The value of ulnar somatosensory evoked potentials (SEPs) in cervical myelopathy

In 57 patients with clinical signs and surgical documentation of compressive myelopathy, ulnar nerve somatosensory evoked potentials (SEPs) were more sensitive (with 74% abnormal) than either median or tibial nerve SEPs. The most frequent abnormalities were reduced or absent neck evoked responses and prolonged central conduction time. All subjects who had an SEP abnormality were identified by combined tibial and ulnar SEPs. Median nerve SEP added no additional information. Normal ulnar and tibial nerve SEPs were also able to exclude major cord damage in patients with cervical radiculopathy but little evidence of myelopathy.     

Nerve,spinal cord and brain somatosensory evoked responses: a comparative study during electrical and magnetic peripheral nerve stimulation

Somatosensory evoked potentials (SEPs) and compound nerve action potentials (cNAPs) have been recorded in 15 subjects during electrical and magnetic nerve stimulation. Peripheral records were gathered at Erb's point and on nerve trunks at the elbow during median and ulnar nerve stimulation at the wrist. Erb responses to electrical stimulation were larger in amplitude and shorter in duration than the magnetic ones when ‘electrical’ and ‘magnetic’ compound muscle action potentials (cMAPs) of comparable amplitudes were elicited. SEPs were recorded respectively at Cv7 and on the somatosensory scalp areas contra- and ipsilateral to the stimulated side. SEPs showed a statistically significant difference in amplitude only for the brachial plexus response and for the ‘cortical’ N20-P25 complex; differences were not found between the magnetic and electrical central conduction times (CCTs) or for the peripheral nerve response latencies. Magnetic stimulation preferentially excited the motor and proprioceptive fibres when the nerve trunks were stimulated at motor threshold intensities.     

The assessment of severe head injury by short-latency somatosensory and brain-stem auditory evoked potentials

The relative prognostic value of short-latency somatosensory evoked potentials (SEPs) and brain-stem auditory evoked potentials (BAEPs) was assessed in 35 patients with post-traumatic coma. Analysis of the evoked potentials was restricted to those recorded within the first 4 days following head injury. Abnormal SEPs were defined as an increase in central somatosensory conduction time or an absence of the initial cortical potential following stimulation of either median nerve. Abnormal BAEPs were classified as an increase in the wave I–V interval or the loss of any or all of its 3 most stable components (waves I, III and V) following stimulation of either ear. SEPs reliably both good and bad outcomes. All 17 patients in whom SEPs were graded as normal had a favourable outcome and 15 of 18 patients in whom SEPs were abnormal had an unfavourable outcome. Although abnormal BAEPs were associated with an unfavourable outcome in almost all patients (6 of 7), only 19 of 28 patients with normal BAEPs had a favourable outcome. The finding of normal BAEPs was therefore of little prognostic significance. These results confirm the superiority and greater sensitivity of the SEP in detecting abnormalities of brain function shortly after severe head trauma.     

Middle-latency somatosensory evoked potentials following median and posterior tibial nerve stimulation in Down's syndrome

Middle-latency somatosensory evoked potentials (SEPs) following median and posterior tibial nerve stimulation were studied in 40 patients with Down's syndrome and in age- and gender-matched healthy controls as well as in middle-aged and aged healthy subjects. In median nerve SEPs, latencies of the initial cortical potentials, N18 and P18, showed no significant difference, but the following potentials N22, P25, N32, P41 and P46 were relatively or significantly shorter in latency in Down's patients than in the controls. Amplitudes of all components in Down's patients were significantly larger than those of age- and gender-matched controls as well as of those of middle-aged healthy subjects, but there was only a small difference in their amplitudes from aged healthy subjects. Results of posterior tibial nerve SEPs were generally consistent with those of median nerve SEPs. Therefore, ‘short latency with large amplitude’ is the main characteristic of middle-latency SEPs in Down's syndrome, possibly related to accelerated physiological aging of the central nervous system.     

Afferent mechanism of cortical myoclonus studied by proprioception-related SEPs

Proprioception-related somatosensory evoked potentials (SEPs) to passive flexion movement of the middle finger at proximal interphalangeal joint were recorded in 7 patients with myoclonus of cortical origin who demonstrated enlarged electrical SEPs (giant SEPs). In 3 out of the 7 patients, the proprioception-related SEPs were also enlarged. The remaining 4 patients showed giant electrical SEPs without enhancement of proprioception-related SEPs. Long loop electromyographic response was recorded during the resting condition in all of the 3 patients with enlarged proprioception-related SEPs. We have previously reported that proprioception-related SEPs are mainly generated by muscle afferent inputs, though electrical SEPs are thought to reflect mostly cutaneous inputs with some contribution from muscle afferents. Therefore, it is concluded that hyperexcitability of the sensorimotor cortex in cortical myoclonus is modality-specific. Cortical excitability is exaggerated to both cutaneous and deep receptor inputs in some patients, but only to cutaneous input in others.     

