Professional Documents
Culture Documents
Omkar N. Markand
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With gratitude and love, I dedicate this book
to the memory of my wife, Pramila Lal
Markand. In her last years of life, she
encouraged me to work on the manuscript of
this book even when it may have cut into a
portion of our time together. Her constant
belief in me was unending.
I also would like to dedicate this book to my
two daughters, Vaneeta M. Kumar and
Sandhya M. Graves. Their belief in me and
constant support inspired me to put my
clinical experience of evoked potentials over
the past several decades in the form of a
book.
Foreword
It was 1976, the second year of Medical School at Indiana University, and the course
was an Introduction to Clinical Medicine. On that day, the lecture was on epilepsy:
a complex topic, especially for students knowing so little about clinical semiology,
neurophysiology, and the world of EEG. In that hour, Dr. Omkar Markand calmly,
with reassurance and certainty, laid out the world of neurophysiology and epilepsy
in a clear, logical, and clinically valuable fashion. Amazingly, organized and com-
plete, we all paid attention and processed his wisdom and understanding. Something
so complex for us became something understandable and a framework for building
an interest and a career in neurology. We immediately, as students, understood that
he was more than a great neurologist and expert in neurophysiology. He was a
teacher in the truest sense – an amazingly, wonderful teacher who would affect so
many of us and contribute to so many careers in neurology.
In 1984, while taking my oral boards in neurology, I was presented with a patient
having an acquired spastic paraparesis. The discussion was intense, and the examin-
ers turned to the diagnostic workup for multiple sclerosis. The back and forth was
challenging, and I had an uneasy feeling about the outcome of the entire session.
My learned examiners brought up the topic of spinal fluid studies and evoked poten-
tials and wanted to know just how good these studies were in providing evidence for
MS. At that moment, my fortunes turned, and I calmly began my response with,
“according to Markand et al. as just recently published in the green journal
(Neurology), the sensitivity and specificity for these are…,” and his data flowed into
the discussion. Hearing Markand’s name, the examiners finally relaxed and smiled,
and for the first time in the session, they seemed comfortable that I knew something
of importance (Bartel et al. 1983).
Being on the faculty in the Department of Neurology at Indiana University since
1985, I have acquired an understanding and complete appreciation for the tremen-
dous professional and personal qualities that lead to Dr. Markand being viewed
uniformly by his colleagues and his students as a unique treasure and gift to the
world of neurology. He knows his field to depths unmatched. His work ethic is
inspirational. And, Dr. Markand, to this day, remains one of the most gifted teachers
of neurology and neurophysiology that the field has ever seen. In an ocean of many
great teachers in neurology, there is none any better than Omkar Markand.
We are so fortunate that he has chosen to share his vast knowledge of evoked
potentials with the neurophysiology and neurology world. There is no greater
vii
viii Foreword
authority on this topic than Omkar Markand. From the fundamental neurophysiol-
ogy and technology to the anatomic considerations to the clinical applications, Dr.
Markand has gathered his experience and understanding from 50 years in the field
to provide the reader with a complete and cogent tour de force of evoked potentials
in clinical medicine – a tremendous resource for practitioners and neurophysiolo-
gists and for those clinicians seeking to apply these important techniques to the
evaluation and management of their patients.
Dr. Markand has not only devoted his career to Indiana University and to the
Department of Neurology but also to our patients. He is an integral part of the very
fabric of what makes us special. He is Professor Emeritus of Neurology and Director
EEG/Evoked Potentials/Epilepsy at Indiana University School of Medicine and is
one of the most remarkable educators at Indiana. He continues to provide excep-
tional training for our residents and fellows in EEG, evoked potentials, and epilepsy.
He is viewed as the ultimate source of truth.
Of his numerous awards and honors, I point to his receiving the Health Care
Hero Award for his lifelong work in epilepsy in Indiana. And, on a national level,
Dr. Markand received the annual Jasper Memorial Award in 2009 from the American
Clinical Neurophysiology Society for lifelong work in clinical neurophysiology. On
the international stage, he received a Lifetime Achievement Award of the Association
of Indian Neurologists in America (AINA) given by the American Academy of
Neurology. And he has received the “Certificate of Medical Excellence” awarded by
the Epilepsy Foundation of Indiana for high values, commitment to public service,
community involvement, leadership, and dedication to those with epilepsy.
The terms “role model” and “mentor” as well as the discussions of “professional-
ism” are often emphasized, defined, and applied to talented and accomplished indi-
viduals in the medical profession; yet, rarely there comes along a person for whom
these terms are insufficient. Professionals like Dr. Markand are the stimuli for which
such words are created. For me, this has always been the case. I love being able to
call Omkar Markand my friend and colleague, and am so thankful he was in my
brain during the oral board exams. His many years of trainees and professional col-
leagues are grateful for his production of this valuable book of truth on evoked
potentials.
