Motor-evoked potentials: unusual findings

Central and Peripheral Motor Conduction Studies by Single-Pulse Magnetic Stimulation

Single-pulse magnetic stimulation is the simplest type of transcranial magnetic stimulation (TMS). Muscle action potentials induced by applying TMS over the primary motor cortex are recorded with surface electromyography electrodes, and they are called motor-evoked potentials (MEPs). The amplitude and latency of MEPs are used for various analyses in clinical practice and research. The most commonly used parameter is the central motor conduction time (CMCT), which is measured using motor cortical and spinal nerve stimulation. In addition, stimulation at the foramen magnum or the conus medullaris can be combined with conventional CMCT measurements to evaluate various conduction parameters in the corticospinal tract more precisely, including the cortical-brainstem conduction time, brainstem-root conduction time, cortical-conus motor conduction time, and cauda equina conduction time. The cortical silent period is also a useful parameter for evaluating cortical excitability. Single-pulse magnetic stimulation is further used to analyze not only the central nervous system but also the peripheral nervous system, such as for detecting lesions in the proximal parts of peripheral nerves. In this review article we introduce four types of single-pulse magnetic stimulation-of the motor cortex, spinal nerve, foramen magnum, and conus medullaris-that are useful for the diagnosis, elucidation of pathophysiology, and evaluation of clinical conditions and therapeutic effects. Single-pulse magnetic stimulation is a clinically useful technique that all neurologists should learn.

Non-invasive electrical and magnetic stimulation of the brain, spinal cord, roots and peripheral nerves: Basic principles and procedures for routine clinical and research application. An updated report from an I.F.C.N. Committee

These guidelines provide an up-date of previous IFCN report on “Non-invasive electrical and magnetic stimulation of the brain, spinal cord and roots: basic principles and procedures for routine clinical application” (Rossini et al., 1994). A new Committee, composed of international experts, some of whom were in the panel of the 1994 “Report”, was selected to produce a current state-of-the-art review of non-invasive stimulation both for clinical application and research in neuroscience.

Since 1994, the international scientific community has seen a rapid increase in non-invasive brain stimulation in studying cognition, brain–behavior relationship and pathophysiology of various neurologic and psychiatric disorders. New paradigms of stimulation and new techniques have been developed. Furthermore, a large number of studies and clinical trials have demonstrated potential therapeutic applications of non-invasive brain stimulation, especially for TMS. Recent guidelines can be found in the literature covering specific aspects of non-invasive brain stimulation, such as safety (Rossi et al., 2009), methodology (Groppa et al., 2012) and therapeutic applications (Lefaucheur et al., 2014).

This up-dated review covers theoretical, physiological and practical aspects of non-invasive stimulation of brain, spinal cord, nerve roots and peripheral nerves in the light of more updated knowledge, and include some recent extensions and developments.

The motor evoked potential in aids and HAM/TSP State of the evidence

OBJECTIVE: We aimed to better understand the involvement of the corticospinal tract, assessed by non-invasive transcranial stimulation, in order to determine the actual involvement of the motor system in patients with HAM/TSP and AIDS. METHOD: An exhaustive MEDLINE search for the period of 1985 to 2008 for all articles cross-referenced for "HTLV-I, HTLV-II, HTLV-III and HIV, HIV1, HIV2, evoked potential, motor evoked potential, high voltage electrical stimulation, transcranial magnetic stimulation, magnetic stimulation, corticomotor physiology, motor pathways, acquired immunodeficiency syndrome, AIDS, SIDA, tropical spastic paraparesis, HTLV-I-associated myelopathy, HAM, TSP, and HAM/TSP" were selected and analysed. RESULTS: Eighteen papers published in English, Spanish, Portuguese, French and Japanese were identified. Only the central motor conduction time has been analyzed in seropositive patients to human retroviruses. The investigations done on HAM/TSP support the involvement of the pyramidal tract mainly at lower levels, following a centripetal pattern; in AIDS, such an involvement seems to be more prominent at brain levels following a centrifugal pattern. CONCLUSION: The central motor conduction time abnormalities and involvement differences of the corticospinal tract of patients with AIDS and HAM/TSP dissected here would allow to re-orient early neurorehabilitation measures in these retroviruses-associated neurodegenerative disorders. Besides this, more sophisticated and sensitive non-invasive corticospinal stimulation measures that detect early changes in thalamocortical-basal ganglia circuitry will be needed in both clinically established as well as asymptomatic patients at times when the fastest corticospinal fibers remain uninvolved.

Corticomotoneuronal connections in primary lateral sclerosis (PLS)

BACKGROUND

The relationship between primary lateral sclerosis (PLS) and amyotrophic lateral sclerosis (ALS) is uncertain. The slow progression and dominant upper motor neuron features of PLS are associated with a high threshold to cortical magnetic stimulation and sometimes slow central motor conduction. In ALS the cortical threshold may be reduced early in the disease and central conduction is usually normal. Corticomotoneuronal function appears to be impaired differently in PLS and ALS.