Vegetative versus Minimally Conscious States: A Study Using TMS-EEG,Sensory and Event-Related Potentials

Differential diagnoses between vegetative and minimally conscious states (VS and MCS, respectively) are frequently incorrect. Hence, further research is necessary to improve the diagnostic accuracy at the bedside. The main neuropathological feature of VS is the diffuse damage of cortical and subcortical connections. Starting with this premise, we used electroencephalography (EEG) recordings to evaluate the cortical reactivity and effective connectivity during transcranial magnetic stimulation (TMS) in chronic VS or MCS patients. Moreover, the TMS-EEG data were compared with the results from standard somatosensory-evoked potentials (SEPs) and event-related potentials (ERPs). Thirteen patients with chronic consciousness disorders were examined at their bedsides. A group of healthy volunteers served as the control group. The amplitudes (reactivity) and scalp distributions (connectivity) of the cortical potentials evoked by TMS (TEPs) of the primary motor cortex were measured. Short-latency median nerve SEPs and auditory ERPs were also recorded. Reproducible TEPs were present in all control subjects in both the ipsilateral and the contralateral hemispheres relative to the site of the TMS. The amplitudes of the ipsilateral and contralateral TEPs were reduced in four of the five MCS patients, and the TEPs were bilaterally absent in one MCS patient. Among the VS patients, five did not manifest ipsilateral or contralateral TEPs, and three of the patients exhibited only ipsilateral TEPs with reduced amplitudes. The SEPs were altered in five VS and two MCS patients but did not correlate with the clinical diagnosis. The ERPs were impaired in all patients and did not correlate with the clinical diagnosis. These TEP results suggest that cortical reactivity and connectivity are severely impaired in all VS patients, whereas in most MCS patients, the TEPs are preserved but with abnormal features. Therefore, TEPs may add valuable information to the current clinical and neurophysiological assessment of chronic consciousness disorders.     

Serial recording of sensory,corticomotor, and brainstem-derived motor evoked potentials in the rat

A method is presented for serial recording of corticomotor evoked potentials (CMEPs), brainstem-derived motor evoked potentials (BMEPs), and somatosensory evoked potentials (SEPs) via permanently implanted cranial screws. One screw was positioned posterior to lambda (posterior screw), and two screws were positioned over the cortical hind limb areas (cortical screws). SEPs were elicited by stimulation of the hind paw and recorded from the contralateral cortex. BMEPs were stimulated via the posterior screw and recorded from both hind limbs, whereas CMEPs were elicited by repeated bipolar stimulation of the cortex and recorded from the contralateral hind limb. BMEPs and CMEPs differed in several points and can be considered as completely separate motor evoked potentials. While BMEPs consisted of a prominent negative peak with short latency (5–7.5 ms), CMEPs were represented by polyphasic signals with long latencies (17–22 ms). The cortical origin of the CMEPs was confirmed by transecting the corticospinal tracts, which abolished the CMEPs but spared the BMEPs. SEPs consisted of three consecutive peaks with mean latencies of the initial peak ranging between 15 and 17 ms. Dorsal column transection also abolished SEPs. In healthy rats, all three signals were recorded for six consecutive weeks. Signal parameters did not change significantly within this observation period. Rats tolerated the screws and the repeated measurements very well and no negative affect on animal behavior was noted. Thus, this method allows serial recording of SEPs, CMEPs, and BMEPs in chronic rat models.     

Serial recording of sensory, corticomotor, and brainstem-derived motor evoked potentials in the rat

