Professional Documents
Culture Documents
5 Electrodiagnostic
Evaluations of
Patients with Lesions
Involving the
Nervous System
Herman F. Flanigin
Anthony M. Murro
Electrical activity of the brain is either spontaneous or ditory, and somatosensory systems. These are described as
event-related. Spontaneous activity is unrelated to transient visual evoked potentials (VEPs), auditory evoked potentials
or repetitive events occurring within the body or in the (AEPs), and somatosensory evoked potentials (SSEPs).
body's environment. Spontaneous activity includes direct
current (DC) potentials, alternating current (AC) potentials,
and unit potentials (Fig. 5-1). *
DC potentials are slowly changing shifts in the brain's ELECTROENCEPHALOGRAPHY (EEG)
electrical baseline. AC potentials are more rapidly changing
potentials, such as rhythmic EEG activity. Unit potentials Comprehensive references covering the general topic of
are small intracellular or extracellular potentials of brief eleclroencephalography may be of assistance in understand-
duration recorded by microelectrodes from individual neur- ing this subject.1
ons. Unit potentials depend on the spatial orientation of the Scalp electroencephalography uses cup-shaped disk elec-
neurons and their processes. In discharging, they create a trodes. The electrodes are fixed to the scalp with collodion.
dipole which may be summated by orientation, synchroniza- An electrolyte gel forms a conductive interface between the
tion, and recruitment to reach a level that can be recorded scalp and electrode. The % system1 has been adopted by the
from the scalp. American EEG society as a standard system for electrode
Event-related potentials (ERPs) or event-related re- placement. The "$" refers to interelectrode distances ex-
sponses (ERRs) occur as a result of external or internal pressed as percentages of anterior-posterior, transverse, and
events. The term event-related responses is more descriptive circumferential head measurements (Fig 5-2).
than evoked responses because the responses occur as a In addition, special electrodes inserted against the inferior
result of a transient or recurrent event. surface of the greater wing of the sphenoid bone beneath the
Examples of internally generated ERPs are the prefrontal medial temporal lobe (sphenoidal electrodes) record from
negative waves recorded while anticipating a movement and the basilar and medial temporal lobe regions (Fig. 5-3).
the potentials recorded from the temporal region while solv- The electroencephalograph amplifies minute scalp poten-
ing a specific problem of choice between two audible tones. tials as low as 2 to 3 microvolts (|xV) and provides a record
External ERPs occur following stimulation of visual, au- of the scalp voltage over time. Differential amplifiers
71
72 CHAPTERS
01 -At —————
There are major differences between EEGs recorded from
Figure 5-4 The montage for a referential montage is illustrated
infants and children of different ages and the adult. In the
on the left side of the head and a sequential montage on the right premature infant with a conceptual age of less than 30
top). Stylized tracings on the left illustrate an assumed spike focus weeks, a discontinuous EEG pattern of prolonged low-
at the C3 electrode recorded with a referential montage and on the voltage periods alternating with brief slow-wave bursts
right an assumed spike focus at F4 recorded with a sequential occurs. Continuous EEG patterns develop between 30 and
montage (bottom).
34 weeks conceptual age. Distinct EEG patterns that distin-
guish sleep from wakefulness develop between 35 and 37
drowsy, or asleep). In general, however, the activity weeks of conceptual age. Fully developed neonatal sleep
recorded in an individual should be fairly symmetrical. patterns of quiet and active sleep occur after 37 weeks of
Frequency is designated in cycles per second, or Hertz conceptual age.
Hz), and is divided into four bands. The bands are delta During infancy, a posterior rhythmic 3- to 4-Hz activity
0.5-4 Hz), theta (4-8 Hz), alpha (8-13 Hz), and beta (13 occurs by 3 months of age. This background frequency
Hz and above) (Fig. 5-5). increases to 5 Hz at 6 months, 6 to 7 Hz at 1 year, 7 to 8 Hz
Amplitude varies markedly from one individual to an- at 18 months, and 9 to 11 Hz during young adulthood. Theta
other, from one location to another, and with frequency. and delta activity is commonly seen in the posterior scalp
regions during childhood and young adulthood (posterior
slow waves of youth).
