Barbara F. Westmoreland, M.D., Omkar N. Markand, M.D., Richard K. Olney, M.D.
Preface - Study Guide for Clinical Neurophysiology
The study guide consists of an outline of topics relating to clinical neurophysiology and a suggested reading list. The study guide is intended as a general guide for programs in clinical neurophysiology and for residents and fellows wishing to become proficient in the various areas of clinical neurophysiology. Although the outline lists areas that are covered in the national board exams, as well as those recommended for accredited programs, it does not represent requirements of certifying boards or organizations. It was approved by AAN, Section Neurophysiology Mar. 26, 1996.
Syllabus for Clinical Neurophysiology
Instrumentation
1. Basic electronics
2. Amplifiers
3. Filters
4. Analog/Digital recording
5. Averaging
6. Electrodes
a. surface (EEG, EMG, EP)
b. needle
1) subdermal EEG
2) monopolar EMG
3) concentric needle EMG
4) single fiber EMG
7. Stimulators and stimulus parameters
8. Averaging
9. Sources of artifact
10. Laboratory and electrical safety
Principles and Techniques of Recording
1. Principles of recording
a. near field versus far field
b. projected or transmitted activities
c. traveling waves
d. signal and frequency analysis
2. Techniques for recording
a. polarity convention
b. monitors
c. montages for EEG
d. montages for EP
1) VEP
2) BAEP
3) SSEP
e. sensory nerve conduction studies
f. motor nerve conduction studies
g. repetitive nerve stimulation studies
h. late responses
1) F-waves
2) H-reflex
i. blink reflex studies
j. needle EMG examination
Waveform appearance and sound potentials:
fibrillation, fasciculation, myotonic, myokymic complex repetitive,
neurotonic end-plate, motor unit potentials (normal and abnormal)
k. single fiber studies
Basic Neurophysiology
1. Potentials (resting, action, synaptic, generator)
2. Membrane properties (nerve and muscle)
3. Ion channels
4. Synaptic transmission
a. neuronal
b. neuromuscular
c. neurotransmitters and neuro modulators
5. Physiologic basis of:
a. normal and abnormal EEG
b. normal and abnormal EMG
c. normal and abnormal evoked potentials
d. normal and abnormal sleep mechanisms
e. normal and abnormal autonomic disorders
f. epilepsy
g. neuromuscular disorders (anterior horn cell, neuromuscular junction,
neuropathies, myopathies, etc.)
h. movement disorders
i. sleep disorders
6. Anatomic substrates of EEG, EMG, evoked potentials, sleep, and autonomic activity
EEG
1. Normal patterns
2. Age-related and maturational changes
3. Activation procedures (hyperventilation, photic stimulation)
4. State-related changes (wake, drowsy, sleep)
5. Benign patterns and patterns of uncertain significance
6. Abnormal patterns
a. nonspecific
b. distinctive
c. epileptiform
d. periodic patterns
e. coma patterns
7. Artifacts
8. EEG findings seen in neurologic and systemic diseases
a. mass lesions
b. vascular
c. degenerative
d. toxic and metabolic
e. drugs
f. inflammatory
g. trauma
h. transient disorders (ischemia, migraine, epilepsy)
i. skull defects and surgical procedures
j. brain death
9. Interpretation of EEG findings in relation to clinical problems
EMG
1. Normal patterns
a. end-plate activity
b. normal motor unit action potentials and recruitment
2. Age-related findings
3. Findings produced by low temperature
4. Abnormalities for nerve conduction studies and their physiologic basis
a. axonal loss
b. demyelination
5. Abnormalities of spontaneous activity and their physiologic basis
a. fibrillation potentials
b. fasciculation potentials
c. myotonic discharges
d. complex repetitive discharges
e. myokymic discharges
f. neuromyotonic discharges
6. Abnormalities for motor unit action potentials (MUAPs) and their physiologic basis
a. MUAPs with small-amplitude or short-duration
b. MUAPs with large-amplitude or long-duration
c. unstable MUAPs
d. rapid recruitment
e. delayed recruitment
7. Abnormalities of repetitive nerve stimulation and their physiologic basis
a. decrement
b. facilitation
8. Abnormalities of single fiber EMG and their physiologic basis
9. Abnormalities of blink reflex studies and their physiologic basis
10. Findings in various diseases
a. central
b. anterior horn cell
c. radiculopathy
d. plexopathy
e. mononeuropathy
f. polyneuropathy
g. sensory neuropathy
h. neuromuscular junction disease
i. myopathy
11. Logic of performance of NCS/EMG
Selection of specific tests