A method is presented for serial recording of corticomotor evoked potentials (CMEPs), brainstem-derived motor evoked potentials (BMEPs), and somatosensory evoked potentials (SEPs) via permanently implanted cranial screws. One screw was positioned posterior to lambda (posterior screw), and two screws were positioned over the cortical hind limb areas (cortical screws). SEPs were elicited by stimulation of the hind paw and recorded from the contralateral cortex. BMEPs were stimulated via the posterior screw and recorded from both hind limbs, whereas CMEPs were elicited by repeated bipolar stimulation of the cortex and recorded from the contralateral hind limb. BMEPs and CMEPs differed in several points and can be considered as completely separate motor evoked potentials. While BMEPs consisted of a prominent negative peak with short latency (5-7.5 ms), CMEPs were represented by polyphasic signals with long latencies (17-22 ms). The cortical origin of the CMEPs was confirmed by transecting the corticospinal tracts, which abolished the CMEPs but spared the BMEPs. SEPs consisted of three consecutive peaks with mean latencies of the initial peak ranging between 15 and 17 ms. Dorsal column transection also abolished SEPs. In healthy rats, all three signals were recorded for six consecutive weeks. Signal parameters did not change significantly within this observation period. Rats tolerated the screws and the repeated measurements very well and no negative affect on animal behavior was noted. Thus, this method allows serial recording of SEPs, CMEPs, and BMEPs in chronic rat models.     

Acidic FGF enhances functional regeneration of adult dorsal roots

It has been well documented that the regeneration of sensory axons severed in the dorsal roots into the spinal cord is largely inhibited in adult mammals. We investigated whether peripheral nerve grafts combined with acidic fibroblast growth factor (aFGF) could induce the regeneration of transected dorsal roots in adult rats, as evaluated by cortical somatosensory evoked potentials (SEPs). Median nerve (forelimb) stimuli produced consistent responses in the primary somatosensory cortex of normal rats, but these were completely eliminated after the transection of cervical 6th - 8th roots. The dorsal root stumps were immediately anastomosed to the cord with intercostal nerve grafts. Subsequently, aFGF in fibrin glue was administered to the grafted area. Four to twenty weeks after rhizotomy, six of the seven rats receiving such reconstruction had recovery of SEPs. The reappearing SEPs typically showed similar waveforms and latencies as normal ones. They were eliminated by retransection of the repaired roots, thus verifying their source as the regenerated roots. We present here substantial evidence that aFGF enhances the functional restoration of cut dorsal roots. Cortical SEPs is considered a useful tool in evaluating such regeneration. These results may offer therapeutic potential in the treatment of dorsal root injuries.     

SEP testing in deeply comatose and brain dead patients: the role of nasopharyngeal,scalp and earlobe derivations in recording the P14 potential

Median nerve somatosensory evoked potentials (SEPs) were tested in 50 patients (20 brain dead, 18 comatose and in 12 progessing from coma to brain death, i.e., 32 cases with brain death and 30 cases with coma were recorded).Derivations were taken from nasopharynx, earlobes, scalp, and neck using cephalic and non-cephalic references. Cortical and subcortical SEP components were evaluated, focussing on the P14 potential. There is evidence that rostral and caudal parts of the P14 generator (lemniscus medialis) are differently affected in brain death, resulting in an abolition of the rostral part, while occassionally leaving intact for some time the caudal part. Non-cephalic referenced scalp records pick up the whole P14 dipole, whereas nasopharyngeal and earlobe derivations pick up different parts of P14, depending on the reference used. Scalp-to-nasopharynx records derive the most rostral part of P14; this “rostral P14” was bilaterally lost in all brain dead patients, but preserved in all deeply comatose patients with diffuse brain-sttem injuries. Scalp-to-earlobe records in contrast, picked up a P14 dipole segment reaching more caudally, resulting in a P14 potential also in brain dead patients. It is concluded that midfrontal scalp-to-nasopharynx derivations give the moset valuable contribution to the electrophysiological assessment of brain death versus deep coma.     

Evoked potential findings in Behçet's disease. Brain-stem auditory,visual, and somatosensory evoked potentials in 44 patients

We studied 54 patients with Behçet's disease, 41 males and 13 females, mean age 28 years. Forty-four patients had auditory brain-stem evoked potential (BAEP) recordings, 39 had pattern reversal visual evoked potentials (VEP), 27 had median nerve somatosensory evoked potential (SEP) recordings, and 25 tibial nerve SEPs. BAEPs were abnormal in 16 patients (52%) with neurological manifestations and in 4 (31%) without, because of decreased amplitude of wave V, prolonged I–III or III–V interpeak latencies, or uncertain/absent waves III and/or V. Eleven patients (40%) with neurological symptoms and 3 patients (25%) without, had abnormal VEPs. Absent potentials, decreased amplitude, with or without prolonged P100 latency, were found in 75% of the cases, the rest had prolonged P100 latency only. Median SEPs were abnormal in 8 patients (38%) with neurological manifestations. Four patients (21%) had abnormal tibial SEPs. Decreased amplitude with or without mild slowing in central conduction was the predominant SEP abnormality. SEPs were normal in all patients without neurological symptoms. In total, 84% of patients with, and 38% of patients without, neurological symptoms had abnormalities of one or more EP modality.When used cautiously, EP studies in Behçet's disease might be helpful to separate neuro-Behçet from other disorders with similar symptomatology, to disclose subclinical CNS involvement, to evaluate and monitor CNS disease activity, and to provide objective measures of treatment response.     