ADULT EEG ACTIVITY
ABNORMAL WAVE FORMS communicate with the patient and record significant behav-
ioral observations for correlation with the EEG.
Spikes are sharply contoured waves, less than 80 ms in
duration. They occur repetitively and have an amplitude
significantly greater than the background. Spikes occur alone ELECTROENCEPHALOGRAPHIC INVESTIGATION
or followed by a slow wave (spike and wave). Multiple
spikes followed by a slow wave (polyspike and wave) are While imaging studies reveal structural brain abnormalities,
associated with generalized seizures. Spike and wave dis- the EEG reveals functional brain abnormalities. The EEG
charges can be regular (rhythmic) or irregular. will reveal abnormalities associated with clinically latent
Sharp waves are similar to spikes but have a duration disease in patients with epilepsy and in metabolic, toxic, and
between 80 to 200 ms. Spikes and sharp waves are epilepti- traumatic disease.
form discharges and are associated with epilepsy. The site of seizure onset (seizure focus) is determined by
Persistent polymorphic focal delta activity is associated the location of epileptiform discharges in the initial stages of
with focal structural brain lesions such as stroke, tumor, electrographic seizure activity. Focal slow-wave activity
abscess, or contusions. The location of this EEG abnormality may occur in association with epileptiform discharges at the
corresponds closely to the site of the structural brain lesion. same site.
Intermittent bilateral synchronous rhythmic delta is asso- Diffuse polymorphic activity is associated with diffuse
ciated with diffuse metabolic, degenerative, or toxic disease. brain disease such as results from inflammatory, toxic, vas-
The location of this EEG abnormality is usually frontal or cular, anoxic, and degenerative disorders.
occipital and does not correspond to the site of the under- Diffuse rhythmic 10-Hz sinusoidal activity is seen at
lying brain abnormality. times in coma states (alpha coma). The frontal predomi-
nance, absence of spindles, and lack of modulation distin-
guish this from true alpha as seen in the normal subject.
ACTIVATION PROCEDURES Acute hemispheric brain lesions and acute exacerbations
of partial seizures are associated with periodic lateralized
Activation procedures have been developed to precipitate epileptiform discharges (PLEDS). Periodic bisynchronous
abnormal EEG activity. 0.5- to 2-Hz discharges are associated with Jakob-Creutzfeld
Hyperventilation over 3 min reduces arterial CO2, pro- (JC) disease. Periodic discharges on a flat background are
duces cerebral vasoconstriction, and results in bilateral associated with anoxic coma and myoclonus. In patients
rhythmic EEG slowing in normal patients. In patients with with subacute sclerosing panencephalitis (SSPE), periodic
absence seizures, hyperventilation will produce paroxysmal 100- to lOOO-jjiV, 0.5- to 3-s, slow-wave bursts occur with
rhythmic spike and wave discharges. 4- to 15-s interburst intervals.
Photic stimulation often produces rhythmic synchronous
posterior activity in normal patients (photi» driving re-
sponse). In some patients, photic stimulation produces syn- CORTICAL MAPPING
chronous myoclonic jerks (photomyoclonic response). In pa-
tients with generalized epilepsy, photic stimulation may Cortical mapping includes the recording of spontaneous
produce seizure activity (photoconvulsive response). electrical activity, stimulation of the cortex for localizing
Sleep deprivation, on the evening prior to the EEG cortical representation of function, and evoked potential
recording, increases the diagnostic sensitivity of the EEG for recording for localization of sensory primary projection cor-
patients with epilepsy. Epileptiform discharges occur more tex. The latter will be described later in this chapter. The use
frequently during non-REM sleep. In some patients, sleep of mapping techniques is not confined to epilepsy surgery.
deprivation will induce seizures. The preservation of functional cortex during resection of
Hydration, alcohol, metrazol, amytal, and brevital have all intracerebral tumors and vascular malformations is aided by
been used to precipitate epileptiform discharges, but this will accurate identification of speech and sensorimotor cortex,
not be discussed further here (Fig. 5-6). and, at times, of visual cortex.
