SlideShare a Scribd company logo

repetitive nerve stimulation

•Download as PPT, PDF•
•
Neurology resident slides
Neurology resident slides

seminar on repetitive nerve stimulation physiology,application in various neuromuscular disorders

Health & Medicine
1 of 59
Repetitive Nerve Stimulation
Plan of the talk ,[object Object],[object Object],[object Object],[object Object]
 
 
definitions ,[object Object],[object Object],[object Object],[object Object],[object Object]
definitions ,[object Object],[object Object],[object Object],[object Object],[object Object]
Calcium and quanta dynamics ,[object Object],[object Object],[object Object],[object Object]
Potentiation ,[object Object],[object Object],[object Object],[object Object]
 
Relationship -EPP,AP,CMAP
Neuromuscular junction disorders ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Repetitive nerve stimulation ( RNS) ,[object Object],[object Object],[object Object]
RNS- technique ,[object Object],[object Object],[object Object],[object Object]
RNS-technique ,[object Object],[object Object],[object Object],[object Object]
Muscle selection ,[object Object],[object Object],[object Object],[object Object]
Machine setup for RNS 30-50 Stimulus rate -high <5 Stimulus rate -low 0.1 Stimulus duration (msec) 2-3 High filter (KHz) 2-5 Low filter (Hz) 2 Sweep time (ms/div) 2-5 Sensitivity (mV/div)
temperature ,[object Object],[object Object],[object Object],[object Object]
Effect of temperature on RNS
Stimulus technique ,[object Object],[object Object],[object Object],[object Object]
Effect of different stimulation rates
Activation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
 
 
Measurement technique ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Slow RNS ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Slow RNS
Rapid RNS ,[object Object],[object Object],[object Object],[object Object]
Rapid RNS
Patterns of response to slow RNS
Activation cycle in MG
Criteria for abnormal decrement ,[object Object],[object Object],[object Object],[object Object],[object Object]
RNS in pre and post synaptic disorders Decrement or normal Increment High rate RNS Decrement Present Present Decrement Present Absent ,[object Object],[object Object],[object Object],[object Object],Normal Small CMAP amplitude Post-synaptic Pre-synaptic Parameter
Double step RNS ,[object Object],[object Object],[object Object],[object Object]
Regional curare test ,[object Object],[object Object],[object Object],[object Object],[object Object]
SFEMG
Jitter and block
Myasthenia gravis
Electrophysiological investigation ,[object Object],[object Object],[object Object],[object Object]
RNS ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
 
Baseline and 10sec exercise
60sec exercise-exhaustion
Congenital Myasthenic Syndromes ,[object Object],[object Object],[object Object],[object Object],[object Object]
Repetitive CMAP
Lambert Eaton Myasthenic Syndrome (LEMS ) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
LEMS
LEMS ,[object Object],[object Object],[object Object],[object Object],[object Object]
Incrementing response after brief exercise (10-15 sec) in LEMS. Increment is 10-fold, with CMAP of 3.2 mV. CP CMAP amplitude is 0.35 mV (normal >1 mV).
Incremental response in LEMS
50hz RNS-increments
Botulism ,[object Object],[object Object],[object Object],[object Object],[object Object]
Botulism ,[object Object],[object Object],[object Object],[object Object]
Miscellaneous conditions ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
 
 
 
[object Object]
References ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Thank you

Recommended

Repetitive Nerve Stimulation (RNS)
Repetitive Nerve Stimulation (RNS)Repetitive Nerve Stimulation (RNS)
Repetitive Nerve Stimulation (RNS)Murtaza Syed
 
Repetitive Nerve Stimulation
Repetitive Nerve Stimulation Repetitive Nerve Stimulation
Repetitive Nerve Stimulation Mohit Patel
 
REPETITIVE NERVE STIMULATION (RNS)
REPETITIVE NERVE STIMULATION (RNS)REPETITIVE NERVE STIMULATION (RNS)
REPETITIVE NERVE STIMULATION (RNS)Dhaval Modi
 
Fundamentals of nerve conduction study
Fundamentals of nerve conduction studyFundamentals of nerve conduction study
Fundamentals of nerve conduction studyNeurologyKota
 
Somatosensory evoked potentials
Somatosensory evoked potentialsSomatosensory evoked potentials
Somatosensory evoked potentialsManideep Malaka
 
Overview on Motor evoked potential
Overview on Motor evoked potentialOverview on Motor evoked potential
Overview on Motor evoked potentialSyed Ahmed Uddin (BSc, REEGT, CNIM)
 
Brainstem auditory evoked potentials (baep)
Brainstem auditory evoked potentials (baep)Brainstem auditory evoked potentials (baep)
Brainstem auditory evoked potentials (baep)NeurologyKota
 
NERVE CONDUCTION STUDIES, ELECTROMYOGRAPHY
NERVE CONDUCTION STUDIES, ELECTROMYOGRAPHYNERVE CONDUCTION STUDIES, ELECTROMYOGRAPHY
NERVE CONDUCTION STUDIES, ELECTROMYOGRAPHYPGIMER,DR.RML HOSPITAL
 

Recommended

Repetitive Nerve Stimulation (RNS)
Repetitive Nerve Stimulation (RNS)Repetitive Nerve Stimulation (RNS)
Repetitive Nerve Stimulation (RNS)Murtaza Syed
 
