Evoked Potenital Reading Session: BAEPs Alan D. Legatt, M.D., Ph.D. Disclosures relevant to this presentation: None AEP Components on a Logarithmic Time Scale Source: Picton TW, Hillyard SA. Human auditory evoked potentials. : Effects of attention. Electroenceph Clin Neurophysiol 1974;36:191-199. Effects of Attention on Latency Classes of AEPs Short-latency AEPs Middle-latency AEPs Long-latency AEPs Source: Picton TW, Hillyard SA. "Human auditory evoked potentials. : Effects of attention." Electroenceph Clin Neurophysiol 1974;36:191-199. 1
Latency Classes of AEPs Long-latency AEPs Affected by the degree of attention being paid to the stimulus and the information content of the stimulus Markedly attenuated by surgical anesthesia Middle latency AEPs ndependent of attention and stimulus information content Prominently affected by surgical anesthesia Small and subject to myogenic contamination Short latency or brainstem AEPs Easy to record, highly consistent across subjects ndependent of attention and stimulus information content May be affected by hypothermia, but relatively unaffected by sedation and surgical levels of anesthesia BAEPs (Cz-Ai recording) V V V V 0.2 µv N VN Source: Legatt AD. Brainstem Auditory Evoked Potentials: Methodology, nterpretation, and Clinical Application. n: Aminoff MJ, editor. Electrodiagnosis in Clinical Neurology, 6th edition. New York: Churchill Livingstone, 2012:519-552. BAEPs in Various Recording Linkages V V V V Cz-Ai N VN Cz-Ac 0.2 µv Ac-Ai Source: Legatt AD. Brainstem Auditory Evoked Potentials: Methodology, nterpretation, and Clinical Application. n: Aminoff MJ, editor. Electrodiagnosis in Clinical Neurology, 6th edition. New York: Churchill Livingstone, 2012:519-552. 2
BAEP Recording Techniques Extraoperative Commonest stimuli are acoustic clicks, generated by delivering 100 µsec duration monophasic electrical square pulses to an acoustic transducer; tone pips can be used, too A single click polarity (rarefaction clicks are typically the best) Typical stimulus intensity 60 65 db nhl; higher intensities may be used in patients with a hearing loss, and lower intensities may be used for hearing threshold measurements Stimulus repetition rate of approximately 10/sec, but not an exact submultiple of the line frequency (= 60 Hz in the U.S.) Stimulate monaurally, with contralateral white noise masking Filter bandpass 100 or 150 Hz to 3,000 Hz Typical analysis time (epoch duration) = 10 msec, increase to 15 msec for BAEPs in babies, abnormal BAEPs, BAEPs to lowered stimulus intensities, and intraoperative monitoring Typical number of sweeps in an average = 2,000 Generators of the Human BAEPs Source: Legatt AD, et al. The anatomic and physiologic bases of brain stem auditory evoked potentials. Neurologic Clinics 1988;6:681-704. Generators of the Human BAEPs The obligate components are waves,, and V Waves V and V may be fused into a V-V complex with a morphology that varies among subjects Wave is the eighth nerve compound action potential in the most distal part (the cochlear end) of the eighth nerve All subsequent components are the composites of contributions from multiple generators; for example, wave receives contributions from the second eighth nerve volley in the distal end of the eighth nerve, and the first eighth nerve volley at the level of the proximal nerve and cochlear nucleus n clinical-pathological correlations, wave reflects activity within the auditory pathways in the lower pons, and wave V reflects activity at the level of the mesencephalon BAEPs cannot be used to assess the auditory pathways rostral to the mesencephalon 3
nterpretation of Extraoperative BAEPs is Predominantly Based on Component Latencies A V V 1.98 msec 1.98 msec 0.2 µv B V 4.04 2.74 Cz-Ai BAEPs to stimulation of each ear in a 35 year old woman with multiple sclerosis. The - and -V interpeak intervals are both abnormally prolonged following right ear stimulation (B). BAEPs to left ear stimulation (A) are normal. Source: Legatt AD. Brainstem Auditory Evoked Potentials: Methodology, nterpretation, and Clinical Application. n: Aminoff MJ, editor. Electrodiagnosis in Clinical Neurology, 6th edition. New York: Churchill Livingstone, 2012:519-552. The Only Amplitude Criterion Used is the V-V: Ratio V-V V 0.5 µv 1.54 3.6 5.36 BAEPs in a 27 year old woman with probable multiple sclerosis. The V-V: amplitude ratio is 0.28; all absolute latencies and interpeak intervals are normal. The stimulus intensity was 65 db nhl. Source: Legatt AD. Brainstem Auditory Evoked Potentials: Methodology, nterpretation, and Clinical Application. n: Aminoff MJ, editor. Electrodiagnosis in Clinical Neurology, 6th edition. New York: Churchill Livingstone, 2012:519-552. BAEP nterpretation (Extraoperative) dentify components Measure the latencies of waves,, and V Calculate the -, -V, and -V interpeak intervals Calculate the right-left differences of these measures Measure the amplitudes of wave and of the V-V complex, each from the highest peak to the low point of the trough that follows Calculate the V-V: amplitude ratios Compare the above values to the laboratory norms 4
BAEP nterpretation Normal values Norms are for 65 db nhl, 11/sec rarefaction clicks Upper limits of normal (ULN) defined as mean + 3 s.d. ULN ULN of R-L diff. Wave latency 1.82 msec 0.10 msec Wave latency 3.87 msec 0.24 msec Wave V latency 6.02 msec 0.4 - interpeak interval 2.44 msec 0.22 msec -V interpeak interval 2.30 msec 0.26 msec -V interpeak interval 4.56 msec 0.2 Lower limit of normal for the V-V: amplitude ratio = 0.50 34 year old man with blurred vision, diplopia, vertigo, and numbness of the fingers; he had a similar episode 5 months ago 1.82 1.72 3.90 3.84 V 6.36 V 5.90 2.08 2.12 V 2.46 V 2.06 V 4.54 V 4.18 17 year old girl with a prior episode of right facial pain and paresthesias, and a new episode of bilateral arm and leg paresthesias 1.40 1.38 3.58 3.45 V 5.38 V 5.36 2.18 2.16 V 1.80 V 1.82 V 3.98 V 3.98 5
35 year old woman with right hand weakness, numbness, and paresthesias as well as dizziness, imbalance, and diplopia 1.66 1.60 3.58 5.66 V 5.60 V 8.52 1.92 4.06 V 2.02 V 2.86 V 3.94 V 6.92 28 year old woman 1.68 1.74 ----- 3.88 V ----- V 6.12 ----- 2.12 V ----- V 2.24 V ----- V 4.38 30 year old woman ( gain) ----- 1.40 ----- 3.62 V ----- V 6.26 ----- 2.22 V ----- V 2.64 V ----- V 4.86 6
Three Major Points from This Talk BAEPs comprise multiple component peaks that are generated in the eighth nerve and in brainstem auditory structures. They cannot be used to assess the auditory pathways rostral to the mesencephalon. BAEPs are interpreted predominantly based on the latencies of waves,, and V, on the -, -V, and -V interpeak intervals, on the right-left differences of these measures, and on the V-V/ amplitude ratios Wave is generated in the distal eighth nerve, wave predominantly reflects activity within the auditory pathways in the lower pons, and wave V predominantly reflects activity within the auditory pathways at the level of the mesencephalon 7