Prolonged EEG-video monitoring is used to evaluate episod- When stimulation mapping is required for identification of
ic events such as seizures. Multiple EEG channels are en- speech and sensorimotor cortex, it is necessary to perform
coded (multiplexed) as a single channel that is stored on an the studies under local anesthesia, as described in Chap. 22.
audio channel of a videotape. A video camera simultane- Electrocorticography may be indicated for seizure activity
ously records the patient's behavior onto the same videotape. associated with the lesion to be resected. Following acquisi-
Radio or cable telemetry EEG recordings allow the patient tion of spontaneous electrographic activity, stimulation stud-
to remain mobile during the recording.3 A technologist may ies are performed as described in Chap. 22.
ELECTRODIAGNOSTIC EVALUATIONS 75
(A)
Figure 5-7 Effect of averaging on recorded signals. A. Single Recording Instrumentation Each channel amplifies
sweep. B. Averaging of 10 sweeps. C. Averaging of 100 sweeps. up to 500,000 times. The low filter settings are typically 1,
D. Averaging of 1000 sweeps. 5, 10, 25, 50, 100, and 300 H/, and the high filter settings
are 100, 250, 500, 1000, and 3000 Hz, providing for cutoff
averaging multiple responses that are time-locked to the stimu- of high frequencies. The rate of signal attenuation (rolloff) is
lus. These responses are summated and averaged so that with a greater for digital than analogue filters. Phase-free digital
sufficient number of epochs the background activity is canceled filters, unlike analogue filters, do not change evoked poten-
and the response can be identified (Fig. 5-7). tial peak latencies. A 60-Hz notch filter reduces artifact from
external power sources.
less variability than strobe light studies and are more sensitive ered unilaterally to the olfactory mucosa by switching
to abnormalities. For infants and uncooperative or unconscious cleaned filtered air, flowing at 20 ml per second, to similar
patients, strobe light or LED studies are necessary. air-containing odoriferous substances. The continuous flow
PSVERs are obtained using a video screen placed 1 m prevents somatosensory response from a puff of air on the
from the patient, who may wear appropriate corrective nonolfactory nasal mucosa.
lenses. A point of fixation is situated in the center of the The switching mechanism serves as the sweep trigger
screen. The screen is illuminated in a checkerboard pattern with a sweep time of 2048 ms. Recording is from Cz
that alternately reverses the illuminated squares. The size of referred to Al.'Waves designated as Nl may be obtained at
the squares and the frequency of reversal are controlled by 306 to 484 ms and PI at 349 to 455 ms. Anosmic subjects
computer. Control of half and quarter fields is also program- are unable to generate evoked responses to vanillin.15
mable. Sensitivity to detection of abnormalities is increased
with smaller squares.
Depth electrode studies reveal both flash VERs and
PRVER responses, as recorded from the scalp, and they INTRAOPERATIVE MONITORING
appear to be generated entirely in the visual cortical struc-
tures. The initial negativity has a more-superficial generator PRINCIPLES
than the large positive peak at 80 to 100 ms.14 The response
is dipole-oriented to the visual cortex, and placement of the The use of intraoperative evoked potential monitoring, par-
recording electrode is critical to the response. Of note is the ticularly VERs, has been criticized for its inability to predict
maximal response in the occipital region on the side of an the outcome of a surgical procedure.16 The expectation that
absent occipital lobe (Fig. 5-12). intraoperative monitoring can predict the outcome of an
operation is doomed to disappointment, although a high
degree of correlation has been reported. Current evaluation
OLFACTORY EVOKED POTENTIALS of the use of intraoperative monitoring has been published
by the American Academy of Neurology.17
Special techniques have been designed to record evoked The concept of "false negatives" and "false positives" as
potentials from the olfactory system. Stimulation is deliv- an evaluator of intraoperative monitoring is subordinated by
whether neural damage is reduced by monitoring. The likeli-
hood of prevention of a major neurological deficit by recog-
nition and reversal of lost evoked potentials is so high that a
controlled study comparing a change with no action taken is with anesthetic agents, especially with bolus delivery during
not acceptable.18 critical stages of monitoring, it is essential for the surgeon
Intraoperative ERs may inform the surgeon that a particu- to have good communication with the anesthesiologist prior
lar maneuver being performed is altering the physiology of to surgery.23-26 This should include consideration of preop-
the neural pathways involved and carries the risk of a erative medications. A steady state of anesthesia using
permanent deficit, or it may notify the anesthesiologist that a minimal level of nitrous oxide and oxygen combined
some alteration in function has occurred that may be based with titrated fentanyl seems to give satisfactory results.4
on a change in the general body state. Such information Administration of up to 0.5% isoflurane seems fairly well
permits appropriate action to correct the change. Admittedly, tolerated in most patients, particularly if a steady state is
there are situations or stages in an operative procedure where established. Anesthetic agents have the most marked effect
a particular maneuver such as the control of bleeding must on long latency responses, while short latency responses
be completed, regardless of an alerting change. Otherwise, in may not be affected.