SUBJECTS AND METHODS

We assessed corticomotoneuronal function by analyzing the primary peak in the peristimulus time histograms (PSTHs) in 12 PLS and 12 ALS patients. Surface recorded motor evoked potentials (MEPs) and central motor conduction time (CMCT) were determined. PSTHs were constructed from 4-5 different, voluntarily recruited motor units in each patient and the onset latency, number of excess bins, duration and synchrony of the primary peak were measured.

RESULTS

The mean cortical threshold of single motor units in PLS was 73.6%, significantly higher than in ALS (60.3%; p < 2.2 x 10(-5)). Profoundly delayed primary peaks occurred in both PLS and ALS. Onset latency and desynchronization of the primary peak were similar in PLS and ALS, but the duration of the primary peak was significantly longer in PLS (p < 0.04).

CONCLUSIONS

Desynchronized primary peaks indicate dysfunction or demise of corticomotoneurones. Higher threshold and longer duration of the primary peak in PLS probably reflect different excitability and greater loss of corticomotoneuronal connections than in ALS.

Magnetic stimulation of the central and peripheral nervous systems

Since 1985, when the technique of transcranial magnetic stimulation (TMS) was first developed, a wide range of applications in healthy and diseased subjects has been described. Comprehension of the physiological basis of motor control and cortical function has been improved. Modifications of the basic technique of measuring central motor conduction time (CMCT) have included measurement of the cortical silent period, paired stimulation in a conditioning test paradigm, repetitive transcranial magnetic stimulation (rTMS), and peristimulus time histograms (PSTH). These methods allow dissection of central motor excitatory versus inhibitory interplay on the cortical motor neuron and its presynaptic connections at the spinal cord, and have proven to be powerful investigational techniques. TMS can be used to assess upper and lower motor neuron dysfunction, monitor the effects of many pharmacological agents, predict stroke outcome, document the plasticity of the motor system, and assess its maturation and the effects of aging, as well as perform intraoperative monitoring. The recent use of rTMS in the treatment of depression and movement disorders is novel, and opens the way for other potential therapeutic applications.

Clinical neurophysiology of ALS

The neurophysiology of amyotrophic lateral sclerosis is important not only in relation to diagnosis, but also in the development of methods to follow progress, and the effects of putative therapies, in the disease. Quantitative techniques can be applied to the measurement of reinnervation using needle electromyogram. The methodology of motor unit number estimation may be useful in measuring loss of functioning motor units in groups of patients but variability in the measurement using current methods limits its sensitivity in the evaluation of individual patients. Conventional neurophysiological measurements, expressed as a multimetric index, may be useful in assessing progress. The cortical and upper motor neuron system can be assessed using transcortical magnetic stimulation protocols, and cortical excitability may be measured by the peristimulus histogram method. In this review the advantages, limitations and promise of these various methods is discussed, in order to indicate the direction for further neurophysiological studies in this disorder.

The physiological basis of conduction slowing in ALS patients homozygous for the D90A CuZn-SOD mutation

Familial amyotrophic lateral sclerosis (ALS) with the autosomal-recessively inherited D90A CuZn-superoxide dismutase (CuZn-SOD) mutation is characterized by a stereotypic slowly progressive, distinctive phenotype and very slow central motor conduction. To determine the basis of this slowing, we assessed corticomotoneuronal function using peristimulus time histograms (PSTHs) in 8 ALS patients homozygous for the D90A CuZn-SOD mutation. The results were compared with findings in 10 patients with multiple sclerosis (MS), in which slowing of central motor conduction is common, and 11 healthy subjects. PSTHs were constructed from 3-7 different, voluntarily recruited motor units recorded in each patient from the extensor digitorum communis muscle (EDC). In D90A and MS patients, the stimulus threshold, onset latency, number of excess bins, duration, amplitude, and synchrony of the primary peak differed significantly from controls (P < 0.0004). The mean onset latency of the primary peak in D90A patients was 35.3 ms, compared to 23.6 ms for MS patients and 19.3 ms for normal subjects (P < 0.0001). In the D90A patients, the onset latencies of the primary peak had a bimodal distribution, whereas in MS the distribution showed a continuum. Loss of synchrony was similar in D90A and MS patients, but the threshold, number of excess bins, and duration differed significantly (P < 0.0057), which suggests that either axonal loss or demyelination can result in delayed and desynchronized primary peaks. We propose that conduction slowing in the D90A homozygotes results from selective loss of fast-conducting large pyramidal cells with preservation of slow-conducting mono- or polysynaptic corticomotoneuronal connections.