PracticeUpdate

Transcranial Magnetic StimulationCanHelp Diagnose andPrognose ChildrenWith Sequelae of Acute TransverseMyelitis Transcranial magnetic stimulation is shown to detect neurophysiologic changes of acute transverse myelitis in 96% of cases

T ranscranial magnetic stimulation has been shown to be helpful in diagnosing and prognosing children with sequelae of acute transverse myelitis, show results of a comparative study reported at ICNMD 2018. Vladislav B. Voitenkov, MD, PhD, of the Pediatric Research and Clinical Center for Infectious Diseases in Saint Petersburg, Russian Federation, and colleagues evaluated motor pathways in chil- dren with viral myelitis using transcranial magnetic stimulation. Dr. Voitenkov explained to Elsevier’s PracticeUpdate , “Since transverse myelitis is devastating and highly disabling, and requires long and costly rehabilitation interventions, it is essential to be able to predict the efficacy of these interventions.”

During the 2 to 5 year follow-up period, ten chil- dren (42%) were unable to walk 50 m and required a walker, eleven (46%) exhibited normal motor function, and three (13%) suffered from total para- plegia with no lower limb movement, and no sign of recovery. Among the eleven who recovered fully, only the first pattern of transcranial magnetic stimulation (the presence of both cortical and spinal motor-evoked potentials) was registered. Those who recovered with sequelae exhibited the first or second pattern. In three participants who did not recover, only the third pattern was seen. Receiver operator curve analysis revealed signifi- cant correlation between long-term (3 to 5 years) recovery of the ability to walk in participants with consequences of myelitis and a central motor con- duction time ≥28.7 ms. In transverse myelitis, progressive loss of the fatty myelin sheath that surrounds the nerves in the affected spinal cord occurs for unclear reasons following infection or due to multiple sclerosis. A major theory posits that immune-mediated inflam- mation is present as the result of exposure to a viral antigen. Lesions are inflammatory and involve the spinal cord, typically on both sides. In acute transverse myelitis, onset is sudden and progresses rapidly in hours and days. Lesions can be present anywhere in the spinal cord, though they are usually restricted to only a small portion. Dr. Voitenkov explained that diagnosis, and espe- cially, prognosis, in acute transverse myelitis in children may be challenging. Dr. Voitenkov concluded that diagnostic transcra- nial magnetic stimulation was shown to detect neurophysiologic changes of acute transverse myelitis in 96% of cases and may be used as a predictive tool. The absence of cortical and spinal motor-evoked potentials may be considered a sign of a highly probable poor clinical outcome of acute transverse myelitis. “Future directions,” Dr. Voitenkov noted, “may be the fusion of MRI and transcranial magnetic stimu- lation in the diagnostic process. In our opinion, the results of our study may probably be extrapolated to spinal processes of different origin, such as trau-

Dr. Vladislav B. Voitenkov

" Future directions may be the fusion of MRI and transcranial magnetic stimulation in the diagnostic process. In our opinion, the results of our study may probably be extrapolated to spinal processes of different origin… "

A total of 20 healthy children (7 to 14 years, average 12 years of age) without signs of spinal disorders were enrolled as controls. The main group con- sisted of 24 individuals (8 to 16 years, average 11 years of age) with acute viral transverse myelitis. In four cases, lesion location was cervical; in seven, thoracic; and in thirteen, lumbar. Lesion etiology was enterovirus (n=20) and Epstein-Barr virus (n=4). A total of 18 children were unable to walk, lower paresis was seen in the other 6 cases. Ventilation was not required in any cases. Single-pulse tran- scranial magnetic stimulation was employed. A Neiro-MS D magnetic stimulator was used. A total of three neurophysiologic patterns were observed in the myelitis group: ƒ ƒ The presence of both cortical (though disperse and low-amplitude) and spinal motor-evoked potentials (n=15) ƒ ƒ The presence of spinal only, without cortical motor-evoked potentials (n=6) ƒ ƒ The total absence of both spinal and cortical motor-evoked potentials (n=3)

matic/neoplastic spinal injury.” www.practiceupdate.com/c/70413

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