most operations, an alteration in technique may be required Positioning and fixation of the head may determine the
while awaiting evoked response recovery. Lacking this op- success of monitoring. The head resting on a pad produces
tion, the surgeon may elect to pause long enough to allow movement artifact and allows fluids to collect and produce
recovery of ERs. shunts between electrodes on the scalp. Therefore, fixation
The outcome of surgery affecting the central nervous in head pins seems mandatory. Both recording and referen-
system (CNS) is the result of the pathological process being tial electrodes must be protected from movement by the
treated as well as the success of the surgeon in correcting its surgeon or assistants.
damage. If irreversible changes have not taken place and Once the patient is draped, the opportunity to replace a
correction occurs, the patient will be improved; if changes faulty electrode is lost. Reliability is assured by applying
are irreversible, regardless of the skill of the surgeon, a two electrodes in each position, making an alternate elec-
permanent residual may be expected. If, however, there is trode available. Electrodes are secured by gauze and collo-
the possibility of improvement or even arrest of a lost dion and gelled to an impedance of <3000 ohm. The use of
function and a manipulation in the surgical procedure jeop- disposable fetal ECG electrodes may offer a satisfactory
ardizes neural pathways, that possibility may be lost. It is to alternative.
this factor that the use of intraoperative evoked potential
monitoring is directed, and the earlier the surgeon is alerted
to such a threat, the greater the chance of preservation of
function. It is inevitable, then, that false-positive and false- INTRAOPERATIVE AERs (lOAERs)
negative alerting responses should occur.
For intraoperative EP monitoring the patient must- serve
INTRACRANIAL RECORDINGS
as his or her own control. The pathological process for
which surgery is performed may have produced alterations
Potentials may be recorded intraoperatively from the audi-
in the evoked responses prior to surgery, in addition to
tory nerve using fine Teflon-coated multistrand silver wire
which the preoperative medications and anesthesia may
electrodes with a small cotton wick attached to the tip.
produce further changes. Preoperative evoked potential
Recordings are made from the intracranial electrode, the
studies serve as an aid in diagnosis and in planning intrao-
earlobe, and the vertex contacts, with a noncephalic refer-
perative recordings, but they arc usually different from the
ence electrode. These are compound nerve action potentials
baseline recording obtained initially in surgery. Intraopera-
(CAPs) and are of short latency.4-5
tive ERs must be compared to this baseline for determina-
tion of change.19-20
Averaging is done with commercial computers, using
programs written to operate the computer. Continuous ac- EXTRACRANIAL RECORDINGS
quisition of averages is obtained. These are designed to
sequence plotting so that a continuous record is obtained, Intraoperative auditory evoked responses are recorded from
with appropriate notation of time and comments. the earlobes or mastoids referred to the vertex. The most
Current instrumentation permits digital filtering, time- important wave forms are the short latency waves originat-
variant filtering, stimulus artifact rejection, and other proces- ing in the brainstem.
