Page 339 - Abstract Book KONIKA 18

Neurology

P-NEU-005
Intraoperative Neurophysiology Monitoring in Rare Pygopagus Conjoint Twins:
A Case Report

Anna Tjandrajani1, Citra Raditha , Pandu Caesaria Lestari , Alvi Aulia Rahma , Ahmad Yanuar Safri ,
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Luh Kurnia Indrawati , Winnugroho Wiratman , Samsul Ashari , Affan Priyambodo 4
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Department of Child Health and Department of Neurosurgery , PKIAN RSAB Harapan Kita,
Department of Neurology and Department of Neurosurgery , Faculty of Medicine, Universitas Indonesia/
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Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
Abstract
Background Conjoint twin represent a rare congenital malformation. The separation surgery imposes risk of
neural injury. Therefore intraoperative neurophysiology monitoring (IONM) is indicated to help surgeons to
be guided and to minimize the impact. Objective To present a case of pygopagus conjoint twins separation
using IONM as an integral part to the division of both neural and soft tissue stuctures. Case 1-year-old
girls reffered to our hospital with conjoined twins fused at sacral and perineal, with one anus, two vaginas,
two urinary meatuses, no sensorymotor deficit. Magnetic resonance imaging (MRI) revealed fusion at
sacral, perineal, coccygeus, distal sacrum level spinalis canal, distal medulla spinal, rectal fascia. Paired
subdermal needle electrodes were placed at head, anterior tibial, gastrocnemius, abductor hallucis muscles
and recorded for each twin. Somatosensory evoked potential (SSEP) and motor evoked potential (MEP)
were tested to confirm intact sensorimotor function. A free-run electromyography (EMG) and triggered
electromyogram (tEMG) was sequentially recorded on each nerve root to distinguish which belonged to either
one twin. Nerve roots were sequentially stimulated to locate the area of least tEMG activity in both twins
for identification of save cleavage plane. All nerve roots were subdivided into inboundary nerve fibers and
seperated sequentially one by one on the boundary where both electromyogram activities were minimized
until the twins were fully separated. Both twins recovered 0with no neurological deficits of the lower limbs
Conclusion We encountered a pygopagus conjoint twins separated succesfully using IONM. The use of
IONM significantly impact surgical decision-making in divison of neurology structures.
Keywords: conjoint twins; intraoperative neuromonitoring; separation, surgery

P-NEU-006
Role of Nerve Conduction Study
in the Diagnosis of Pediatric Guillain Barre Syndrome: A Case Report

Raden Muhammad Indra, Amanda Soebadi, Irawan Mangunatmadja
Department of Child Health, Dr Cipto Mangunkusumo Tertiary General Hospital/Faculty of Medicine Universitas
Indonesia, Jakarta, Indonesia

Abstract
Background Nerve conduction study is a sensitive tool to detect nerve lesions in Guillain Barre syndrome
(GBS). Objective To describe the diagnostic value of nerve conduction study in a case of GBS. Case A 6-year-
old girl presented with sudden weakness of both lower extremities causing inability to walk three weeks
before admission. There were also pain, pruritus, and warm sensations on the left leg and foot. She was
diagnosed with acute transverse myelitis (ATM) and was given methylprednisolone with little improvement.
Muscle strength at presentation was 4444|4444 and 3344|4444 for upper and lower extremities respectively
with reduced tendon reflexes. A nerve conduction study (NCS) was performed that showed increased distal
latency, reduced conduction velocity and amplitude on motor and sensory nerves of bilateral median,
posterior tibial, peroneal nerves. Absence of response was noted on sensory sural nerves, and F waves
of right median and bilateral tibial nerves. These findings were suggestive of acute motor-sensory axonal
neuropathy subtype of GBS. Patient was started on intravenous immunoglobulin followed by azathioprine
and regained full mobility after one month. Conclusion Nerve conduction study in GBS can readily show
axonal or demyelinating abnormalities even at first days of onset, while upper motor neuron lesions such
as ATM will not have any apparent abnormalities on routine NCS. Thus, NCS is a valuable diagnostic tool
to detect nerve lesions in GBS, determine its subtype, and predict prognosis, particularly early after onset
when distinction between upper and lower motor lesions may not be clear.
Keywords: Guillain Barre syndrome; acute motor-sensory axonal neuropathy; nerve conduction
study

KONIKA XVIII Abstract Book 291