Repetitive Nerve Stimulation
Repetitive Nerve Stimulation Repetitive Nerve Stimulation
Repetitive Nerve Stimulation Mohit Patel
 
REPETITIVE NERVE STIMULATION (RNS)
REPETITIVE NERVE STIMULATION (RNS)REPETITIVE NERVE STIMULATION (RNS)
REPETITIVE NERVE STIMULATION (RNS)Dhaval Modi
 
Fundamentals of nerve conduction study
Fundamentals of nerve conduction studyFundamentals of nerve conduction study
Fundamentals of nerve conduction studyNeurologyKota
 
Somatosensory evoked potentials
Somatosensory evoked potentialsSomatosensory evoked potentials
Somatosensory evoked potentialsManideep Malaka
 
Overview on Motor evoked potential
Overview on Motor evoked potentialOverview on Motor evoked potential
Overview on Motor evoked potentialSyed Ahmed Uddin (BSc, REEGT, CNIM)
 
Brainstem auditory evoked potentials (baep)
Brainstem auditory evoked potentials (baep)Brainstem auditory evoked potentials (baep)
Brainstem auditory evoked potentials (baep)NeurologyKota
 
NERVE CONDUCTION STUDIES, ELECTROMYOGRAPHY
NERVE CONDUCTION STUDIES, ELECTROMYOGRAPHYNERVE CONDUCTION STUDIES, ELECTROMYOGRAPHY
NERVE CONDUCTION STUDIES, ELECTROMYOGRAPHYPGIMER,DR.RML HOSPITAL
 
Nerves conduction study
Nerves conduction study Nerves conduction study
Nerves conduction study Sachin Adukia
 
Somato Sensory Evoked Potentials (SSEP) By: Murtaza Syed
Somato Sensory Evoked Potentials (SSEP) By: Murtaza SyedSomato Sensory Evoked Potentials (SSEP) By: Murtaza Syed
Somato Sensory Evoked Potentials (SSEP) By: Murtaza SyedMurtaza Syed
 
Late Responses (F-wave and H.Reflex)
Late Responses (F-wave and H.Reflex)Late Responses (F-wave and H.Reflex)
Late Responses (F-wave and H.Reflex)Murtaza Syed
 
Repetitive nerve stimulation test
Repetitive nerve stimulation test Repetitive nerve stimulation test
Repetitive nerve stimulation test NeurologyKota
 
Evoked potential - An overview
Evoked potential - An overviewEvoked potential - An overview
Evoked potential - An overviewAnbarasi rajkumar
 
Motor evoked potentials - IONM Basics
Motor evoked potentials - IONM BasicsMotor evoked potentials - IONM Basics
Motor evoked potentials - IONM BasicsSimon Jeba Kumar
 
Interpretation of NCS and EMG
Interpretation of NCS and EMG Interpretation of NCS and EMG
Interpretation of NCS and EMG Mohamed E Elsebaey
 
Overview of Nerve Conduction Study
Overview of Nerve Conduction StudyOverview of Nerve Conduction Study
Overview of Nerve Conduction StudyPramod Krishnan
 
Nerve Conduction Studies- Lower Leg
Nerve Conduction Studies- Lower LegNerve Conduction Studies- Lower Leg
Nerve Conduction Studies- Lower Legsm171181
 
NCV AND EMG
NCV AND EMGNCV AND EMG
NCV AND EMGPGIMER,DR.RML HOSPITAL
 
Ncs
NcsNcs
Ncsgulabsoni
 
Somatosensory evoked potential
Somatosensory evoked potentialSomatosensory evoked potential
Somatosensory evoked potentialdahmed hamed
 
H reflex (Hoffmann's Reflex)
H reflex (Hoffmann's Reflex)H reflex (Hoffmann's Reflex)
H reflex (Hoffmann's Reflex)Murtaza Syed
 
Nerves conduction study
Nerves conduction studyNerves conduction study
Nerves conduction studyAhmad Shahir
 
Evolked potential
Evolked potentialEvolked potential
Evolked potentialDr Nilesh Kate
 
Electrodiagnosis in gbs
Electrodiagnosis in gbsElectrodiagnosis in gbs
Electrodiagnosis in gbsDr. Munish Kumar
 
Nerve conduction studies
Nerve conduction studiesNerve conduction studies
Nerve conduction studiesSanjogChandana
 
Brainstem auditory evoked response
Brainstem auditory evoked responseBrainstem auditory evoked response
Brainstem auditory evoked responseMeenakshy Royals
 
Basics of emg
Basics of emgBasics of emg
Basics of emgBhawesh Kumar
 
Blink reflex
Blink reflex Blink reflex
Blink reflex Murtaza Syed
 
GBS Acute Polyneuropathies (GBS)
GBS Acute Polyneuropathies (GBS)GBS Acute Polyneuropathies (GBS)
GBS Acute Polyneuropathies (GBS)Murtaza Syed
 
Rapid Nerve Stimulation study Part 1
Rapid Nerve Stimulation study Part 1Rapid Nerve Stimulation study Part 1
Rapid Nerve Stimulation study Part 1Roopchand Ps
 

More Related Content

What's hot

Nerves conduction study
Nerves conduction study Nerves conduction study
Nerves conduction study Sachin Adukia
 
Somato Sensory Evoked Potentials (SSEP) By: Murtaza Syed
Somato Sensory Evoked Potentials (SSEP) By: Murtaza SyedSomato Sensory Evoked Potentials (SSEP) By: Murtaza Syed
Somato Sensory Evoked Potentials (SSEP) By: Murtaza SyedMurtaza Syed
 
