Visual evoked potentials in clinical neurology

A. W. de WEERD

Introduction

Visual evoked potentials (VEPs) have been used now for more than two decades.
Reviews of methodology and clinical applications were published some years
ago by among others Halliday, Chiappa, Sokol, Spehlmann and Lowitzsch
[1-5]. Since these texts were written new fields of use have emerged; on the
other hand areas of previous interest are thought less important nowadays.
After a summary of technical aspects of VEPs, this chapter will focus on
new developments, in particular on those with clinical implications. Moreover,
applications of VEPs which will probably be clinically important in the near
future as well as new aspects of VEPs thought to be relevant for insight in
functions of the nervous system, will be described.

Methods and normal values

Methods

Brain potentials can be evoked visually in many ways. It has been recognized
after wide dispute that the universally applicable method does not exist.
Stimulation and recording parameters should be tailored to the clinical problem
and condition of the patient under study. For example, flash VEPs (FVEPs)
will be preferred in the examination of young children, uncooperative patients
and in the intensive care unit or operation room. Commercially available
stimulator units allow a wide choice in methods for pattern VEPs for almost
every laboratory. It is advisable to get optimal experience in one or two of
them, but it should be remembered that other methods often have a higher
diagnostic yield in special cases. Examples for this are VEPs to gratings in
patients with Parkinson's disease and the combination of pattern VEPs and
electroretinography in ophthalmologic disorders and detailed studies of de-
myelinating diseases. A description of all available methods in YEP studies
is outside the scope of this chapter. Reviews can be found in the monographs

E. J. Colon and S. L. Visser (eds), Evoked potential manual, pp. 161-204.

© 1990 Kluwer Academic Publishers.
162 A. W de Weerd

Table 1. Recommended standards for pattern visual evoked potentials (checkerboard).

A. Full field stimulation.

Monocular stimulation.
Check sizes 28-30' arc.
> 50' arc.
Contrast (Lmax - Lmin)l(Lmax + Lmin) > 50%.
Field size > 8° arc. with a central fixation point.
Stimulus rate < 2/sec.
System bandpass: 0.5-\.0 Hz to 100-300 Hz (-3 dB).
Analysis time 200 - 300 msec.
Averaging 100 - 200 trials.
Electrodes and montage: Queen Square System, i.e. midoccipital (5 cm above inion) MO,
right/left occipital (5 cm lateral to MO) RO and LO, referenced to midfrontal (12 cm above
nasion) MF or 02,01, Oz referenced to Fz.
Analysis: peak latencies, amplitudes ofN75, PIOO, (N 145) components and interocular difference
for PIOO latencies.

B. Half field stimulation

Monocular stimulation.
Check size > 50' arc.
Field size > 10° arc., fixation point just lateral to inner edge of pattern.
Montage Queen Square System, i.e. MO referenced to MF, left and right temporal
(10 cm lateral to MOl LT and RT referenced to MF or T6, T5, Oz referenced to Fz. If
more channels can be analysed use also LO or 0 I and RO or 02 referenced to MF or
Fz.
Analysis latencies of the ipsilateral N75, PIOO and N145 components and the
contralateral P70, NI05 and PI35 components; amplitudes of the PIOO and NI05 components.
Other stimulus parameters and recording conditions as for full field stimulation.

These recommendations are in agreement with those by the IFSECN and American Electroen-
cephalographic Society. (6,7)

on evoked potentials mentioned above and in the contribution by Speckreyse

and Riemslag to this book. Pattern evoked VEPs and in particular the
checkerboard reversal method have found general acceptance and are con-
sidered as the method of choice in most situations. Unless stated otherwise,
the studies mentioned in this chapter were performed using this way of
generating VEPs. They will be referred to as PVEPs. Recommendations for
stimulation and recording of (P)VEPs can be found in the "Standards in
Clinical Neurophysiology" of the IFSECN [6] and in the publications from
the American Electroencephalographic Society [7], (see Table I for a summary).
The methods used in most studies referred to in this chapter are in accordance
with these specifications.

Normal values

Full field checkerboard pattern stimulation of one eye and recording from
a row of electrodes at the backside of the head result in curves which for
the first 200 msec after stimulation are characterized by a positive component