McCracken C, Price EW, Guglani L, Verma S. Serial Stimulated Jitter Analysis In Juvenile Myasthenia Gravis. Muscle Nerve 2018; 58:729-732. [DOI: 10.1002/mus.26319] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 07/27/2018] [Accepted: 08/05/2018] [Indexed: 11/08/2022]
Affiliation(s)
| | - Haley Quinlan
- Department of Rehabilitation and Therapy Services; Children's Healthcare of Atlanta; Atlanta Georgia USA
| | - Courtney McCracken
- Division of Biostatistics, Department of Pediatrics; Emory University School of Medicine; Atlanta Georgia USA
| | - Eric W. Price
- Division of Pulmonology, Allergy/Immunology, Cystic Fibrosis and Sleep, Department of Pediatrics; Emory University School of Medicine; Atlanta Georgia USA
| | - Lokesh Guglani
- Division of Pulmonology, Allergy/Immunology, Cystic Fibrosis and Sleep, Department of Pediatrics; Emory University School of Medicine; Atlanta Georgia USA
| | - Sumit Verma
- Division of Pediatric Neurology, Department of Pediatrics; Emory University School of Medicine, Atlanta, 1605 Chantilly Drive NE, Suite 300; Atlanta Georgia 30324 USA
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Pitt MC, Mchugh JC, Deeb J, Smith RA. Assessing neuromuscular junction stability from stimulated EMG in children. Clin Neurophysiol 2016; 128:290-296. [PMID: 28042994 DOI: 10.1016/j.clinph.2016.11.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 10/28/2016] [Accepted: 11/16/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVE We present our 9-year experience of stimulated EMG potential analysis using concentric electrodes (SPACE) to evaluate neuromuscular junction (NMJ) disorders in awake children. The technique uses high frequency filtration of stimulated motor unit potentials and applies peak detection software to estimate mean consecutive difference (MCD). METHODS SPACE was carried out in orbicularis oculi of 878 children (377 girls; median age 47months) between 2007 and 2015, stimulating the facial nerve with a monopolar cathode. Mean MCD-index (MCD-I) was expressed as a ratio of the measured MCD to the upper normal limit. Diagnostic accuracy was calculated for primary NMJ disorders based on the 660 cases with clinical follow-up data. RESULTS Primary NMJ disorders were present in 106 children, including 46 with genetically confirmed congenital myasthenic syndrome (CMS). Mean MCD-I was two times higher in children with primary NMJ disorders compared to others (205±108μs vs 94±38μs, p<0.005). After excluding children with neuronopathies, an MCD-I >100% had 84% sensitivity and 74% specificity for the primary NMJ disorders. Receiver operating characteristics (ROC) curve identified an MCD-I >115% as providing best diagnostic accuracy with sensitivity of 77% and specificity of 84%. CONCLUSION SPACE is practicable and safe in unsedated children. SIGNIFICANCE In combination with routine EMG, it has high diagnostic accuracy and can facilitate recognition of paediatric NMJ transmission disorders.
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Affiliation(s)
- Matthew C Pitt
- Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, United Kingdom.
| | - John C Mchugh
- Department of Clinical Neurophysiology, Our Lady's Children's Hospital, Crumlin, Dublin 12, Ireland
| | - Jacquie Deeb
- Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, United Kingdom; Department of Clinical Neurophysiology, Queen's Hospital, Barking, Havering and Redbridge University Hospitals NHS Trust, London, United Kingdom
| | - Ralph A Smith
- Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, United Kingdom
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C.N. Machado F, A. Kouyoumdjian JOÃO, E. Marchiori P. Diagnostic accuracy of concentric needle jitter in myasthenia: Prospective study. Muscle Nerve 2016; 55:190-194. [DOI: 10.1002/mus.25229] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 06/03/2016] [Accepted: 06/24/2016] [Indexed: 11/09/2022]
Affiliation(s)
- Flavia C.N. Machado
- Department of Neurology; Medical School, Universidade de São Paulo; São Paulo Brazil
- Fleury Medicina e Saúde; São Paulo Brazil
| | - JOÃO A. Kouyoumdjian
- Neuromuscular Investigation Laboratory; Faculdade Medicina São José do Rio Preto; São Paulo Brazil
| | - Paulo E. Marchiori
- Department of Neurology; Medical School, Universidade de São Paulo; São Paulo Brazil
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Verma S, Lin J. Stimulated jitter analysis for the evaluation of neuromuscular junction disorders in children. Muscle Nerve 2016; 53:471-2. [DOI: 10.1002/mus.25012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2015] [Indexed: 11/12/2022]
Affiliation(s)
- Sumit Verma
- Department of Pediatrics and Neurology; Emory University School of Medicine; 1605 Chantilly Drive NE, Suite 300 Atlanta Georgia 30324 USA
| | - Jenny Lin
- Emory University School of Medicine; Atlanta Georgia USA
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Verma S, Lin J, Barkhaus PE. Reply. Muscle Nerve 2015; 52:692. [DOI: 10.1002/mus.24736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 06/06/2015] [Accepted: 06/09/2015] [Indexed: 11/08/2022]