Late Responses (F-wave and H.Reflex)
Late Responses (F-wave and H.Reflex)Late Responses (F-wave and H.Reflex)
Late Responses (F-wave and H.Reflex)Murtaza Syed
 
Repetitive nerve stimulation test
Repetitive nerve stimulation test Repetitive nerve stimulation test
Repetitive nerve stimulation test NeurologyKota
 
Evoked potential - An overview
Evoked potential - An overviewEvoked potential - An overview
Evoked potential - An overviewAnbarasi rajkumar
 
Motor evoked potentials - IONM Basics
Motor evoked potentials - IONM BasicsMotor evoked potentials - IONM Basics
Motor evoked potentials - IONM BasicsSimon Jeba Kumar
 
Overview of Nerve Conduction Study
Overview of Nerve Conduction StudyOverview of Nerve Conduction Study
Overview of Nerve Conduction StudyPramod Krishnan
 
Nerve Conduction Studies- Lower Leg
Nerve Conduction Studies- Lower LegNerve Conduction Studies- Lower Leg
Nerve Conduction Studies- Lower Legsm171181
 
Somatosensory evoked potential
Somatosensory evoked potentialSomatosensory evoked potential
Somatosensory evoked potentialdahmed hamed
 
H reflex (Hoffmann's Reflex)
H reflex (Hoffmann's Reflex)H reflex (Hoffmann's Reflex)
H reflex (Hoffmann's Reflex)Murtaza Syed
 
Nerves conduction study
Nerves conduction studyNerves conduction study
Nerves conduction studyAhmad Shahir
 
Nerve conduction studies
Nerve conduction studiesNerve conduction studies
Nerve conduction studiesSanjogChandana
 
Brainstem auditory evoked response
Brainstem auditory evoked responseBrainstem auditory evoked response
Brainstem auditory evoked responseMeenakshy Royals
 

What's hot (20)

Nerves conduction study
Nerves conduction study Nerves conduction study
Nerves conduction study
 
Somato Sensory Evoked Potentials (SSEP) By: Murtaza Syed
Somato Sensory Evoked Potentials (SSEP) By: Murtaza SyedSomato Sensory Evoked Potentials (SSEP) By: Murtaza Syed
Somato Sensory Evoked Potentials (SSEP) By: Murtaza Syed
 
Late Responses (F-wave and H.Reflex)
Late Responses (F-wave and H.Reflex)Late Responses (F-wave and H.Reflex)
Late Responses (F-wave and H.Reflex)
 
Repetitive nerve stimulation test
Repetitive nerve stimulation test Repetitive nerve stimulation test
Repetitive nerve stimulation test
 
Evoked potential - An overview
Evoked potential - An overviewEvoked potential - An overview
Evoked potential - An overview
 
Motor evoked potentials - IONM Basics
Motor evoked potentials - IONM BasicsMotor evoked potentials - IONM Basics
Motor evoked potentials - IONM Basics
 
Interpretation of NCS and EMG
Interpretation of NCS and EMG Interpretation of NCS and EMG
Interpretation of NCS and EMG
 
Overview of Nerve Conduction Study
Overview of Nerve Conduction StudyOverview of Nerve Conduction Study
Overview of Nerve Conduction Study
 
Nerve Conduction Studies- Lower Leg
Nerve Conduction Studies- Lower LegNerve Conduction Studies- Lower Leg
Nerve Conduction Studies- Lower Leg
 
NCV AND EMG
NCV AND EMGNCV AND EMG
NCV AND EMG
 
Ncs
NcsNcs
Ncs
 
Somatosensory evoked potential
Somatosensory evoked potentialSomatosensory evoked potential
Somatosensory evoked potential
 
H reflex (Hoffmann's Reflex)
H reflex (Hoffmann's Reflex)H reflex (Hoffmann's Reflex)
H reflex (Hoffmann's Reflex)
 
Nerves conduction study
Nerves conduction studyNerves conduction study
Nerves conduction study
 
Evolked potential
Evolked potentialEvolked potential
Evolked potential
 
Electrodiagnosis in gbs
Electrodiagnosis in gbsElectrodiagnosis in gbs
Electrodiagnosis in gbs
 
Nerve conduction studies
Nerve conduction studiesNerve conduction studies
Nerve conduction studies
 
Brainstem auditory evoked response
Brainstem auditory evoked responseBrainstem auditory evoked response
Brainstem auditory evoked response
 
Basics of emg
Basics of emgBasics of emg
Basics of emg
 
Blink reflex
Blink reflex Blink reflex
Blink reflex
 

Viewers also liked

GBS Acute Polyneuropathies (GBS)
GBS Acute Polyneuropathies (GBS)GBS Acute Polyneuropathies (GBS)
GBS Acute Polyneuropathies (GBS)Murtaza Syed
 
Rapid Nerve Stimulation study Part 1
Rapid Nerve Stimulation study Part 1Rapid Nerve Stimulation study Part 1
Rapid Nerve Stimulation study Part 1Roopchand Ps
 
Electromyography
ElectromyographyElectromyography
ElectromyographyRajesh Goit
 

Viewers also liked (8)

GBS Acute Polyneuropathies (GBS)
GBS Acute Polyneuropathies (GBS)GBS Acute Polyneuropathies (GBS)
GBS Acute Polyneuropathies (GBS)
 