Brain-stem somatosensory dysfunction in a case of long-standing left hemispherectomy with removal of the left thalamus: a nasopharyngeal and scalp SEP study

We have studied median nerve somatosensory evoked potentials (SEPs) in a patient who had undergone early surgical removal of the left cerebral hemisphere and left thalamus. Stimulation of the right side evoked normal latency P9, P11 and P13 potentials at scalp as well as at nasopharyngeal (NP) leads, while P14 and N18 potentials were absent. These SEP abnormalities, that have been described previously in cervico-medullary lesions and in comatose patients with upper brain-stem involvement, suggest that in our patient the removal of the left thalamus has caused retrograde degeneration of the cuneate-thalamic projections. Moreover, this study confirms that P13 and P14 potentials have different generators.     

Monitoring of subcortical and cortical somatosensory evoked potentials during carotid endarterectomy: comparison with stump pressure levels

Monitoring of multichannel somatosensory evoked potentials (SEPs) has been performed in 40 cases of carotid endarterectomy (CEA). SEPs were obtained after median nerve stimulation at wrist, recording from 2nd cervical and from the scalp parietal (ipsi- and contralateral) and central (contralateral) positions. The reduction of CBF due to clamping of the carotid artery provoked SEP abnormalities in 10 of the 40 cases. None of the 30 patients with unmodified SEPs developed post-surgical neurological sequelae.SEP alterations were characterized exclusively by amplitude decrements and latency increases of the cortical components, the subcortical ones being unaffected. In 5 of these patients, SEPs returned to normal values before the end of the intervention and no neurological deficit was observed on awakening. In the remaining 5 cases SEPs retained their abnormalities and patients developed post-surgery neurological sequelae (4 immediately, 1 the day after).SEP alterations affected parietal and central components to a similar extent; however, in a few cases cerebral blood flow deficits provoked by carotid clamping modified differently the central P22 and the parietal N20–P25 waves.Comparisons with stump (back) pressure in the carotid artery revealed a higher sensitivity of the SEP technique in detecting vascularization problems due to carotid clamping.The time course of the appearance of SEP abnormalities seems to discriminate alterations secondary to collateral revascularization from those determined by embolization.     

Somatotopy of human hand somatosensory cortex as studied in scalp EEG

We recorded somatosensory evoked potentials (SEPs) in scalp EEGs during stimulation of the median nerve, the ulnar nerve and the individual digits in 3 normal subjects and in 1 epilepsy patients. In this patient we also measured SEPs from chronically indwelling subdural grid electrodes during electrocorticography (ECoG). We applied dipole modelling techniques to study the 3-dimensional intracerebral locations and time activities of the neuronal sources underlying stimulation of different peripheral receptive fields. The sources underlying median nerve SEPs were located an average of 10.8 mm lateral inferior to those underlying ulnar nerve SEPs. Digit SEP sources showed a somatotopic arrangement from lateral inferior to medial superior in the order thumb, index finger, middle finger, ring finger and little finger, with some overlap or reversal for adjacent digits. The average distance between thumb and little finger was 12.5 mm. Thumb, index finger and middle finger were clustered around median nerve cortical representation, whereas ring finger and little finger were arranged around ulnar nerve cortex. In the epilepsy patient, the source localizations obtained in scalp EEGs showed good agreement with those on ECoGs. We conclude that SEPs recorded in scalp EEGs can be used to study functional topography of human somatosensory cortex non-invasively.     

Modality-specific organization for cutaneous and proprioceptive sense in human primary sensory cortex studied by chronic epicortical recording

Modality specificity of human primary somatosensory cortex was studied by recording somatosensory evoked potentials (SEPs) from subdural electrodes in a patient with intractable focal motor seizure. A newly developed device was used for selectively activating proprioception. The spatial and temporal distributions of proprioception-related SEPs elicited by brisk passive flexion movement at the proximal interphalangeal (PIP) joint of the middle finger (4 degrees in 25 ms) were quite different from those to cutaneous sense evoked by electric stimulation of the digital nerve at the same site. It was for the first time demonstrated that proprioception-related SEPs following passive finger movement do not originate in area 3b, which was clearly activated by cutaneous stimulation, and that other sites at the sensorimotor cortex such as areas 2, 3a and 4 possibly contribute to the cortical processing of proprioception.     