sing for acquisition of cleaner evoked responses with fewer Two groups of patients undergoing posterior fossa micro-
sweeps.21'22 The use of these developments permits a more- vascular decompression before and after instituting intra-
rapid recycling time so that the responses recorded may be operative monitoring were evaluated for hearing loss. None
reported within 30 to 60 s of the initial sample. This offers of the monitored group suffered profound hearing loss, while
the surgeon an alerting notification approaching real time 6.6 percent of the nonmonitored group had profound hearing
during a manipulation so that a corrective action may be loss. A latency shift in wave V of 1.0 ms is considered
taken. significant, and the surgical procedure was altered in 43
Because of changes, in evoked responses that may occur percent of the cases.27
ELECTRODIAGNOSTIC EVALUATIONS 81
(B)
Figure 5-13 lOAERs. A. Normal mtracramal CAP from CM VIII with permission.) B. Extracranial recording during craniotomy for
at different stimulation intensities, recorded near the internal aneurysm with retraction of cerebellum. Note amplitude and
auditory canal. (Mfiller AR: Evoked Potentials in Intraoperative morphological changes with increased latency of wave V (indicated
Monitoring. Baltimore, Williams & Wilkins, 1988. Reproduced by tic marks) and subsequent improvement.
ing from the C2 vertebra or from the exposed spinal cord below
INTRAOPERATIVE SERs (lOSERs) and above the level of surgery.
A two-channel stimulator is used to deliver an isolated
Intraoperative monitoring of SSERs has been in use for the stimulus of 200 ms duration at 4.7 to 7.7 per second, with a
longest time. Its value, although contested, has received a current less than 20 mA. Artifact rejection is used, and
number of supporting reports (Fig. 5-13).28-30 sweep delay may be used to avoid stimulus artifact.
Bilateral stimulation of the median nerves at the wrist or Sweeptime is 50 ms, with 100 to 500 responses being
the posterior tibial nerves using needle electrodes has proved averaged. Filter settings range from 10 to 30 LFF to 250 to
most satisfactory. The stimulating electrodes are placed in or IK HFF.
near the nerves after the patient is anesthetized, with a In monitoring procedures below the cervical region it is
minimal interelectrode distance of 3.0 cm and with the advisable to be prepared to monitor evoked responses from
cathode proximal. the median nerve in addition to those from the lower ex-
Recording electrodes may be applied with collodion prior to tremities. In the event of loss of responses from the lower
surgery, or coiled fetal scalp monitoring electrodes may be used extremities, loss of the upper extremity responses indicates a
and applied after anesthesia. Impedance is below 3000 ohms. systemic change rather than one resulting from injury to the
Recording from Erb's point during median nerve stimulation or spinal cord.
from the lumbar spine during lower extremity stimulation, re- Interpretation during monitoring requires almost constant
ferred to an indifferent site, verifies neural input. Additional observation. Patients serve as their own controls since
channels recording from the scalp at the C3' and C4' sites for preoperative alterations in function are frequently present.
upper and Cz' for lower extremity stimulation provides long During critical periods in the operation, a decrease in
latency evoked responses from the primary projection areas of amplitude of more than 30 percent is considered significant
the cortex. Short latency responses may be obtained by record- by some and of more than 50 percent by most others. An
82 CHAPTER 5
capacitor from which the current originates is very brief, The safety of transcranial magnetic stimulation remains
while recharging the capacitor requires more time. This unproven, but the maximal charge of 50 |xC per pulse
limits the repetition rate of the stimulus. Rates more rapid appears to be acceptable. Thermal effect on the tissues at
than 0.3 per second require a cooling coil for heat dissipa- maximal stimulus of 3 per second is only 1/300 the limits
tion. A stimulus duration of 100 pis has been found to be suggested by international standards.57 A study of 58 epilep-
satisfactory.48 tic patients on medication who received an average of 25
The magnetic field produced is 1 to 2.5 tesla in the center transcranial magnetic stimuli (TMS) revealed no statistical
of the coil. An electrical field is generated at right angles to change in seizure frequency on follow-up.58
the magnetic field, parallel to the plane of the coil, and it is Rapid rate TMS (rTMS) is possible with a stimulation coil
proportional to the time rate change of the magnetic field. which is cooled to prevent overheating. Stimulation rates of
The direction of current flow determines the orientation of up to 25 Hz in trains of 10 s have permitted identification of
the field.51 Action potentials are produced in excitable cells language lateralization in preoperative studies. Stimulation
lying in the electrical field. of both left and right hemispheres induced speech arrest and
The geometry of the coil determines the 3-dimensional counting errors during stimulation on the left, but not on the
power of the induced electrical field. Coils formed in a single right. Subsequent intracarotid amytal studies confirmed
loop produce maximal electrical fields near the margin of the speech lateralization on the left. One of the six patients
loop decreasing to the center, with reversal of the field outside studied had an after-discharge following an initial train of