Rapid Nerve Stimulation study Part 1
Rapid Nerve Stimulation study Part 1Rapid Nerve Stimulation study Part 1
Rapid Nerve Stimulation study Part 1
 
EMG
EMGEMG
EMG
 
EMG
EMGEMG
EMG
 
Emg fundamental
Emg fundamentalEmg fundamental
Emg fundamental
 
CIDP and NCS protocol
CIDP and NCS protocolCIDP and NCS protocol
CIDP and NCS protocol
 
Electromyography
ElectromyographyElectromyography
Electromyography
 
Electromyogram
ElectromyogramElectromyogram
Electromyogram
 

Similar to repetitive nerve stimulation

Basics of rnst,vep ,baer and emg
Basics of rnst,vep ,baer and emgBasics of rnst,vep ,baer and emg
Basics of rnst,vep ,baer and emgNeurologyKota
 
Nerve conduction studies
Nerve conduction studiesNerve conduction studies
Nerve conduction studiesmahmood wajeeh
 
ncs study - basics of nerve conduction study
ncs study - basics of nerve conduction studyncs study - basics of nerve conduction study
ncs study - basics of nerve conduction studypiyushbhardwaj93
 
electrodiagnostics for pmr - dr henry prakash
electrodiagnostics for pmr - dr henry prakashelectrodiagnostics for pmr - dr henry prakash
electrodiagnostics for pmr - dr henry prakashmrinal joshi
 
Melior Neurophysiology Models
Melior Neurophysiology ModelsMelior Neurophysiology Models
Melior Neurophysiology Modelsjagruner
 
Trans cranial magnetic stimulation - Diagnostic & Therapeutic application
Trans cranial magnetic stimulation - Diagnostic & Therapeutic applicationTrans cranial magnetic stimulation - Diagnostic & Therapeutic application
Trans cranial magnetic stimulation - Diagnostic & Therapeutic applicationNeurologyKota
 
Interpretation of NCV.pptx
Interpretation of NCV.pptxInterpretation of NCV.pptx
Interpretation of NCV.pptxKetakiPatani1
 
Anatomy of neuromuscular junction
Anatomy of neuromuscular junction Anatomy of neuromuscular junction
Anatomy of neuromuscular junction Shehzad Hussain Raja
 
russiancurrent-180205124702.pdf
russiancurrent-180205124702.pdfrussiancurrent-180205124702.pdf
russiancurrent-180205124702.pdfBMmugal
 
Russian current (Electrotherapy)
Russian current (Electrotherapy) Russian current (Electrotherapy)
Russian current (Electrotherapy) Apatel99094
 
Neuromuscular transmission and its pharmacology
Neuromuscular transmission and its pharmacologyNeuromuscular transmission and its pharmacology
Neuromuscular transmission and its pharmacologyPradeep Singh Narwat
 
NEUROMUSCULAR MONITORING .pptx
NEUROMUSCULAR MONITORING .pptxNEUROMUSCULAR MONITORING .pptx
NEUROMUSCULAR MONITORING .pptxKavitaKadyan1
 

Similar to repetitive nerve stimulation (20)

RNS
RNS RNS
RNS
 
Basics of rnst,vep ,baer and emg
Basics of rnst,vep ,baer and emgBasics of rnst,vep ,baer and emg
Basics of rnst,vep ,baer and emg
 
Electrodiagnosis 2
Electrodiagnosis 2Electrodiagnosis 2
Electrodiagnosis 2
 
118194784-4-NCV1.ppt
118194784-4-NCV1.ppt118194784-4-NCV1.ppt
118194784-4-NCV1.ppt
 
Nerve conduction studies
Nerve conduction studiesNerve conduction studies
Nerve conduction studies
 
ncs study - basics of nerve conduction study
ncs study - basics of nerve conduction studyncs study - basics of nerve conduction study
ncs study - basics of nerve conduction study
 
electrodiagnostics for pmr - dr henry prakash
electrodiagnostics for pmr - dr henry prakashelectrodiagnostics for pmr - dr henry prakash
electrodiagnostics for pmr - dr henry prakash
 
Melior Neurophysiology Models
Melior Neurophysiology ModelsMelior Neurophysiology Models
Melior Neurophysiology Models
 
Trans cranial magnetic stimulation - Diagnostic & Therapeutic application
Trans cranial magnetic stimulation - Diagnostic & Therapeutic applicationTrans cranial magnetic stimulation - Diagnostic & Therapeutic application
Trans cranial magnetic stimulation - Diagnostic & Therapeutic application
 
RNS
RNSRNS
RNS
 
Interpretation of NCV.pptx
Interpretation of NCV.pptxInterpretation of NCV.pptx
Interpretation of NCV.pptx
 
Electrodiagnosis 1
Electrodiagnosis 1Electrodiagnosis 1
Electrodiagnosis 1
 
Anatomy of neuromuscular junction
Anatomy of neuromuscular junction Anatomy of neuromuscular junction
Anatomy of neuromuscular junction
 
Additional notes on MG.pptx
Additional notes on MG.pptxAdditional notes on MG.pptx
Additional notes on MG.pptx
 
Russian current
Russian currentRussian current
Russian current
 
russiancurrent-180205124702.pdf
russiancurrent-180205124702.pdfrussiancurrent-180205124702.pdf
russiancurrent-180205124702.pdf
 