Affiliation(s)
- Sumit Verma
- Department of Pediatrics and Neurology; Emory University School of Medicine; Atlanta Georgia USA
| | - Jenny Lin
- Department of Pediatrics and Neurology; Emory University School of Medicine; Atlanta Georgia USA
| | - Paul E. Barkhaus
- Department of Neurology; Medical College of Wisconsin; Milwaukee Wisconsin USA
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Sanders DB. Stimulated jitter in infant botulism. Muscle Nerve 2015; 52:691-2. [DOI: 10.1002/mus.24737] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 06/09/2015] [Indexed: 11/08/2022]
Affiliation(s)
- Donald B. Sanders
- Department of Neurology; Duke University Medical Center; Durham North Carolina USA
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Abstract
PURPOSE OF REVIEW This article reviews the clinical presentations, diagnostic findings, and treatment options for autoimmune myasthenia gravis (MG) and Lambert-Eaton myasthenic syndrome. RECENT FINDINGS Immunologic research is unraveling the immunopathology of MG and identifying targets for novel immune-based therapy of this condition. MG patients with antibodies to muscle-specific tyrosine kinase (MuSK) frequently present with symptoms and clinical findings that suggest nerve or muscle disease. SUMMARY Early diagnosis and treatment have a marked effect on outcome in these diseases. In most cases, the diagnosis of MG or Lambert-Eaton myasthenic syndrome can be made from the history, supplemented with directed questions, and a physical examination designed to demonstrate variable weakness in affected muscle groups. Appropriate confirmatory tests almost always establish the diagnosis. Although several novel treatment modalities for MG are under investigation, currently available therapies produce substantial improvement in function and quality of life in most patients with this condition. Knowledge about the dosing, adverse effects, and costs of immunomodulatory therapies is essential for the effective management of patients with MG and Lambert-Eaton myasthenic syndrome.
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Hourigan ML, McKinnon NB, Johnson M, Rice CL, Stashuk DW, Doherty TJ. Increased motor unit potential shape variability across consecutive motor unit discharges in the tibialis anterior and vastus medialis muscles of healthy older subjects. Clin Neurophysiol 2015; 126:2381-9. [PMID: 25727901 DOI: 10.1016/j.clinph.2015.02.002] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Revised: 01/31/2015] [Accepted: 02/02/2015] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To study the potential utility of using near fiber (NF) jiggle as an assessment of neuromuscular transmission stability in healthy older subjects using decomposition-based quantitative electromyography (DQEMG). METHODS The tibialis anterior (TA) and vastus medialis (VM) muscles were tested in 9 older men (77 ± 5 years) and 9 young male control subjects (23 ± 0.3 years). Simultaneous surface and needle-detected electromyographic (EMG) signals were collected during voluntary contractions, and then analyzed using DQEMG. Motor unit potential (MUP) and NF MUP parameters were analyzed. RESULTS NF jiggle was significantly increased for both the TA and VM in the old age group relative to the younger controls (P<0.05). NF jiggle was significantly higher in the TA compared to VM (P<0.05). For TA, NF jiggle was negatively correlated with MUNE, and positively correlated with S-MUP amplitude, NF count, MUP duration, MUP peak-to-peak voltage, and MUP area (P<0.05). For VM, NF jiggle was positively correlated with NF count and MUP area (P<0.05), and no significant correlations were found between NF jiggle and S-MUP amplitude, MUP duration, or MUP peak-to-peak voltage (MUNE was not calculated for VM, so no correlation could be made). CONCLUSIONS Healthy aging is associated with neuromuscular transmission instability (increased NF jiggle) and MU remodeling, which can be measured using DQEMG. SIGNIFICANCE NF jiggle derived from DQEMG can be a useful method of identifying neuromuscular dysfunction at various stages of MU remodeling and aging.
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Affiliation(s)
- Maddison L Hourigan
- Department of Anatomy and Cell Biology, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Neal B McKinnon
- School of Kinesiology, Faculty of Health Sciences, Western University, London, Ontario, Canada
| | - Marjorie Johnson
- Department of Anatomy and Cell Biology, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Charles L Rice
- Department of Anatomy and Cell Biology, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; School of Kinesiology, Faculty of Health Sciences, Western University, London, Ontario, Canada
| | - Daniel W Stashuk
- Department of Systems Design Engineering, University of Waterloo, Waterloo, Ontario, Canada
| | - Timothy J Doherty
- School of Kinesiology, Faculty of Health Sciences, Western University, London, Ontario, Canada; Department of Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
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