the margins of the loop. Smaller coils and more tightly wound stimuli, as well as a partial motor seizure compatible with
coils produce more focali/ed electrical fields.52 the area stimulated following a second train. This was dif-
Adjacent coils forming a butterfly or figure-8 shape with ferent from the patient's habitual seizures. EEG monitoring
current flowing in opposite directions in the two loops is indicated for such an application, and an after-discharge
produce electrical fields maximal under the center of the is a contraindication to continuing stimulation at that
butterfly, and they are considered best-suited for localized intensity.59
transcranial cortical stimulation and mapping. The magni- Significant increases in motor latencies have been demon-
tude of the electrical field decreases with the square of the strated in subjects with multiple sclerosis. This is also seen
distance from the plane of the coil, so that at 2, 3, and 4 cm in cervical myelopathy, cervical spondylosis, spinal cord
the value is 50 percent, 27 percent, and 16 percent of the trauma, hemiplegia, and hereditary spastic paraparesis.49'50'57
value 1 cm below the plane.52 On the other hand, motor latencies are reported as normal in
In addition to transcranial stimulation of the brain, elec- Parkinson's disease, essential tremor, Huntington's disease,
tromagnetic stimulation may also be used on peripheral and torsion dystonia.50-54
nerves for SSEPs and nerve conduction studies. This pro- Intraoperative monitoring using MEPs provides assess-
duces less discomfort than electrical stimulation. For nerve ment of the potential threat to motor pathways not demon-
conduction studies, the exact position of the stimulation field strated by SSEPs. Recording is from the peripheral nerves,
may be difficult to define. The butterfly coil^also appears using needle electrodes. This avoids displacement and alter-
superior in this application. The orientation of the junction ation of EMG response by muscle-relaxing agents used
of the two loops should be parallel to the nerve for maximal during surgery. To avoid the enhancing effect of muscle
stimulation.53 contraction, drip titration rather than bolus administration of
Motor responses following electrical and magnetic stim- muscle relaxants should be used. A combination of SSEP
ulation of the cerebral cortex are very similar, although and MEP monitoring is desirable since the integrity of both
latencies are about 2 ms shorter with electrical stimulation. motor and sensory systems can be assessed. In addition, the
Differences are also observed in response to active contrac- SSEP has an enhancing effect on the MEP. When loss of
tion of the stimulated muscle, with only a small decrease in MEP does not occur or is transient, no permanent motor
latency observed with magnetic stimulation, while latencies deficit is present, but when a weakened MEP does not
with electrical stimulation were decreased 2 to 6 ms.49-54 resolve, a resulting permanent or slowly resolving deficit is
Although the motor strip is the area of principle interest for observed. An optimal monitoring system should provide
stimulation, the cells of origin of the fibers in the pyramidal feedback to the surgeon approximately every 30 s for maxi-
tract are not exclusively located in the precentral gyrus. In the mal safety (Fig. 5-17).47
primate only 31 percent arise in area 4, 20 percent from area 6,
and 40 percent from the parietal lobe.55 The direct response
from the Betz cells is, therefore, supplemented by an indirect
delayed response from collateral pathways of other origins. In
general, the direct response pathways are required for fine MAGNETOENCEPHALOGRAPHY
motor activity of the distal limbs and digits, and the slower (MEG)
indirect responses are associated with more proximal structures
involved in posturing and locomotion. An increased intensity Electroencephalography is handicapped by the high imped-
of the stimulus may increase the distribution of pathways in- ance of tissues through which a signal from an electrical
volvedi>y including collateral structures.56 generator must pass before being recorded. Tissue imped-
ELECTRODIAGNOSTIC EVALUATIONS 85
at the onset of interictal discharge, with 3-dimensional correlation has been found to be within 1 cm. These were
spread away from the onset location and resolution of multi- localized within the area subsequently resected. The MEG
ple areas of excitation that are separated 1 to 2 cm and have localization was also in close agreement with intraoperative
different time amplitude patterns.66 MEG has the capability cortical recordings.67
of determining latency differences and propagation distances At present the role of MEG may be to provide informa-
of spikes consistent with the conduction velocity of cortico- tion complementary to EEG.68 It has added a more realistic
cortical fibers.61 Noninvasive derivation of the cortical sur- approach to quantification of the interictal spike zone in the
face area of spikes agrees with localization obtained by study of epilepsy.69 Its potential for both research and clini-
electrocorticography over temporal neocortex. cal application seems to be on the threshold of significant
Using replicated preoperative MEG studies with dipole contribution.70
electrical signals inserted through depth electrodes, spatial
REFERENCES
1. Kooi KA: Fundamentals of Electroencephalography. 2d ed. 8. Morioka T, Shima F, Kato M, Fukui M: Origin and distribu-
New York, Harper & Row, 1978. tion of thalamic somatosensory evoked potentials in humans.