Russian current (Electrotherapy)
Russian current (Electrotherapy) Russian current (Electrotherapy)
Russian current (Electrotherapy)
 
Neuromuscular transmission and its pharmacology
Neuromuscular transmission and its pharmacologyNeuromuscular transmission and its pharmacology
Neuromuscular transmission and its pharmacology
 
Gbs Eps Am
Gbs Eps AmGbs Eps Am
Gbs Eps Am
 
NEUROMUSCULAR MONITORING .pptx
NEUROMUSCULAR MONITORING .pptxNEUROMUSCULAR MONITORING .pptx
NEUROMUSCULAR MONITORING .pptx
 

More from Neurology resident slides

lithium in treatment of motor neuron disease
lithium in treatment of motor neuron disease lithium in treatment of motor neuron disease
lithium in treatment of motor neuron diseaseNeurology resident slides
 
Differential diagnosis of suspected multiple sclerosis
Differential diagnosis of suspected multiple sclerosisDifferential diagnosis of suspected multiple sclerosis
Differential diagnosis of suspected multiple sclerosisNeurology resident slides
 
neurologic presentations of systemic vasculitis
neurologic presentations of systemic vasculitisneurologic presentations of systemic vasculitis
neurologic presentations of systemic vasculitisNeurology resident slides
 
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICUapproach to neurologic illness in medical ICU
approach to neurologic illness in medical ICUNeurology resident slides
 

More from Neurology resident slides (19)

MS diagnostic criteria
MS diagnostic criteriaMS diagnostic criteria
MS diagnostic criteria
 
Differential diagnosis of LETM in adults
Differential diagnosis of LETM in adultsDifferential diagnosis of LETM in adults
Differential diagnosis of LETM in adults
 
journal club ccsvi
journal club ccsvijournal club ccsvi
journal club ccsvi
 
lithium in treatment of motor neuron disease
lithium in treatment of motor neuron disease lithium in treatment of motor neuron disease
lithium in treatment of motor neuron disease
 
Immunotherapy for gbs
Immunotherapy for gbsImmunotherapy for gbs
Immunotherapy for gbs
 
neurological illness in ICU
neurological illness in ICUneurological illness in ICU
neurological illness in ICU
 
Hirayama jc
Hirayama jcHirayama jc
Hirayama jc
 
Gbs hyperreflexia
Gbs hyperreflexiaGbs hyperreflexia
Gbs hyperreflexia
 
Differential diagnosis of suspected multiple sclerosis
Differential diagnosis of suspected multiple sclerosisDifferential diagnosis of suspected multiple sclerosis
Differential diagnosis of suspected multiple sclerosis
 
Brachial plexus
Brachial plexusBrachial plexus
Brachial plexus
 
Artifacts in eeg final
Artifacts in eeg finalArtifacts in eeg final
Artifacts in eeg final
 
IIcranial nerve
IIcranial nerveIIcranial nerve
IIcranial nerve
 
V isual evoked potentials
V isual evoked potentialsV isual evoked potentials
V isual evoked potentials
 
Multiple sclerosis and rituximab
Multiple sclerosis and rituximabMultiple sclerosis and rituximab
Multiple sclerosis and rituximab
 
Management of parkinson’s disease
Management of parkinson’s diseaseManagement of parkinson’s disease
Management of parkinson’s disease
 
neurologic presentations of systemic vasculitis
neurologic presentations of systemic vasculitisneurologic presentations of systemic vasculitis
neurologic presentations of systemic vasculitis
 
oral drugs in multiple sclerosis
oral drugs in multiple sclerosisoral drugs in multiple sclerosis
oral drugs in multiple sclerosis
 
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICUapproach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
 
multiple system atrophy-newer developments
multiple system atrophy-newer developmentsmultiple system atrophy-newer developments
multiple system atrophy-newer developments
 

Recently uploaded

Manyata Tech Park ( Call Girls ) Bangalore ✔ 6297143586 ✔ Hot Model With Sexy...
Manyata Tech Park ( Call Girls ) Bangalore ✔ 6297143586 ✔ Hot Model With Sexy...Manyata Tech Park ( Call Girls ) Bangalore ✔ 6297143586 ✔ Hot Model With Sexy...
Manyata Tech Park ( Call Girls ) Bangalore ✔ 6297143586 ✔ Hot Model With Sexy...vidya singh
 
VIP Hyderabad Call Girls Bahadurpally 7877925207 ₹5000 To 25K With AC Room 💚😋
VIP Hyderabad Call Girls Bahadurpally 7877925207 ₹5000 To 25K With AC Room 💚😋VIP Hyderabad Call Girls Bahadurpally 7877925207 ₹5000 To 25K With AC Room 💚😋
VIP Hyderabad Call Girls Bahadurpally 7877925207 ₹5000 To 25K With AC Room 💚😋TANUJA PANDEY
 
Premium Call Girls In Jaipur {8445551418} ❤️VVIP SEEMA Call Girl in Jaipur Ra...
Premium Call Girls In Jaipur {8445551418} ❤️VVIP SEEMA Call Girl in Jaipur Ra...Premium Call Girls In Jaipur {8445551418} ❤️VVIP SEEMA Call Girl in Jaipur Ra...
Premium Call Girls In Jaipur {8445551418} ❤️VVIP SEEMA Call Girl in Jaipur Ra...parulsinha
 
