Nerve conduction and biopsy correlation in over 100 consecutive patients with suspected polyneuropathy

Neuropathy was classified physiologically and histologically as normal, axonal, demyelinative, or indeterminate using specific motor nerve conduction (NC) and sural sensory nerve biopsy (NB) criteria. Physiological and histological diagnoses were concordant in 63%, and minimally discordant in 14% of patients. The most important discordant patients were 6 with demyelinative neuropathy, 4 by NC, of which 2 were pure motor syndromes, and 2 by NB, both predominantly sensory syndromes. In the 55 patients with predominant axonal degeneration on biopsy, the extent of NC slowing was determined. As compound motor and sensory nerve action potential (CMAP and SNAP) amplitude declined, distal motor latency increased, whereas motor and sensory conduction velocity (CV) did not. Minimum F response latency increased as motor CV decreased, more in lower than upper extremity nerves. We conclude that: (1) except for sensory neuropathy, routine motor NC studies generally suffice in identifying demyelinative neuropathy; (2) NC slowing in axonal neuropathy is usually slight but may result in significantly prolonged distal motor latencies when CMAP amplitude is very low, and prolonged F wave latency when motor CV is slightly low; and (3) The physiologic criteria employed in this study rarely misclassifies neuropathy as demyelinative in patients with predominant axon loss on biopsy. © 1994 John Wiley & Sons, Inc.     

Nerve,muscle, and neuromuscular junction electrophysiology at high temperature

Although the effect of low temperature on the peripheral nervous system has been systematically studied, the effect of high temperature has not. We investigated the effect of elevating limb temperature from 32°C to 42°C by performing sequential motor studies, antidromic sensory studies, and 3-Hz repetitive stimulation in normal subjects. In addition, we recorded single motor units by using threshold stimulation. On average, motor amplitude and duration decreased by 27% and 19%, respectively, whereas sensory amplitude and duration decreased by 50% and 26%, respectively. Neuromuscular transmission remained normal at 42°C. Single motor unit recordings revealed a reduction in amplitude of 26%, similar to the overall reduction in compound motor amplitude. These findings demonstrate that significant reductions in sensory and motor amplitudes can occur in normal nerves at high temperature; we hypothesize that these changes are secondary to alterations in nerve and muscle ion channel function. © 1997 John Wiley & Sons, Inc. Muscle Nerve, 20, 431–436, 1997     

The value of sensory electrophysiology in chronic inflammatory demyelinating polyneuropathy.

OBJECTIVE: The purpose of this study was to evaluate the usefulness of sensory nerve conduction studies in comparison and in combination with motor conductions in diagnosing chronic inflammatory demyelinating polyneuropathy (CIDP). METHODS: We retrospectively compared the electrophysiology of 20 patients with CIDP to that of 20 controls with axonal polyneuropathy, and 20 controls with myopathy. Five sensory abnormality patterns were evaluated. RESULTS: The "abnormal radial normal sural" ("ARNS") pattern showed a sensitivity of 25% for CIDP and specificity of 100% versus axonal neuropathies (p=0.047). The "abnormal sural normal radial" ("ASNR") pattern had a sensitivity of 75% for axonal neuropathy with a specificity of 80% versus CIDP (p=0.0012). Presence of ARNS or absence of ASNR patterns showed equivalent or superior sensitivity and specificity to most individual motor demyelinating defects for CIDP. Presence of ARNS or absence of ASNR patterns, integrated within three different sets of electrodiagnostic criteria for CIDP, increased sensitivity in all without significantly altering specificity. Effects were most remarkable with the American Academy of Neurology criteria (1991), which showed significantly improved sensitivity (50-85%; p=0.041), with preserved specificity of 100%. CONCLUSIONS: The use of sensory abnormality patterns appears justified in comparison and combination with motor defects in diagnosing CIDP. SIGNIFICANCE: Sensory studies may be useful in contributing to the electrodiagnosis of CIDP and their inclusion in existing electrodiagnostic criteria deserves consideration.     

Identified postnatal mesolimbic dopamine neurons in culture: morphology and electrophysiology.