2. Jasper HH: The ten-twenty electrode system of the Interna- Electroencephalogr Clin Neurophysiol 74:186-193, 1989.
tional Federation. Electroencephalogr Clin Neurophysiol 9. Leandri M, Parodi CI, Favale E: Early trigeminal evoked
10:371-375, 1958. potentials in tumors of the base of the skull and trigeminal
3. Binnie CD: Telemetric EEG monitoring in epilepsy, in Pedley neuralgia. Electroencephalogr Clin Neurophysiol 71:114-124,
TA, Meldrum BS (eds): Recent Advances in Epilepsy, I. Edin- 1988.
burgh, Churchill Livingstone, 1983, pp 155-178. 10. Leandri M, Parodi C, Favale E: Early scalp responses evoked
4. NMler AR: Evoked Potentials in Intraoperative Monitoring. by stimulation of the supraorbital nerve in man. Electroence-
Baltimore, Williams & Wilkins, 1988, pp 50-60. phalogr Clin Neurophysiol 74:367-377, 1989.
5. Mdller AR, Jannetta PJ, Sekhar LN: Contributions from the 11. Kaufman D, Celesia GG. Simultaneous recording of pattern
auditory nerve to the brain-stem auditory evoked potentials electroretinogram and visual evoked responses in neuro-
(BAEPs): Results of intracranial recording in man. Electroen- ophthalmological disorders. Neurology 35:644—651, 1985.
cephalogr Clin Neurophysiol 71:198-211, 1988. 12. Tan CB, King PJL, Chiappa KH: Pattern ERG: Effects of
6. Jacobson GB, Tew JM: The origin of the scalp recorded P14 reference electrode site, stimulus mode and check size. Elec-
following electrical stimulation of the median nerve: Intraoper- troencephalogr Clin Neurophysiol 74:11-18, 1988.
ative observations. Electroencephalogr Clin Neurophysiol 13. Chiappa KH: Evoked Potentials in Clinical Practice, 2d ed.
71:73-76, 1988. New York, Raven, 1990.
7. Mervaala E, Paakkonen A, Partanen JV: The influence of 14. Ducati A, Favi E, Motti EDF: Neuronal generators of the
height, age and gender on the interpretation of median nerve visual evoked potentials: Intracerebral recording in awake
SEPs. Electroencephalogr Clin Neurophysiol 71:109-113, humans. Electroencephalogr Clin Neurophysiol 71:89-99,
1988. 1988.
88 CHAFFERS
58. Tassinari CA, Michelucci R, Forti A, et al: Transcranial mag- 65. Robinson SE, Rose DF: Current source estimation by spatially
netic stimulation in epileptic patients: Usefulness and safety. filtered MEG (abstract). Eighth International Conference on
Neurology 40:1132-1133, 1990. Biomagnetism, 1991, pp 337-338.