Call Girls Service Jaipur {8445551418} ❤️VVIP BHAWNA Call Girl in Jaipur Raja...
Call Girls Service Jaipur {8445551418} ❤️VVIP BHAWNA Call Girl in Jaipur Raja...Call Girls Service Jaipur {8445551418} ❤️VVIP BHAWNA Call Girl in Jaipur Raja...
Call Girls Service Jaipur {8445551418} ❤️VVIP BHAWNA Call Girl in Jaipur Raja...parulsinha
 
8980367676 Call Girls In Ahmedabad Escort Service Available 24×7 In Ahmedabad
8980367676 Call Girls In Ahmedabad Escort Service Available 24×7 In Ahmedabad8980367676 Call Girls In Ahmedabad Escort Service Available 24×7 In Ahmedabad
8980367676 Call Girls In Ahmedabad Escort Service Available 24×7 In AhmedabadGENUINE ESCORT AGENCY
 
Call Girls Jaipur Just Call 9521753030 Top Class Call Girl Service Available
Call Girls Jaipur Just Call 9521753030 Top Class Call Girl Service AvailableCall Girls Jaipur Just Call 9521753030 Top Class Call Girl Service Available
Call Girls Jaipur Just Call 9521753030 Top Class Call Girl Service AvailableJanvi Singh
 
Russian Call Girls Lucknow Just Call 👉👉7877925207 Top Class Call Girl Service...
Russian Call Girls Lucknow Just Call 👉👉7877925207 Top Class Call Girl Service...Russian Call Girls Lucknow Just Call 👉👉7877925207 Top Class Call Girl Service...
Russian Call Girls Lucknow Just Call 👉👉7877925207 Top Class Call Girl Service...adilkhan87451
 
Call Girls in Delhi Triveni Complex Escort Service(🔝))/WhatsApp 97111⇛47426
Call Girls in Delhi Triveni Complex Escort Service(🔝))/WhatsApp 97111⇛47426Call Girls in Delhi Triveni Complex Escort Service(🔝))/WhatsApp 97111⇛47426
Call Girls in Delhi Triveni Complex Escort Service(🔝))/WhatsApp 97111⇛47426jennyeacort
 
Call Girls Service Jaipur {9521753030 } ❤️VVIP BHAWNA Call Girl in Jaipur Raj...
Call Girls Service Jaipur {9521753030 } ❤️VVIP BHAWNA Call Girl in Jaipur Raj...Call Girls Service Jaipur {9521753030 } ❤️VVIP BHAWNA Call Girl in Jaipur Raj...
Call Girls Service Jaipur {9521753030 } ❤️VVIP BHAWNA Call Girl in Jaipur Raj...khalifaescort01
 
The Most Attractive Hyderabad Call Girls Kothapet 𖠋 9332606886 𖠋 Will You Mis...
The Most Attractive Hyderabad Call Girls Kothapet 𖠋 9332606886 𖠋 Will You Mis...The Most Attractive Hyderabad Call Girls Kothapet 𖠋 9332606886 𖠋 Will You Mis...
The Most Attractive Hyderabad Call Girls Kothapet 𖠋 9332606886 𖠋 Will You Mis...chandars293
 
Andheri East ) Call Girls in Mumbai Phone No 9004268417 Elite Escort Service ...
Andheri East ) Call Girls in Mumbai Phone No 9004268417 Elite Escort Service ...Andheri East ) Call Girls in Mumbai Phone No 9004268417 Elite Escort Service ...
Andheri East ) Call Girls in Mumbai Phone No 9004268417 Elite Escort Service ...Anamika Rawat
 
Night 7k to 12k Navi Mumbai Call Girl Photo 👉 BOOK NOW 9833363713 👈 ♀️ night ...
Night 7k to 12k Navi Mumbai Call Girl Photo 👉 BOOK NOW 9833363713 👈 ♀️ night ...Night 7k to 12k Navi Mumbai Call Girl Photo 👉 BOOK NOW 9833363713 👈 ♀️ night ...
Night 7k to 12k Navi Mumbai Call Girl Photo 👉 BOOK NOW 9833363713 👈 ♀️ night ...aartirawatdelhi
 
Call Girls Rishikesh Just Call 8250077686 Top Class Call Girl Service Available
Call Girls Rishikesh Just Call 8250077686 Top Class Call Girl Service AvailableCall Girls Rishikesh Just Call 8250077686 Top Class Call Girl Service Available
Call Girls Rishikesh Just Call 8250077686 Top Class Call Girl Service AvailableDipal Arora
 
Jogeshwari ! Call Girls Service Mumbai - 450+ Call Girl Cash Payment 90042684...
Jogeshwari ! Call Girls Service Mumbai - 450+ Call Girl Cash Payment 90042684...Jogeshwari ! Call Girls Service Mumbai - 450+ Call Girl Cash Payment 90042684...
Jogeshwari ! Call Girls Service Mumbai - 450+ Call Girl Cash Payment 90042684...Anamika Rawat
 
Coimbatore Call Girls in Coimbatore 7427069034 genuine Escort Service Girl 10...
Coimbatore Call Girls in Coimbatore 7427069034 genuine Escort Service Girl 10...Coimbatore Call Girls in Coimbatore 7427069034 genuine Escort Service Girl 10...
Coimbatore Call Girls in Coimbatore 7427069034 genuine Escort Service Girl 10...chennailover
 
