EVOKED POTENTIALS: CLINICAL

BASIS & INTERPRETATION

DR AVANISH BHARDWAJ
SENIOR RESIDENT
NEUROANAESTHESIA
Evoked potentials ( E.Ps.)
“E.Ps. are the measurement of the
electrical potentials produced in response
to stimulating the nervous system
(evoked) by sensory, electrical, magnetic
or cognitive stimulation”
BASICS
Record the EP’s produced after stimulation
of the specific neural tracts
Most commonly utilized – Sensory EP’s
Recorded plot – Voltage Vs Time
Initial artifact - neuronal response recorded
as peaks & troughs
Peaks – positive or negative (wrt active
electrode), plotted downward or upward
Arise from specific neural generators
BASICS
AMPLITUDE:– Peak to adjacent trough
LATENCY:– Time from stimulation to
peak
CONDUCTION TIME:- Time between
peaks or inter peak latency
Peaks named by polarity & latency
P (positive) or N (negative) followed by
latency in millisec
BASICS
Evoked response to most sensory
stimulation is very small (1-2 microV)
Amplifier reduces the electrical noise
Signal is filtered & the noise is reduced
further using a third ground electrode
Signal averaging is done
Delay in rapid feedback to the surgeon
Moving average / staggering of stimuli
BASICS
Goals: Identify impending neural
compromise & allow intervention to
prevent permanent damage
Requires pre op identification of type &
location of neural tissue at risk for
mechanical or vascular injury
Helps monitoring team to choose to
choose the most appropriate evoked
potentials
BASICS
Onset of an insult is identified by
decrease in amplitude & increase in
latency
Also used for diagnostic testing during
surgery : decision making
Identification of non-surgical problems
which require correction
BASICS
Change in evoked response – assess
surgical, physiological & anaesthetic
enviornment
Ischaemia produces loss of response
Directly related to residual blood flow &
inversely to metabolic demand of the
tissue
Time lag between change in evoked
potentials & irreversible injury
BASICS
Slow loss of response amplitude &
increase in latency – diffuse ischaemia
Fast loss of amplitude with minimal
change in latency – mechanical injury or
localized ischaemia
Amplitude reduction of 50% or latency
increase of 10% is considered significant
Smaller changes – impending
compromise
FOCUS OF INTEREST
SOMATOSENSORY EVOKED
POENTIALS (SSEP)
AUDITORY BRAINSTEM RESPONSES
(ABR)
VISUAL EVOKED POTENTIALS
(VEP)
MOTOR EVOKED POTENTIALS
SSEP
Most commonly monitored
Peripheral sensory nerves stimulated
electrically
Response measured along the sensory
pathway
Median (C6-T1), Ulnar (C8-T1),
Common peroneal (L4-S1) & post tibial
(L4-S2) are commonly used
SSEP
Stimulation activates predominantly large
diameter, fast conducting Ia muscle
afferent & group II cutaneous nerves
Stimulation produces orthodromic &
antidromic transmission
Orthodromic motor stimulation – muscle
response – twitch
Orthodromic sensory stimulation –
produces SSEP
SSEP
Stimulus ascends through the sensory
pathway primarily through ipsilateral
dorsal column
First synapse – Nu cuneatus & gracilis
Decussates near cervicomedullary
junction – ascends in contralateral medial
leminiscus
Second synapse – VPL nucleus of
thalamus
Projects to contralateral sensory cortex
SSEP
Upper extremity – electrodes placed over
antecubital fossa, supraclavicular fossa,
cervical spine & cortex
Lower extremity – popliteal fossa, along
the spinal cord, cervical & cortical
Cortical response best over primary
somatosensory cortex
SSEP
Stimulation using electronic stimulator
constant Sq. wave current of 0.1 ms
duration, and 3/s in repetition rate
Filter of 30-300 cycles /sec; Imped : 5000
ohms
Average of 256 evoked responses
Generators of SSEP after
Median Nerve stimulation
Peak Generators
N9 Brachial plexus
N11 Posterior columns or spinal roots
N13/ P13 Dorsal column, Nucleus cuneatus
N14/N15 Medial lemniscus
N19/P22 Parietal sensory cortex
Cortical monitoring using SSEP
Detects ischemia in & localizes specific
areas of cortical tissue
SSEP responses are lost at a local blood
flow between 15 – 18 ml/100gm/min
Employed during intracranial vascular
procedures:
 Determine the adequacy of collateral blood flow
 Tolerance during temporary vessel occlusion
 Adequacy of cerebral blood flow
SSEP during Aneurysm surgery
SSEP from upper extremity is generated in the
cerebral cortex supplied by MCA – utilized for
aneurysms of ICA & MCA
From lower limb – ACA
Prompt loss of cortical SSEP response (< 1min)
– permanent neurological deficit
Delayed loss with prompt recovery – presence
of collateral circulation
N20 of median n dissapears slowly (over 4min)
– 10 min of additional occlusion tolerated safely
Cortical monitoring using SSEP
CEA surgeries – indication for shunt
placement, prediction of adverse outcome
Identify ischaemia from vasospasm
Neuroradiology – occlusion of vessels,
dissolution of clots
Localization of sensory-motor cortex in
anaesthetized patients
SSEP for spinal surgey
Identifies mechanical or ischaemic insults
Distraction of spine, placement of pedicle
screws & bony decompression : spinal
cord itself or N. may be injured
SSEPs moniotrs integrity of posterior
aspect of spinal cord : hence, isolated
anterior spinal injury may go undetected
