Dissociation of P13–P14 far-field potentials: clinical and MRI correlation

P13 and P14 far-field potentials are recorded over the scalp with median nerve stimulation when non-cephalic reference is used to measure somatosensory evoked potentials. The dissociation of these 2 potentials is exceptional. Only 2 cases subsequent to pontine lesions have been described hitherto. We report the case of a 31-year-old woman with a low grade gliomallocated at the spino-medullary junction who presented a P13–P14 far-field dissociation. This case fully supports the independent nature of the P13 and P14 potential generators.     

The somatosensory central conduction time: physiological considerations and normative data

The somatosensory central conduction time (CCT) can be measured from the peak of N13 to the peak of N20 (peak CCT) or from the onset of N11 to the onset of N20 (onset CCT). The onset and peak CCT were measured concomitantly in 40 normal subjects and the mean peak CCT was significantly shorter than the mean onset CCT. Records with different reference electrodes (linked earlobes, F3, over the ipsilateral parietal scalp, non-cephalic reference in some subjects) showed no significant latency change of the N11 onset, the N20 onset, the peak and onset CCT in contrast with the significant latency changes of the N13 and N20 peak with different montages. The onset CCT was divided by the onset of the P14 far-field in 2 parameters, the N11-P14 interval predominantly concerned with spinal conduction and the P14-N20 interval which reflected only supraspinal conduction. The onset and peak CCT, the N11-P14 and P14-N20 intervals were not correlated with height or age. Three independent recording sessions over 1 year in 16 subjects showed that the parameters were reproducible. From the physiological point of view the onset and peak CCT are different parameters and the anatomical correlates of both parameters are discussed.     

Nasopharyngeal recordings of somatosensory evoked potentials document the medullary origin of the N18 far-field

Because the nasopharyngeal electrode provides non-invasive access to the ventral brain-stem at the medullo-pontine level we used it for recording somatosensory evoked potentials (SEPs) to median nerve stimulation (non-cephalic reference). After the P9 and P11 far-fields, the nasopharyngeal SEPs disclosed a negative-going component which was interpreted as the near-field equivalent of the P14 scalp far-field generated in the caudal part of the medial lemniscus. Nasopharyngeal SEPs also revealed a large N18 with voltage and features strikingly similar to those of the scalp-recorded N18 far-field. These results suggest that N18 is generated in the medulla and not more rostrally in the brain-stem. The use of a nasopharyngeal electrode as reference for topographic brain mapping is discussed. The paper documents the feasibility and relevance of nasopharyngeal recordings for non-invasive analysis of short-latency SEPs.     

Short latency somatosensory evoked potentials following mechanical taps to the face. Scalp recordings with a non-cephalic reference

Trigeminal somatosensory evoked potentials were recorded over the scalp using non-cephalic reference sites following mechanical taps to the face. A negative wave form, Nf17, was recorded bilaterally with its highest amplitude over the frontal scalp contralateral to the side of stimulation. A localized negative form, Np25, was recorded over the centro-parietal scalp contralateral to the side of stimulation. Np25 had an onset latency of 16.46 msec. The location and restricted spatial distribution of Np25 suggest that it represents the initial activation of the face area of the primary sensory cortex. The widespread bilateral nature of Nf17 and its latency of onset preceding that of Np25 suggest that Nf17 may be a ‘far-field’ potential reflecting activity in subcortical sensory pathways subserving the face.     

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.     

Dissociation of frontal N100 from occipital P100 in pattern reversal visual evoked potentials

We studied the relationship between occipital P100 and frontal N100 in visual evoked potentials produced by pattern reversal in normal subjects and two groups of patients. Recording derivation was critical for interpretation since both Fz and Oz electrode sites are active. In 9 patients, but no normal subjects, P100 was absent. In these patients, use of a standard Oz-Fz montage resulted in the erroneous impression of a ‘normal’ P100 since a downward deflection was produced by the inverting effect of the amplifier on an intact N100 at Fz. When both P100 and N100 were present (at Oz and Fz respectively), their latencies were usually similar but not identical which contributed to apparent latency shifts or W-shaped wave forms in the Oz-Fz derivation. We conclude that use of a non-cephalic or relatively inactive scalp position (such as the mastoid) should be used as a reference site in addition to Fz to reduce interpretive errors.     