Mumbai ] (Call Girls) in Mumbai 10k @ I'm VIP Independent Escorts Girls 98333...
Mumbai ] (Call Girls) in Mumbai 10k @ I'm VIP Independent Escorts Girls 98333...Mumbai ] (Call Girls) in Mumbai 10k @ I'm VIP Independent Escorts Girls 98333...
Mumbai ] (Call Girls) in Mumbai 10k @ I'm VIP Independent Escorts Girls 98333...Ishani Gupta
 
Call Girls Hosur Just Call 9630942363 Top Class Call Girl Service Available
Call Girls Hosur Just Call 9630942363 Top Class Call Girl Service AvailableCall Girls Hosur Just Call 9630942363 Top Class Call Girl Service Available
Call Girls Hosur Just Call 9630942363 Top Class Call Girl Service AvailableGENUINE ESCORT AGENCY
 
Top Quality Call Girl Service Kalyanpur 6378878445 Available Call Girls Any Time
Top Quality Call Girl Service Kalyanpur 6378878445 Available Call Girls Any TimeTop Quality Call Girl Service Kalyanpur 6378878445 Available Call Girls Any Time
Top Quality Call Girl Service Kalyanpur 6378878445 Available Call Girls Any TimeCall Girls Delhi
 
9630942363 Genuine Call Girls In Ahmedabad Gujarat Call Girls Service
9630942363 Genuine Call Girls In Ahmedabad Gujarat Call Girls Service9630942363 Genuine Call Girls In Ahmedabad Gujarat Call Girls Service
9630942363 Genuine Call Girls In Ahmedabad Gujarat Call Girls ServiceGENUINE ESCORT AGENCY
 
(Low Rate RASHMI ) Rate Of Call Girls Jaipur ❣ 8445551418 ❣ Elite Models & Ce...
(Low Rate RASHMI ) Rate Of Call Girls Jaipur ❣ 8445551418 ❣ Elite Models & Ce...(Low Rate RASHMI ) Rate Of Call Girls Jaipur ❣ 8445551418 ❣ Elite Models & Ce...
(Low Rate RASHMI ) Rate Of Call Girls Jaipur ❣ 8445551418 ❣ Elite Models & Ce...parulsinha
 

Recently uploaded (20)

Manyata Tech Park ( Call Girls ) Bangalore ✔ 6297143586 ✔ Hot Model With Sexy...
Manyata Tech Park ( Call Girls ) Bangalore ✔ 6297143586 ✔ Hot Model With Sexy...Manyata Tech Park ( Call Girls ) Bangalore ✔ 6297143586 ✔ Hot Model With Sexy...
Manyata Tech Park ( Call Girls ) Bangalore ✔ 6297143586 ✔ Hot Model With Sexy...
 
VIP Hyderabad Call Girls Bahadurpally 7877925207 ₹5000 To 25K With AC Room 💚😋
VIP Hyderabad Call Girls Bahadurpally 7877925207 ₹5000 To 25K With AC Room 💚😋VIP Hyderabad Call Girls Bahadurpally 7877925207 ₹5000 To 25K With AC Room 💚😋
VIP Hyderabad Call Girls Bahadurpally 7877925207 ₹5000 To 25K With AC Room 💚😋
 
Premium Call Girls In Jaipur {8445551418} ❤️VVIP SEEMA Call Girl in Jaipur Ra...
Premium Call Girls In Jaipur {8445551418} ❤️VVIP SEEMA Call Girl in Jaipur Ra...Premium Call Girls In Jaipur {8445551418} ❤️VVIP SEEMA Call Girl in Jaipur Ra...
Premium Call Girls In Jaipur {8445551418} ❤️VVIP SEEMA Call Girl in Jaipur Ra...
 
Call Girls Service Jaipur {8445551418} ❤️VVIP BHAWNA Call Girl in Jaipur Raja...
Call Girls Service Jaipur {8445551418} ❤️VVIP BHAWNA Call Girl in Jaipur Raja...Call Girls Service Jaipur {8445551418} ❤️VVIP BHAWNA Call Girl in Jaipur Raja...
Call Girls Service Jaipur {8445551418} ❤️VVIP BHAWNA Call Girl in Jaipur Raja...
 
8980367676 Call Girls In Ahmedabad Escort Service Available 24×7 In Ahmedabad
8980367676 Call Girls In Ahmedabad Escort Service Available 24×7 In Ahmedabad8980367676 Call Girls In Ahmedabad Escort Service Available 24×7 In Ahmedabad
8980367676 Call Girls In Ahmedabad Escort Service Available 24×7 In Ahmedabad
 
Call Girls Jaipur Just Call 9521753030 Top Class Call Girl Service Available
Call Girls Jaipur Just Call 9521753030 Top Class Call Girl Service AvailableCall Girls Jaipur Just Call 9521753030 Top Class Call Girl Service Available
Call Girls Jaipur Just Call 9521753030 Top Class Call Girl Service Available
 
Russian Call Girls Lucknow Just Call 👉👉7877925207 Top Class Call Girl Service...
Russian Call Girls Lucknow Just Call 👉👉7877925207 Top Class Call Girl Service...Russian Call Girls Lucknow Just Call 👉👉7877925207 Top Class Call Girl Service...
Russian Call Girls Lucknow Just Call 👉👉7877925207 Top Class Call Girl Service...
 