Scalp-recorded short and middle latency peroneal somatosensory evoked potentials in normals: comparison with peroneal and median nerve SEPs in patients with unilateral hemispheric lesions

Peroneal somatosensory evoked potentials (SEPs) were performed on 23 normal subjects and 9 selected patients with unilateral hemispheric lesions involving somatosensory pathways.Recording obtained from right and left peroneal nerve (PN) stimulations were compared in all subjects, using open and restricted frequency bandpass filters. Restricted filter (100–3000 Hz) and linked ear reference (A1–A2) enhanced the detection of short latency potentials (P1, P2, N1 with mean peak latency of 17.72, 21.07, 24.09) recorded from scalp electrodes over primary sensory cortex regions. Patients with lesions in the parietal cortex and adjacent subcortical areas demonstrated low amplitude and poorly formed short latency peroneal potentials, and absence of components beyond P3 peak with mean latency of 28.06 msec. In these patients, recordings to right and left median nerve (MN) stimulation showed absence or distorted components subsequent to N1 (N18) potential.These observations suggest that components subsequent to P3 potential in response to PN stimulation, and subsequent to N18 potential in response to MN stimulation, are generated in the parietal cortical regions.     

Effect of stimulus rate on the cortical posterior tibial nerve SEPs: a topographic study

We performed topographical mapping of somatosensory evoked potentials (SEPs) in response to posterior tibial nerve stimulation delivered at 2, 5 and 7.5 Hz in 15 healthy subjects. P37 was significantly attenuated at 5 and 7.5 Hz and the N50 component attenuated only at 5 Hz, its amplitude remaining stable for further increases in stimulus frequency. Frontal N37 and P50 potentials showed no significant decrease when the stimulus repetition frequency was changed from 2 to 7.5 Hz. P60 showed an attenuation of the amplitude only at 7.5 Hz. Latency and scalp topographies of all cortical components examined remained uncharged for the 3 stimulus rates tested The optimal stimulus rate for mapping of tibial nerve SEPs was lower than 5 Hz. The distinct recovery function of the contralateral N37-P50 and ipsilateral P37-N50 responses suggests that these potentials arise from separate generators     

The origin of the scalp recorded P14 following electrical stimulation of the median nerve: intraoperative observations

Direct and far-field recorded somatosensory evoked potentials (SEPs) obtained from 2 patients during neurosurgical procedures are presented. A previous report (Møller et al. 1986) has suggested that the P14 component of the SEP following median nerve stimulation is generated at the cuneate nucleus. The present data suggest that the scalp recorded P14 component (scalp-noncephalic electrode derivation) is generated rostral to the junction of the cervical cord and the medulla.     

Somatosensory evoked potentials after stimulation of digital nerves in upper limbs: Normative data

Normative data for somatosensory evoked potentials (SEPs) after stimulation of digital nervesfrom the first, third and fifth digits, which reach the spinal cord through C6, C7 and C8 roots are presented in 20 normal adults. SEP peak latencies and amplitudes are indicated for Erb's point, the level of the seventh and second cervical vertebrae and contralateral cortical hand area.     

Dermatomal and mixed nerve somatosensory evoked potentials in the diagnosis of neurogenic thoracic outlet syndrome

To evaluate the diagnostic utility of dermatomal and mixed nerve somatosensory evoked potentials (SEPs) in patients with thoracic outlet syndrome (TOS) and to compare their value with routine electrodiagnostic methods, we studied a group of 44 patients with neurogenic TOS and 30 healthy controls. In addition to bilateral median and ulnar SEPs, evoked potentials were recorded after stimulation of C6 and C8 dermatomes from the first and fifth digits, respectively. The patients were classified into 3 groups according to the nature of their clinical condition. The abnormality rate for both ulnar and C8 dermatomal SEPs was 100% in a small group of patients with severe neurological signs like atrophy. In groups of patients with lesser degrees of neurogenic damage, abnormality rates for ulnar and C8 dermatomal SEPs on affected limb(s) were 67 and 50%, respectively. Same abnormality rates were 25 and 18% in patients with only subjective symptoms. In patients with objective neurological signs, the major increase in sensitivity was with electromyography (EMG). Abnormalities of routine nerve conduction studies and F-wave latency were observed in patients with severe neurogenic damage. We concluded that the most useful tests in the diagnosis of neurogenic TOS are needle EMG and ulnar SEPs.