Reference
Bartel DR, Markand ON, Kolar OJ. The diagnosis and classification of multiple
sclerosis: evoked responses and spinal fluid electrophoresis. Neurology.
1983;33:611–7.
Robert M. Pascuzzi, MD
Professor and Chair Department of Neurology
Indiana University School of Medicine
Indianapolis, IN, USA
Preface
With the introduction of evoked potentials (EPs) in clinical medicine in the mid-
1970s, visual, brainstem auditory, and somatosensory EPs played a major role in the
diagnosis of suspected demyelinating disorder. Although their applications have
significantly changed since magnetic resonance imaging became a major diagnostic
modality for multiple sclerosis, the use of EPs continues in order to exclude, detect,
or confirm conduction abnormalities involving major afferent systems in the central
nervous system. In addition, somatosensory EPs, along with the transcranial motor
EPs, have established themselves as a standard of care for intraoperative monitoring
during various spinal and intracranial surgeries. The major role the EPs play during
intraoperative monitoring is reflected in several excellent texts, published over the
last few decades on the subject of monitoring during surgery. But only a few texts
have appeared which have devoted themselves exclusively to diagnostic applica-
tions of EPs in clinical medicine.
At the Indiana University School of Medicine, Department of Neurology, there
has been a strong clinical neurophysiology section for the last five decades. As the
only university medical center in the State, all the attached hospitals have been an
excellent source of neurologic referrals. This has provided me with a large collec-
tion of abnormal EPs, which I was able to use for teaching purposes. Because of my
interest in EPs, I have been the sole clinical neurophysiologist at the institution who
has had the distinct privilege of interpreting almost all of the diagnostic EPs, in
addition to directing this subspecialty of clinical neurophysiology at the institution.
I also developed a handout on “clinical evoked potentials” for the neurology resi-
dents and the clinical neurophysiology fellows to help them learn the basics of EPs.
This handout has been updated on several occasions and is still used today. Many of
the fellows in the past encouraged me to publish a book on clinical EPs based on
this handout, as well as include a large number of EP illustrations I had in my col-
lection. So during my semiretirement, I decided to undertake their request for writ-
ing this book.
One of the problems facing the writer was to limit the area of his presentation.
Evoked potentials are utilized extensively in the operating room, as well as in the
clinical diagnostic laboratories. Because there have been excellent texts already
available on EPs for intraoperative monitoring, I decided to limit myself essentially
to the diagnostic applications of EPs in my work. Thus, this book represents an
attempt to provide essential basic knowledge pertinent to all modalities of the
ix
x Preface
xi
xii Contents
°C Degree Centigrade
ADEM Acute disseminated encephalomyelitis
ALS Amyotrophic lateral sclerosis
BAEP Brainstem auditory evoked potential
C clicks Condensation clicks
C5S Fifth cervical spine
CMAP Compound muscle action potential
CNAP Compound nerve action potential
CNS Central nervous system
CP angle Cerebellopontine angle
dB Decibel
DNEPs Descending neurogenic evoked potentials
ECOG Electrocochleogram
EEG Electroencephalogram
EMG Electromyogram
EPSP Excitatory postsynaptic potential
FFP Far-field potential
GABA Gamma aminobutyric acid
HF High-frequency filter
HL Hearing level
Hz Hertz
IOM Intraoperative monitoring
IPL Interpeak latency
ISI Interstimulus interval
KHz Kilohertz
KΩ Kiloohm
LCD Liquid crystal display
LED Light-emitting diode
LF Low-frequency filter
LICI Long-interval intracortical inhibition
LMN Lower motor neuron
LO, RO Left and right occipital
LT, RT Left and right temporal
MEP Motor evoked potential
xv
xvi Abbreviations
MF Mid-frontal
MND Motor neuron disorder
MO Mid-occipital
MP Mid-parietal
MRI Magnetic resonance imaging
MS Multiple sclerosis
msec Millisecond (10−3 seconds)
μsec Microsecond (10−6 seconds)
MVD Microvascular decompression
M-wave CMAP on peripheral stimulation
NCS Nerve conduction study
NFP Near-field potential
nHL Normalized hearing level
PRVEP Pattern reversal visual evoked potential
R clicks Rarefaction clicks
rTMS Repetitive transcranial magnetic stimulation
SD Standard deviation
SICI Short interval intracortical inhibition
SL Sensitivity level
SNAP Sensory nerve action potential
SP Silent period
SPL Sound pressure level
SSEP Somatosensory evoked potential
Subscript c Contralateral
Subscript i Ipsilateral
TCES Transcranial electrical stimulation
TCMS Transcranial magnetic stimulation
TIVA Total intravenous anesthesia
TST Triple stimulation technique
UMN Upper motor neuron
VEP Visual evoked potential