Call Girls in Delhi Triveni Complex Escort Service(🔝))/WhatsApp 97111⇛47426
Call Girls in Delhi Triveni Complex Escort Service(🔝))/WhatsApp 97111⇛47426Call Girls in Delhi Triveni Complex Escort Service(🔝))/WhatsApp 97111⇛47426
Call Girls in Delhi Triveni Complex Escort Service(🔝))/WhatsApp 97111⇛47426
 
Call Girls Service Jaipur {9521753030 } ❤️VVIP BHAWNA Call Girl in Jaipur Raj...
Call Girls Service Jaipur {9521753030 } ❤️VVIP BHAWNA Call Girl in Jaipur Raj...Call Girls Service Jaipur {9521753030 } ❤️VVIP BHAWNA Call Girl in Jaipur Raj...
Call Girls Service Jaipur {9521753030 } ❤️VVIP BHAWNA Call Girl in Jaipur Raj...
 
The Most Attractive Hyderabad Call Girls Kothapet 𖠋 9332606886 𖠋 Will You Mis...
The Most Attractive Hyderabad Call Girls Kothapet 𖠋 9332606886 𖠋 Will You Mis...The Most Attractive Hyderabad Call Girls Kothapet 𖠋 9332606886 𖠋 Will You Mis...
The Most Attractive Hyderabad Call Girls Kothapet 𖠋 9332606886 𖠋 Will You Mis...
 
Andheri East ) Call Girls in Mumbai Phone No 9004268417 Elite Escort Service ...
Andheri East ) Call Girls in Mumbai Phone No 9004268417 Elite Escort Service ...Andheri East ) Call Girls in Mumbai Phone No 9004268417 Elite Escort Service ...
Andheri East ) Call Girls in Mumbai Phone No 9004268417 Elite Escort Service ...
 
Night 7k to 12k Navi Mumbai Call Girl Photo 👉 BOOK NOW 9833363713 👈 ♀️ night ...
Night 7k to 12k Navi Mumbai Call Girl Photo 👉 BOOK NOW 9833363713 👈 ♀️ night ...Night 7k to 12k Navi Mumbai Call Girl Photo 👉 BOOK NOW 9833363713 👈 ♀️ night ...
Night 7k to 12k Navi Mumbai Call Girl Photo 👉 BOOK NOW 9833363713 👈 ♀️ night ...
 
Call Girls Rishikesh Just Call 8250077686 Top Class Call Girl Service Available
Call Girls Rishikesh Just Call 8250077686 Top Class Call Girl Service AvailableCall Girls Rishikesh Just Call 8250077686 Top Class Call Girl Service Available
Call Girls Rishikesh Just Call 8250077686 Top Class Call Girl Service Available
 
Jogeshwari ! Call Girls Service Mumbai - 450+ Call Girl Cash Payment 90042684...
Jogeshwari ! Call Girls Service Mumbai - 450+ Call Girl Cash Payment 90042684...Jogeshwari ! Call Girls Service Mumbai - 450+ Call Girl Cash Payment 90042684...
Jogeshwari ! Call Girls Service Mumbai - 450+ Call Girl Cash Payment 90042684...
 
Coimbatore Call Girls in Coimbatore 7427069034 genuine Escort Service Girl 10...
Coimbatore Call Girls in Coimbatore 7427069034 genuine Escort Service Girl 10...Coimbatore Call Girls in Coimbatore 7427069034 genuine Escort Service Girl 10...
Coimbatore Call Girls in Coimbatore 7427069034 genuine Escort Service Girl 10...
 
Mumbai ] (Call Girls) in Mumbai 10k @ I'm VIP Independent Escorts Girls 98333...
Mumbai ] (Call Girls) in Mumbai 10k @ I'm VIP Independent Escorts Girls 98333...Mumbai ] (Call Girls) in Mumbai 10k @ I'm VIP Independent Escorts Girls 98333...
Mumbai ] (Call Girls) in Mumbai 10k @ I'm VIP Independent Escorts Girls 98333...
 
Call Girls Hosur Just Call 9630942363 Top Class Call Girl Service Available
Call Girls Hosur Just Call 9630942363 Top Class Call Girl Service AvailableCall Girls Hosur Just Call 9630942363 Top Class Call Girl Service Available
Call Girls Hosur Just Call 9630942363 Top Class Call Girl Service Available
 
Top Quality Call Girl Service Kalyanpur 6378878445 Available Call Girls Any Time
Top Quality Call Girl Service Kalyanpur 6378878445 Available Call Girls Any TimeTop Quality Call Girl Service Kalyanpur 6378878445 Available Call Girls Any Time
Top Quality Call Girl Service Kalyanpur 6378878445 Available Call Girls Any Time
 
9630942363 Genuine Call Girls In Ahmedabad Gujarat Call Girls Service
9630942363 Genuine Call Girls In Ahmedabad Gujarat Call Girls Service9630942363 Genuine Call Girls In Ahmedabad Gujarat Call Girls Service
9630942363 Genuine Call Girls In Ahmedabad Gujarat Call Girls Service
 
(Low Rate RASHMI ) Rate Of Call Girls Jaipur ❣ 8445551418 ❣ Elite Models & Ce...
(Low Rate RASHMI ) Rate Of Call Girls Jaipur ❣ 8445551418 ❣ Elite Models & Ce...(Low Rate RASHMI ) Rate Of Call Girls Jaipur ❣ 8445551418 ❣ Elite Models & Ce...
(Low Rate RASHMI ) Rate Of Call Girls Jaipur ❣ 8445551418 ❣ Elite Models & Ce...
 

repetitive nerve stimulation