To examine the intrinsic properties of postnatal mesolimbic dopamine (DA) neurons, we dissociated the ventral tegmental area (VTA) from postnatal rats, enriched for DA neurons by microdissection or gradient purification, and grew the cells in culture. In these cultures, up to 50% of neurons were dopaminergic. DA neurons resembled their in vivo counterparts in soma shapes, and in showing two levels of tyrosine hydroxylase (TH) expression, axodendritic differentiation, two sizes of synaptic vesicles, nest-like synaptic arrangements with non-DA cells, and synaptic specializations. Electrophysiologically, however, they could not be distinguished from non-DA cells, which could be consistent with heterogeneity in cell properties. To examine a functional subset of VTA DA neurons, we retrogradely labeled VTA neurons projecting to the nucleus accumbens. These mesoaccumbens neurons were 86% TH positive, 56% cholecystokinin positive, and 0% neurotensin positive; they also displayed the soma shapes characteristic of DA neurons more generally and two levels of TH expression. Like their in vivo counterparts, mesoaccumbens cells generally fired single broad spikes that were triggered by slow depolarizations and had robust spike afterhyperpolarizations, low- and high-threshold Ca2+ spikes, rapid accommodation of firing, time-dependent anomalous rectification, and hyperpolarizing autoreceptor responses. Strikingly, the expression of these active properties did not change with time in culture. Mesoaccumbens DA cells could be identified by a distinctive subset of properties that made up an electrophysiological signature; however, unlike their in vivo counterparts, they were less often spontaneously active and never fired in bursts. These results suggest that most DA cell properties are intrinsic to the cells, including a significant heterogeneity that is maintained in postnatal culture; their level and mode of activity, however, appear to require afferent input. Culturing identified postnatal VTA DA neurons now makes possible examination of the impact of their individual properties on synaptic function.     

Familial amyloid polyneuropathy: a clinical and biopsy report

The first case of familial amyloid polyneuropathy (FAP) in China is reported and the literature reviewed. FAP is an autosomal dominant inherited disorder that primarily affects the peripheral and autonomic nervous systems. The exact onset of the disease begins so insidiously. Because of the confusion with other neurologic disease, the diagnosis is often delayed until advanced stage. In this case, sural musculus and sural nerve biopsy confirmed the presence of amyloid. Both the patient's grandfather and his (or her) father have the like history of the disease. Colchicine or Dimethyl-Sulphoxide (DMSO) treatment may prevent the development of FAP. The prognosis is poor. Most deaths result from heart or renal failure.     

Nerve biopsy and conduction studies in diabetic neuropathy.

Morphological findings in sural nerves were related to nerve conduction in 12 patients with diabetic neuropathy, five with mainly sensory involvement, four with severe, symmetrical sensory-motor polyneuropathy, and three with multiple mononeuropathy. All had loss of large and small myelinated and of unmyelinated fibres, even early in the disease; segmental remyelination was the most prominent myelin alteration in teased fibres, segmental demyelination was found in only a few fibres. Axonal degeneration and Schwann cell damage seem to proceed independently of each other. The relation between recorded conduction velocity and that expected from the diameter of the largest fibres indicated that slowing of 20 to 30% was due to causes other than fibre loss; a grossly diminished conduction velocity was caused mainly by fibre loss. Electrophysiological findings in the sural nerve were largely representative of findings in other nerves, though abnormalities were less marked in the median nerve. In half the endoneurial vessels from diabetic neuropathy the perivascular space was thickened or contained more layers of basal laminae than normal. The same abnormalities were found in one-quarter of the endoneurial vessels from other acquired neuropathies.     

Nerve conduction studies in polyneuropathy: practical physiology and patterns of abnormality

Nerve conduction studies are an essential part of the work-up of peripheral neuropathies. Many neuropathic syndromes can be suspected on clinical grounds, but optimal use of nerve conduction study techniques (in combination with needle electromyography) allows diagnostic classification and is therefore crucial to understanding and separation of neuropathies. Multifocal motor neuropathy, for example, may clinically present as ALS. Detection of evidence of demyelination (conduction blocks) leads to the correct diagnosis and to proper treatment. Nerve conduction studies provide essential information on (1) the spatial pattern of neuropathy, (2) the pattern of abnormalities distinguishing between primarily axonal and demyelinating pathology, and (3) the severity of neuropathic damage. This information is very comprehensive since many nerves and long segments of individual nerves can be sampled. Moreover the information is extremely detailed to the extent that the cellular pathology of a patient's neuropathy is usually defined best by physiological testing rather than by biopsy. Neuropathies can be generalized, focal, or multifocal; they can be symmetric or asymmetric; they can be distally predominant or proximal and distal. Primarily axonal neuropathies mainly affect sensory nerve and compound muscle action potential amplitudes, whereas demyelinating neuropathies lead to slowing of nerve conductions, and to increased temporal dispersion or conduction block. Usually, the pattern of demyelination allows to distinguish hereditary (uniform demyelination) from acquired (segmental demyelination) neuropathies. Electrodiagnostic criteria for primary demyelination are helpful to identify acquired demyelinating neuropathies.     