Evoked Potentials
1. Principles of averaging
2. Methods of recording
3. Montages
4. Parameters
5. Names of waveforms
6. Postulated origin or generators of waveforms
7. Finding with various diseases and condition
8. Age-related changes
9. Brain death
Brainstem Auditory Evoked Potentials
1. Changes associated with hearing problems
2. Brainstem lesions
3. Mass lesions
4. Demyelinating disorders
Visual Evoked Potentials
1. Demyelinating disorders
2. Visual pathway disorders
3. Occipital lobe dysfunction
SEPs
Finding with disease
1. Peripheral nerve plexus and roots
2. Spinal cord
3. Brainstem
4. Cerebral hemispheres
5. Demyelinating disorders
6. Trauma
7. Compressive lesion
8. Vascular disorders
Sleep Recordings
1. Polysomnography
2. Multiple sleep latency test
3. Age-related changes
4. Sleep states
5. Circadian rhythms
6. Sleep disorders
Autonomic Function Tests
1. Quantitative sweat axonal reflex test (QSART)
2. Systemic vascular response
3. Thermoregulatory sweat test
4. Skin sympathetic response
5. Heart rate and blood pressure changes
6. Changes with various diseases, including peripheral neuropathy and system atrophies
Special Recordings
1. Prolonged EEG monitoring
2. Ambulatory EEG monitoring
3. Intraoperative recording
a. corticography
b. carotid endarterectomy
c. SEPs
d. root stimulation
e. motor evoked potentials
4. Intracranial recording (depth - subdural grids)
5. Recording in the ICU
6. Movement disorders
Special Procedures
1. Botox injection
2. Pharmacologic and physiologic activation
3. Injection of antiepileptic drugs for status
4. Motor evoked potentials
5. Magnetic stimulation
Statistical Principles and Analysis
References
American EEG Society Guidelines in EEG, Evoked Potentials, and Polysomnography. J Clin
Neurophysiolol 11:1, 1994.
American Association of Electrodiagnostic Medicine - Glossary of Terms in Clinic
Electromyography, Muscle and Nerve. 10:85(Supplement), 1987.
American Association of Electrodiagnostic Medicine Monographs.
Aminoff M. Electrodiagnosis. Neurologic Clinics, Vol 3, No 3, WB Saunders, 1985.
Aminoff M. Electrodiagnosis in Clinical Neurology, ed 3, Churchill and Livingstone, 1992.
Chatrian GE, Bergamini L, Dondey M, Klass DW, Lennox-Buchthal M, and Petersen I. A
glossary of terms most commonly used by clinical electroencephalographs. In:
International Federation of Societies for Electroencephalography and Clinical
Neurophysiology (Cobb WA (ed)). Recommendations for Practice of Clinical
Neurophysiology. Amsterdam, Elsevier Science Publishers, pp 11-26, 1983.
Chiappa K. Evoked Potentials in Clinical Medicine, ed 2, Raven Press, 1990.
Chu-Andrews J, Johnson RJ. Electrodiagnosis: An Anatomical and Clinical Approach.
Philadelphia, JB Lippincott, 1986.
Daly DD, Pedley TA (eds). Current Practice of Clinical EEG, ed 2, Raven Press, 1990.
Daube JR. Clinical Neurophysiology, FA Davis, 1996.
Delagi EF, Perotto A. Anatomic Guide for the Electromyographer, ed 2, Springfield, Charles C
Thomas, 1980.
Dumitru D. Electrodiagnostic Medicine. Philadelphia, Hanley & Belfus, 1995.
Dyck PJ, Thomas PK, Griffin JW, Low PA, Poduslo JF. Peripheral Neuropathy, ed 3,
Philadelphia, WB Saunders, 1993.
Engel AG, Franzini-Armstrong C. Myology: Basic and Clinical. ed 2, Vol 1&2, New York,
McGraw-Hill, 1994.
Engel J, Jr. Seizures in Epilepsy, FA Davis, 1989.
Fisch B. Spehlmann's EEG Primer, ed 2, Elsevier, 1991.
Ganong WF. Review of Medical Physiology, Appleton & Lange, 1993.
Grundy B. Evoked Potentials: Intraoperative and ICU Monitoring, New York, Springer Verlag,
1989.
Guyton AC. Basic Neuroscience, Anatomy and Physiology, ed 2, Saunders, 1991.
Kandel ER, Schwartz JH, Jessel TM. Principles of Neuroscience, ed 3, Elsevier, 1991.
Kimura J. Electrodiagnosis in Diseases of Nerve and Muscle, ed 2, FA Davis, 1989.
Kryger MH, Roth T, Dement WC. Principles and Practice of Sleep Medicine, ed 2, WB
Saunders, 1994.
Low PA (ed). Clinical Autonomic Disorders: Evaluation and Management, Boston, Little
Brown, 1993.
Luders H, Lesser R. Epilepsy-Electroclinical Syndromes, Springer Verlag, 1987.
Niedermeyer E, Lopes da Silva F. Electroencephalography, ed 3, Williams and Wilkins, 1993.
Stewart JD. Focal Peripheral Neuropathies, ed 2, New York, Raven Press, 1993.
Tyner FS, Knott JR, Mayer WV. Fundamentals of EEG Technology: Basic Concepts and
Methods, New York, Raven Press, 1983.
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