Two distinct cervical N13 potentials are evoked by ulnar nerve stimulation

To investigate the dual nature of the posterior neck N13 potential, we attempted to establish the presence of a latency dissociation between caudal (cN13) and rostral (rN13) potentials on stimulating the ulnar nerve, in view of its lower radicular entry compared to the median nerve. SEPs were evaluated in 24 normal subjects after both median and ulnar nerve stimulation. cN13 was prominent in the lower cervical segments, and rN13 was localized mainly in the upper ones using anteroposterior and longitudinal bipolar montage, respectively. The N9-cN13 interpeak latency did not differ significantly from N9-rN13 when stimulating the median nerve. On the other hand, the N9-rN13 interpeak was significantly longer than the N9-cN13 interpeak when the ulnar nerve was stimulated. The rN13 presented the same latency as P13-P14 far-field potentials in 17 out of 24 ulnar nerves tested. Therefore, the ulnar nerve stimulation evokes two distinct posterior neck N13 potentials. It is widely accepted that the caudal N13 is a postsynaptic potential reflecting the activity of the dorsal horn interneurons in the lower cervical cord. We suggest that the rostral N13 is probably generated close to the cuneate nucleus, which partly contributes to the genesis of P13-P14 far-field potentials.     

Neural generators of the somatosensory evoked potentials: Recording from the cuneate nucleus in man and monkeys

The neural generators of the somatosensory evoked potentials (SEPs) elicited by electrical stimulation of the median nerve were studied in man and in rhesus monkeys. Recordings from the cuneate nucleus were compared to the far-field potentials recorded from electrodes placed on the scalp. It was found that the shape of the response from the surface of the human cuneate nucleus to stimulation of the median nerve is similar to that of the response recorded more caudally in the dorsal column, i.e., an initially small positivity followed by a negative wave that is in turn followed by a slow positive wave. The beginning of the negative wave coincides in time with the N14 peak in the SEP recorded from the scalp, and its latency is 13 msec. The response from the cuneate nucleus in the rhesus monkey has a similar shape and its negative peak appears with the same latency as the positive peak in the vertex response that has a latency of 4.5 msec; the peak negativity has a latency of about 6 msec and thus coincides with P6.2 in the vertex recording. Depth recordings from the cuneate nucleus and antidromic stimulation of the dorsal column fibers in the monkey provide evidence that the early components of the response from the surface of the cuneate nucleus are generated by the dorsal column fibers that terminate in the nucleus.The results support the hypothesis that the P14 peak in the human SEP is generated by the termination of the dorsal column fibers and that the cuneate nucleus itself contributes little to the far-field potentials.     

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.     

Scalp topography and dipolar source modelling of potentials evoked by CO2 laser stimulation of the hand

CO₂ laser evoked potentials to hand stimulation recorded using a scalp 19-channel montage in 11 normal subjects consistently showed early N1/P1 dipolar field distribution peaking at a mean latency of 159 ms. The N1 negativity was distributed in the temporoparietal region contralateral to stimulation and the P1 positivity in the frontal region. The N1/P1 response was followed by 3 distinct components: (1) N2a reaching its maximal amplitude at the vertex and ipsilaterally to the stimulated hand, (2) N2b mostly distributed in the frontal region, and (3) P2 with a mid-central topography. Brain electrical source analysis showed that this sequence was explained, with a residual variance below 5%, by a model including two dipoles in the upper bank of the Sylvian fissure of each hemisphere, a frontal dipole close to the midline, and two anterior medial temporal dipoles, thus suggesting a sequential activation of the two second somatosensory areas, anterior cingulate gyrus and the amygdalar nuclei or the hippocampal formations, respectively. This model fitted well with the scalp field topography of grand average responses to stimulation of left and right hand obtained across all subjects as well as when applied to individual data. Our findings suggest that the second somatosensory area contralateral to the stimulation is the first involved in the building of pain-related responses, followed by ipsilateral second somatosensory area and limbic areas receiving noxious inputs from the periphery.     