Ganglion cells of the terminal nerve: morphology and electrophysiology

The ganglion cells of the terminal nerve (TN cells) in the carp were identified using intracellular recording and staining techniques. The TN cells showed characteristic location and morphology as well as characteristic response after electrical shocks to the olfactory nerve and tracts. These features of the TN cells were distinct from those of the mitral or other cells in the olfactory bulb.     

慢性酒精性多发性神经病的临床、病理及电生理特征

报告３５例慢性酒精性多发性神经病患者，全部为男性，年龄３３～７０岁，平均５３．７岁。主要临床症状是四肢疼痛、麻木，袜套－手套式痛温觉减退，震动党消失和肌肉萎缩。运动神经和感觉神经传导速度均有不同程度的减慢。腓浅神经活检见有髓神经纤维髓鞘变性，轴索变性或消失。Ｓｃｈｗａｎｎ细胞变性，也累及神经束膜。此种改变来源于长期饮酒所引起的维生素缺乏所致。     

Carbon disulfide induced polyneuropathy: sural nerve pathology, electrophysiology, and clinical correlation

We report the clinical features, electrophysiological studies, sural nerve pathology and recovery course of carbon disulfide-(CS2) induced polyneuropathy in a 48-year-old man who worked in a viscose rayon plant. Sural nerve biopsy 2 years later still showed degeneration of both axon and myelin with a predominant loss of large myelinated fibers and remyelination. Electrophysiologic studies revealed mixed axonal and demyelinating polyneuropathy. To our knowledge, this is the first human report of sural nerve pathology in the recovery stage due to CS2 intoxication. After diagnosis, the patient was removed from the toxic environment. In the following three years, he showed part recovery predominantly in motor function compatible with the serial nerve conduction studies. We conclude that CS2 polyneuropathy may partly recover years after cessation of exposure.     

Nerve root hypertrophy in chronic inflammatory demyelinating polyneuropathy

A patient with chronic inflammatory demyelinating polyneuropathy (ClDP) and centrel demyelinating disease is desoribed in whom striking nodular filling defects on multiple lumbar–sacral nerve roots, mimicking neurofibromata, were observed at myelography and magnetic resonance imaging. We suggest that these lesions are secondary to recurrent segmental demyelination and remyelination and that the differential diagnosis of this radiological feature should include CIDP. © 1994 John Wiley & Sons, Inc.     

Nerve ultrasound in diabetic polyneuropathy: Correlation with clinical characteristics and electrodiagnostic testing

Introduction: Diabetic polyneuropathy (DPN) is increasingly prevalent in the USA, but nerve ultrasound (US) findings have not been assessed systematically. Our aim was to establish the sonographic characteristics of lower extremity nerves in DPN and correlate them with electrodiagnostic (EDx) findings. Methods: Consecutive patients (n = 25) with evidence of DPN and 25 patient controls without DPN underwent blinded US imaging of the fibular and sural nerves. Nerve cross‐sectional area (CSA), diameter and echogenicity were recorded. Results: There were no differences in fibular or sural nerve CSA, diameter, or echogenicity between the 2 groups. No correlations between nerve CSA and EDx studies were found. In DPN, there were moderate inverse correlations with age (r = ?0.44 sural ankle, r = ?0.39 sural leg, r = ?0.45 fibular ankle). Conclusions: US measurements of lower extremity nerves in DPN do not differ from controls or correlate with EDx findings. Novel US techniques and/or pedal nerve US may be necessary to detect differences. Muscle Nerve 47:379‐384, 2013     

Nerve, muscle, and serotonin.