59. Pascual-Leone A, Gates JR, Dhuna A: Induction of speech 66. Rose DF, Robinson SE, Ebersole JS, Karnaze D: 3D current
arrest and counting errors with rapid rate transcranial magnetic imaging of interictal spikes in spatially filtered MEG (ab-
stimulation. Neurology 41:697-702, 1991. stract). Eighth International Conference on Biomagnetism,
60. Sato S, Ballish MS: Principles of magnetoencephalography, in 1991. pp 39^U).
Luders H (ed) Epilepsy Surgery. New York, Raven, 1992, pp 67. Eisenberg HM, Papanicolaou AC, Baumann SB, et al: Magne-
415-421. toencephalographic localization of interictal spike sources,
61. Sutherling WW, Earth DS: Neocortical propagation in tem- (case report). J Neurosurg 74:660-667, 1991.
poral lobe spike foci on magnetoencephalography and elec- 68. Cohen D, Cuffm BN, Yunokuchi K, et al: MEG versus EEG
troencephalography. Ann Neural 25:373-381, 1989. localization test using implanted sources in the human brain.
62. Earth DA, Sutherline W, Engel J Jr, Beatty J: Neuromagnetic Ann Neural 28:811-817, 1990.
localization of epileptiform spike activity in the human brain. 69. Sutherling WW, Levesque MF, Crandall PH, Earth DS: A
Science 218:891-894, 1968. complete physical description of the dynamic electric currents
63. Pantev C, Hoke M, Lehnertz K, et al: Identification of sources of human partial epilepsy and essential cortex using MEG,
of brain neuronal activity with high spatiotemporal resolution EEG, chronic ECoG grid recordings, and direct cortical stimu-
through combination of neuromagnetic source localization lation, in Luders H (ed) Epilepsy Surgery. New York, Raven,
(NMSL) and magnetic resonance imaging (NMI). Electro- 1992. pp 429-450.
encephalogr Clin Neurophysiol 75:173-184, 1990. 70. Stefan H: Multichannel magnetoencephalography: Recordings
64. Kaufman L, Kaufman JH, Wang JZ: On cortical folds and of epileptiform discharges, in Luders H (ed) Epilepsy Surgery.
neuromagnetic fields. Electroencephalogr Clin Neurophysiol New York, Raven, 1992, pp 423^28.
79:211-226, 1991.
STUDY QUESTIONS
J. "A 25-year-old male, having recently had a series of important waves to be observed? 3. What are the sources of
generalized seizures beginning in the left arm, is sent for an these waves? 4. How are the response waves differentiated
EEG. The report indicates alpha activity throughout except from the routine electrical activity of the brain? 5. Initial
for the right frontal area where there is a focal area of delta recordings show prolongation between the waves recorded
activity with intermittent spikes. from the vertex and that recorded from the earlobe. What is
the significance of this increase in conduction time?
1. What is the size and frequency of the alpha activity?
2. When is it most likely to appear? 3. What is the
implication of delta activity? 4. What is its rate? 5. What is IV. Intraoperative evoked responses are being recorded dur-
the interpretation of the spike activity? ing the course of resection of a vascular malformation at the
cervicomedullary junction.
D. An 18-year-old girl has an EEG after being kept awake 1. Where should the recording electrodes be placed?
all night the night before. She falls asleep during the exami- 2. What are the normally recorded responses? 3. Of what
nation, progressing through the various levels of sleep to significance is an increase in the latency of responses?
REM sleep. 4. What is the significance of loss of the later responses
during the administration of anesthesia? 5. How should the
1. What was the most likely rhythm when the individual head be held during the recordings?
being examined was awake? 2. Describe the expected EEG
recordings during non-REM sleep. 3. What is the appearance V. A 40-year-old male is undergoing laminectomy for an
of the EEG during REM sleep? 4. What is the explanation of extraaxial mass of the mid-cervical area.
this later category? 5. What is the purpose of depriving a
patient of sleep before an EEG? 1. What form of evoked potentials (sensory or motor)
would be most predictive of future function? 2. Where might
stimulations for each of these forms of monitoring be per-
III. A 36-year-old female is being monitored with auditory formed? 3. Where would recording electrodes be placed?
evoked responses while undergoing a surgical procedure in 4. What are the advantages and disadvantages of magnetic
the posterior fossa. stimulation as compared to electrical stimulation? 5. What
indications on the recordings would lead one to recommend
1. What anesthesia should be used? 2. What are the most an alteration of the conduct of the procedure?