The role of upper limb somatosensory evoked potentials in the management of cervical spondylotic myelopathy: preliminary data

We studied upper limb somatosensory evoked potentials (SEPs) in 11 patients with MRI and clinical evidence of cervical spondylotic myelopathy (CSM), before and after cervical open-door laminoplasty. SEP studies before surgery revealed two main types of abnormality, the first characterized by the isolated loss of the spinal N13 response, reflecting the dysfunction of dorsal horn cervical cells in 4 patients. The second combined abnormalities of both spinal N13 and scalp far-field P14 potential, suggesting the involvement of both dorsal horn cells and dorsal columns at the cervical level in 7 patients. After surgery, N13 recovered in 9 patients, while P14 abnormalities remained unchanged. Clinical recovery, evaluated by means of the Japanese Orthopaedic Association (JOA) disability scale, was accompanied by SEP improvement. Moreover, this improvement was more pronounced in patients with isolated loss of the N13 than in patients with combined abnormalities of the N13 and scalp P14 response. Our data strongly suggest that upper limb SEPs can be useful in monitoring the effectiveness of surgery, as well as in selecting before surgery patients who are likely to have a better postsurgical outcome.     

P3 latency jitter assessed using 2 techniques. II. Surface and sphenoidal recordings in subjects with focal epilepsy

We compared the latency variability in auditory P3s of 13 subjects with unilateral temporal lobe epilepsy (TLE) to that of normal controls. We predicted that increased latency jitter would occur in TLE subjects, particularly on the epileptic side. ERPs were recorded from scalp and sphenoidal sites relative to a balanced non-cephalic reference. Signal-to-noise ratios (SNRs) were calculated for each subject. Data were excluded if SNRs fell below 0.4. P3 latency jitter was estimated using 2 methods: Woody's algorithm and the maximum likelihood technique (MLT), a novel method of jitter assessment.SNRs were significantly higher in controls and were maximal posteriorly for both groups. P3 peak amplitude was significantly smaller in TLE subjects at temporal sites. Latency jitter (MLT method) was greatest in posterior sites and mirrored the jitter profiles of controls. Latency jitter was significantly higher in TLE subjects in bilateral frontal and temporal sites, but was not higher on the side of the focus and could not be attributed to lower SNRs. The increased bilateral latency jitter in these patients may be related to effects of anticonvulsants or the more extensive nature of the underlying epileptic disorder.     

Latency and amplitude abnormalities of the scalp far-field P14 to median nerve stimulation in multiple sclerosis. A SEP study of 122 patients recorded with a non-cephalic reference montage

The frequency and characteristics of P14 abnormalities were investigated in 122 patients with probable (68), or definite (54) multiple sclerosis by recording SEPs to median nerve stimulation with a non-cephalic reference montage. The most frequent SEP abnormality found in our series (62% of abnormal results) combined latency increase and amplitude reduction of P14. Interindividual variability, inherent in absolute amplitude measurements, was by-passed by calculating the ration between the amplitudes of far-field P9 and P14 components, which proved to be normally distributed in controls. In spite of the strong association (P ⪡ 0.001) between the P9–P14 interpeak interval (IPL) and the P9/P14 amplitude ratio in MS patients, the latter parameter was found to be the only abnormality in 12 patients whose P9–P14 and P14–N20 IPLs were normal. Also IPLs were increased in 12 patients with normal P14 amplitudes. These results suggest that adding the P9/P14 amplitude criterion to standard IPL data might be useful to detect conduction troubles in MS patients.     

Absence of spinal N13-P13 and normal scalp far-field P14 in a patient with syringomyelia

Short latency somatosensory evoked potentials to median or ulnar nerve stimulation were recorded in a patient with syringomyelia. Scalp-recorded far-field P14 was clearly preserved, but spinal N13-P13 components disappeared. Our findings support the hypothesis that spinal N13-P13 is generated by structures intrinsic to the cervical cord, most likely in the ventral central gray matter.     

Origin of scalp far-field N18 of SSEPs in response to median nerve stimulation

To identify the origin of scalp-recorded far-field negativity of short-latency somatosensory evoked potentials to median nerve stimulation (designated N18), direct records were made from the thalamus and ventricular system during 4 stereotaxic and 3 posterior fossa operations.In the thalamus a negative potential with almost the same latency as the scalp N18 was restricted to the Vim nucleus, but there was a large positive potential in the VC nucleus and medial lemniscus. Vim negativity increased in amplitude when high frequency stimulation was given to the median nerve, indicative of a facilitation effect. In contrast, the amplitude of scalp N18 decreased at high frequency stimulus.Direct recordings made through the medulla oblongata to the mid-brain showed a negative potential with gradually increasing latency. Above the upper pons, there was stationary negativity with no latency shift. The similarity between this negative potential and N18 is shown by their having the same latency and same response to the amplitude reduction and latency prolongation produced by high frequency stimulus.Our data suggest that scalp N18 comes from brain-stem activity between the upper pons and the mid-brain rather than from the thalamus.     