Effects of serotonin one neuromuscular transmission and muscle contraction were studied in the tibialis anterior of rabbits. Serotonin antagonised the Mg++-induced block of transmission, and also provided dual effects on the curare-induced block, anti-curare phase followed by curare-potentiating phase. Independent of transmission processes, serotonin caused a reduction in twitch tension, mainly associated with decreased acceleration of twitch development. These serotonin actions were independent of vascular changes; pharmacological mechanisms are discussed in comparison with those of adrenaline and isoprenaline. A possible role of serotonin in causing a myopathy is proposed.     

Symmetric sarcoid polyneuropathy: analysis of a sural nerve biopsy

A 20-year-old woman with sarcoidosis had uveitis, subacute symmetric sensorimotor neuropathy, and noncaseous granulomas in biopsies of gastrocnemius muscle and sural nerve. Morphologic studies of the nerve confirmed the electrodiagnostic impression of an acute axonal and demyelinating neuropathy. Of 100 teased myelinated nerve fibers, 15% contained myelin ovoids and 24% demonstrated segmental demyelination. Quantitative analysis showed a reduction in the numerical density of myelinated fibers. By electronmicroscopy, unmyelinated fibers were largely spared. The exact mechanism of nerve fiber damage was not determined, but a local effect of the granuloma seemed likely, because most lesions were found in the endoneurium.     

Correlated electrophysiology and morphology of the ependyma in rat hypothalamus

The ependyma lines the ventricular system of the vertebrate brain and spinal cord. Although its embryology and morphology have been studied extensively, little is known of its physiological properties, particularly in mammals. Tanycytes are modified ependymal cells that are found predominantly lining the floor of the third ventricle, overlying the median eminence. Their processes accompany and enwrap neuroendocrine axons that course from hypothalamic nuclei to terminals in the median eminence, but the significance of this interaction is not yet understood. Intracellular recording and injection techniques were used to study ependymal cells and tanycytes of the rat in the hypothalamic slice preparation after differentiating their respective regions morphologically. With extracellular [K+] = 6.24 mM, the mean membrane potential (+/- SD) for common ependyma was -79.9 +/- 1.40 mV and for tanycytes, -79.5 +/- 1.77 mV. Input resistances (Rin) were very low (much less than 1 M omega). Single-cell injection of Lucifer yellow revealed dye coupling among 2-70 ependymal cells and 5-48 tanycytes. In both freeze-fractured replicas and thin sections, large numbers of gap junctions were found between adjacent ependymal cells and between adjacent tanycytes. The observations of numerous gap junctions, extensive dye coupling and low input resistance demonstrated that both populations are strongly coupled networks. Perhaps for this reason, attempts to uncouple these cells using sodium propionate or CO2 were unsuccessful. Electrical stimulation of the arcuate nucleus did not elicit any detectable synaptic response in impaled tanycytes, so that the functional significance of synaptoid contacts between neuroendocrine neurons and the postsynaptic tanycytes is not yet apparent. Ependymal cells and tanycytes demonstrated a near-Nernstian response to changes in extracellular [K+] between 3 and 20 mM. This finding, as well as their high negative resting potential, low Rin, extensive coupling and absence of spontaneous electrical excitability demonstrate that ependymal cells possess numerous glial characteristics and may therefore have similar functions. In the hypothalamus, ependyma probably take up K+ released from adjacent endocrine neurons and shunt it to the ventricular space.     

Nerve biopsy: requirements for diagnosis and clinical value

In many instances, nerve biopsy is not necessary in the diagnostic work-up of a peripheral neuropathy. However, histological examination of a tissue sample is still mandatory to show specific lesions in various conditions involving peripheral nerves. As there are fewer laboratories that examine human nerve samples, practitioners including neurologists and general pathologists may not be completely aware of the technical issues and data that are provided by nerve biopsy. Nerve biopsy is considered an invasive diagnostic method, although, its complications are by far less disabling than most of the disorders that lead to its indications. Nevertheless, the decision to perform a nerve biopsy has to be made on a case-by-case basis, and its results must be discussed between the pathologist and the clinician who is in charge of the patient’s care. In this paper, we review the minimal technical requirements for proper peripheral nerve tissue analysis. Moreover, we provide data on the usefulness of nerve biopsy in various situations including abnormal deposits, cell infiltrates, link between peripheral neuropathy and monoclonal gammopathy, and numerous hereditary disorders.