SSEP in spinal surgery
295 pts undergoing spinal stabilisation :
neurologic injury rate ↓ed from 6.9% to 0.7%
with SSEP monitoring (Meyer et al, 1988)
100 pts cervical spine surgery : ↓ in
paraplegia from 3.7% to 0% with SSEP
monitoring ( Numer et al, 1995)
Scoliosis research society & european spinal
deformities society analysis 1995 – overall
injury incidence 0.55%; definitive false
negative response was 0.063%
AUDITORY BRAINSTEM
RESPONSES (ABR)
Produced when sound activates the auditory
pathway
Refers to the responses recorded from the
brainstem usually in the first 10 msec after
stimulation
Performed with “clicks” & “pips”
Clicks have a broad spectrum of frequency
content (significant stimulation between 1000-
4000 Hz)
Also referred to as BAEP & BAER
ABR
3 major peaks
Wave I: extracranial portion of VIII CN
Wave III: acoustic relay nuclei & tracts
deep in the midline of the lower pons
Wave V: lateral leminiscus & inferior
colliculus in the contralateral pons
Used extensively for monitoring during
surgery involving the posterior fossa
Alteration in ABR
Sound conduction problems in the
external or middle ear
Ischemia of cochlea
Traction on VIII CN
Ischemia or damage to auditory pathways
in the brainstem
Changes in ABR
Most common intraoperative change:
increase in the latency of wave V &
increase in the interpeak latency of I
through V with retractor placement in the
post fossa
Complete loss of wave I: loss of cochlear
blood supply by vascular obstruction or
vasospasm or surgical transection
Changes in ABR
Changes in wave V are less significant
Waves I & V preserved – hearing
generally preserved
Both are lost – hearing generally lost
Other indications
Decompression of space occupying
lesions in the cerebellum
Removal of cerebellar vascular
malformations
Microvascular decompression for relief of
hemifacial spasm or trigeminal neuralgia
Visual evoked potentials (VEP)
Produced in response to light stimulation
of the eyes
Response is generated bilaterally in the
visual (occippital) cortex, supplied by the
post cerebral A
Flash stimulation is utilised
ERG can be measured by placing the
electrodes near the eye
Indications
Monitor anterior visual pathways
◦ Craniofacial procedures
◦ Pituitary surgery
◦ Surgery in the retrochiasmatic visual tracts &
occipital cortex
Pitfalls
Flash stimulation may not measure the
pathways of useful clinical vision
Technical problems with cumbersome
equipment
Focal changes are obscured as the
response is bilateral in nature
Sensitivity to anaesthetics
Motor evoked potentials (MEP)
Becoming common particularly for spinal
surgery
Better correlation with postoperative motor
outcome
Allow differentiation of the motor pathways
as MEP’s & SSEP’s arise from different areas
Transcranial stimulation of motor cortex –
descending response via corticospinal tract –
muscle response in form of CMAP
INDICATIONS
Correction of axial skeleton deformity
Intra medullary spinal cord tumors
Intracranial tumors
Vascular lesions
Assessment of spinal cord function during
thoraco abdominal aneurysm repair
MEP
Electricalstimulation of the motor cortex
Wave of depolarization involving the
corticospinal tract
Measured in epidural space : direct or D wave
Additional transsynaptic activation of
internuncial pathways in the cortex: indirect
or I waves
D + I waves summate in ant horn cells =
CMAP
MEP
Monitoring can be perfomed in the epidural
space (D wave) or in a muscle (CMAP)
Spinal surgery: MEP’s recorded in lower
extremity (tibialis anterior, lat or medial
gastrocnemius & ant hallucis) & upper
extremity (add poll brevis)
Only reliable monitor of motor pathways
Early predictor of spinal cord damage
Also useful during aneurysm clipping surgeries
Complications
Corticalthermal injury
Tongue laceration
Arrythmias
Burns
Jaw fracture
Awareness
C/I
Epilepsy
Raised ICP
Intra cranial apparatus
Cardiac pacemakers
Anaesthetic considerations
Physiological alterations:
◦ Inadequate oxygen delivery
◦ Hypothermia
◦ Electrolyte abnormalities
◦ Hypoglycemia
◦ Hypotension
Mechanism of action
SSEP: reduce synaptic transmission
hence recordings at cervical & further
peripheral level are affected less
Gating of information at the level of
thalamus
Dose dependent reduction in cortical
response
MEP: D wave altered less
I waves are progressively affected
Prominent effect on cortical response
with conc. above 0.5-1 MAC
Smaller effect on peripheral response
Minimal change in D waves
CMAP response most easily abolished by
inhalational agents
Opioids: mild depression of all responses
with loss of late sensory evoked response
Ketamine: effect on subcortical &
peripheral response – minimal; enhances
cortical SSEP amplitude & CMAP
response
Thiopentone & midazolam: mild
depression of cortical sensory response
but long lasting depression of MEP
Etomidate: amp increase in cortical
sensory component
Dexmedetomidine: minimal effect
Propofol: induction produces amp
depression in cortical SSEP with rapid
recovery after termination of infusion
Infusion allows cortical SSEP & MEP
monitoring
Depression of MEP at higher doses
TIVA is preferred when MEP are to be
monitored
NM blockers: prevent CAMP monitoring;
no effect on SSEP & epidural recordings
of MEP monitoring
THANK YOU