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.     

Origin and distribution of P13 and P14 far-field potentials after median nerve stimulation. Scalp,nasopharyngeal and neck recording in healthy subjects and in patients with cervical and cervico-medullary lesions

We studied median nerve SEPs in 10 healthy subjects, by means of simultaneous recording over the scalp, around the neck and near the ventral surface of the medulla using a nasopharyngeal (NP) electrode. This recording technique enabled us to clearly differentiate P13 and P14 potentials. The former was always found in NP records, while the latter was more evident in scalp traces. The same technique was used to study 9 patients with various lesions of the cervical cord or cervico-medullary junction. Patients with high cervical lesions demonstrated abnormalities of both P13 and P14 potentials, while patients with lesions of the cervico-medullary junction demonstrated a clear dissociation between normal P13 in scalp and NP traces, and abnormal scalp P14. Patients with lower cervical lesions, selectively involving the central grey matter, showed normal P13 and P14 potentials, in spite of abnormal N13 cervical responses. Our findings strongly suggest that both scalp and NP P13 have the same generators in higher segments of the cervical cord, and that NP more than scalp records are effective in analyzing the P13 response. We suggest that the selective recording of the P13 potential could be useful in the assessment of focal lesions of the higher cervical cord or of the cervico-medullary junction.     

Detailed analysis of the latencies of median nerve somatosensory evoked potential components, 1: selection of the best standard parameters and the establishment of normal values

In order to objectively select the standard parameters best suited for the evaluation of somatosensory conduction in median nerve somatosensory evoked potentials (SEP), we performed a detailed statistical analysis of intersubject variability for the latencies of SEP components based on the recordings of 62 normal subjects. Multiple regression analyses for height, age, (age - 20)² and sex were performed for the latencies of 13 components and 78 intercomponent intervals, and the residual variance was used as an indicator of the stability of each parameter. As a result, N9 onset in EPi-NC lead, N11′ onset in C6S-Fz lead, P13/14 onset in scalp-NC leads, for which N13′ onset recorded in C6S-Fz lead may substitute, and N20 onset in CPc-Fz lead were the most stable time-points selected as standards. N11 onset in C6S-NC, which other authors have recommended as the standard point representing spinal entry, was not recorded consistently, and P11 onset in scalp-NC leads was also unstable. N20 and peak and N13′-N20 interval (equivalent to conventional central conduction time) were extremely unstable. We presented the nomograms to find normal limits of the standard parameters corresponding to the given values of the predictor variables (height, age or sex). As the standard recording montage in routine clinical examinations, we recommended a simple method using Fz reference, for example (1) EPi-Fz, (2) C6S-Fz, (3) CPc-Fz, because this montage is sufficient to measure the stable standard parameters.     

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.     

Effect of manipulation and fractionated finger movements on subcortical sensory activity in man

Previous studies have shown that the somatosensory evoked potentials (SEPs) recorded from the scalp are modified or gated during motor activity in man. Animal studies show corticospinal tract terminals in afferent relays, viz. dorsal horn of spinal cord, dorsal column nuclei and thalamus. Is the attenuation of the SEP during movement the result of gating in subcortical nuclei? This study has investigated the effect of manipulation and fractionated finger movements of the hand on the subcortically generated short latency SEPs in 9 healthy subjects. Left median nerve SEPs were recorded with electrodes optimally placed to record subcortical activity with the least degree of contamination. There was no statistically significant change in amplitude or latency of the P9, N11, N13, P14, N18 and N20 potentials during rest or voluntary movement of the fingers of the left hand or manipulation of objects placed in the hand. The shape of the N13 wave form was not modified during these 3 conditions. It is concluded that in man attenuation of cortical waves during manipulation is not due to an effect of gating in the subcortical sensory relay nuclei.