Brainstem

Auditory
Evoked
Response
Dr Gerald Pagaling
Outline
• Anatomy and Physiology
• Technical Aspects
• Conduct of examination
• Case application
Anatomy
Anatomy and Physiology

1) Hair cells of the organ of Corti

2) Spiral ganglion
3) Cochlear Nerve
4) Cochlear Nuclei
5) Lateral Lemnisci
6) Trapezoid body
7) Inferior colliculus
8) Medial geniculate body
9) Primary and association auditory cortex
(Area 41)
Anatomy
4
1st Order neurons
- Neuroepithelial hair cells. 3
2nd Order neurons
- Dorsal and ventral cochlear nuclei
3rd Order neurons
- Inferior colliculus
4th Order neurons 2
- Medial geniculate

1
Auditory pathway

Hair cells of the organ of Corti Vestibulocochlear Nerve

- 1st order neuron
Auditory pathway

Cochlear Nuclei:
- 2nd order neuron
- Ventral
- Dorsal
Lateral lemniscal pathway:
- Dorsal acoustic striae
- Intermediate acoustic striae
- Ventral acoustic striae
Auditory pathway

Cochlear Nuclei:
- 2nd order neuron
- Ventral
- Dorsal
Lateral lemniscal pathway:
- Dorsal acoustic striae
- Intermediate acoustic striae
- Ventral acoustic striae
Auditory pathway
Lateral lemniscal pathway:
- Dorsal acoustic striae
- Intermediate acoustic striae
- Ventral acoustic striae
Auditory pathway

Lateral lemniscal nucleus

Auditory pathway

Inferior Colliculus
- 3rd order neuron
- Midbrain tectum
Auditory pathway

Medial geniculate
- 4th order neuron
Auditory pathway
Auditory pathway

E– Eigth nerve
C– Cochlear nucleus
t– trapezoid body
o– olives, superior
L– Lateral lemniscus
I– Inferior colliculus
M– Medial geniculate
A– Auditory cortex
Technical
Aspects
Definition of terms
Short-latency auditory evoked potentials (SAEP)
- Electrical responses of the auditory pathway that occur within 10 - 15 ms of an
appropriate stimulus in normal subjects

Electrocochleogram
- electrical responses of the cochlea and the auditory nerve to acoustic
stimulation.

Brainstem auditory evoked potentials

- responses of the auditory nerve, brainstem, and perhaps higher
subcortical structures to acoustic stimulation.
Latency Responses

Short <10 MS
Middle 10 – 100 MS
Long >100 MS
Far field potentials
Far field potentials
1) Traveling on different medium with
different conductance.
2) Change in geometry
3) Traversing a bend in the nerve tract

I and II 8th nerve

III Entry of cochlear nerve to
the cochlear nuclei
IV and V Rostral brainstem
Brainstem auditory evoked potentials

Vertex Positive: I through VII

Vertex Negative: I’ through VI’
Definition of terms

Amplitude:
Number of neurons firing

Latency:
Speed of transmission

Interpeak latency:
time between peaks

Interaural latency:
difference in the wave V between ears
Definition of terms

Amplitude:
Number of neurons firing

Latency:
Speed of transmission

Interpeak latency:
time between peaks

Interaural latency:
difference in the wave V between ears
Definition of terms

Amplitude:
Number of neurons firing

Latency:
Speed of transmission

Interpeak latency:
time between peaks

Interaural latency:
difference in the wave V between ears
Definition of terms

Amplitude:
Number of neurons firing

Latency:
Speed of transmission

Interpeak latency:
time between peaks

Interaural latency:
difference in the wave V between ears
Definition of terms

Amplitude:
Number of neurons firing

Latency:
Speed of transmission

Interpeak latency:
time between peaks

Interaural latency:
difference in the wave V between ears
Stimulus
Stimulus polarity
Stimulus rate
- 5 to 200/s
- Waves I, II, VI and VII ar particularly reduced in amplitude
at rates higher than 10/s

Stimulus intensity
- 40 and 120 dB peak equivalent sound pressure level
Monoaural stimulation
- The clicks should be delivered one ear at a time

Contralateral masking
- The contralateral (nonstimulated) ear must be masked by white
noise at 60 dB SPL to eliminate crossover response.
Conduct of
Examination
Set-up
Montage

Channel 1: Vertex-ipsilateral earlobe or mastoid

(Cz-Ai or Mi)
- Very variable even in normal subjects

Channel 2: Vertex-contralateral earlobe or mastoid

(Cz-Ac or Mc)
- Generally demonstrate better separation of waves IV and V
Minimal test protocol

✓Includes rarefaction, condensation, or summated separate

rarefaction and condensation clicks.

✓Delivered monaurally at intensities of 90—120 dB pe SPL,

(115 or 120 dB pe SPL) and at rates below 25/s.

✓The contralateral ear should be masked by white noise

at 60 dB SPL.
Interpretation
Measures
✓ Latency
✓ Wave I peak
✓ Wave III peak
✓ Wave V peak
✓ Interval
✓ Wave I-III interpeak
✓ Wave III-V interpeak
✓ Wave I-V interpeak
✓ Amplitude
✓ Wave I
✓ Wave V
✓ Amplitude ratio
✓ Wave IV-VI
✓ BAER threshold
Interpretation
✓ Beyond 2.5 to 3 SD from the mean of an age-matched control.
Interpretation
✓ Beyond 2.5 to 3 SD from the mean of an age-matched control.
Interpretation
✓ Beyond 2.5 to 3 SD from the mean of an age-matched control.
Interpretation
✓ Beyond 2.5 to 3 SD from the mean of an age-matched control.
Case
Application
Indications
• Vestibulocochlear and Brainstem tumors.
• Auditory neuropathy
• Meniere’s Disease.
• Demyelinating disease (Infratentorial auditory pathway).
• Intraoperative monitoring during surgery.
• Bell’s Palsy
• Others:
 Marcus Gunn ptosis
 Duanne retraction Syndrome
 Gaucher Disease
 Migraine
 Krabbe’s Disease
 Mitochondrial encephalomyopathies
Hearing Loss
Eight nerve tumor
Eight nerve tumor
Large eight nerve tumor
Multiple Sclerosis
Multiple Sclerosis
Multiple Sclerosis
Intraoperative monitoring
 As nerve decompression and tumor
resection progressed, waveform amplitudes
increased and a clearly recognizable Wave V
became apparent on the left.

It was eventually not possible to preserve

the nerve and obtain complete tumor removal,
and the left cochlear nerve was sectioned with
loss of all evoked waveforms beyond Wave I.
Exercises
A 49-year-old woman with a history of chronic ethanol abuse was admitted to a
first hospital for generalized tonic– clonic seizures related to ethanol withdrawal.

The electroencephalogram was symmetric with predominant beta waves and no

epileptiform discharges.

There was a mild hyponatremia on admission (122 mmol/l). The following values
were recorded: 127 mmol/l (day 2), 130 (day 3), 137 (day 4), 148 (day 5).

She was admitted to the intensive care unit on day 7, following progressive
deterioration of consciousness with flaccid quadriplegia and preservation of the
horizontal and vertical eye movements. The Glasgow Coma Score was only 5/15
(E3,V1, M1). Brain computed tomography was unremarkable.
NORMAL

PATIENT
Sources
• Recommended standards for short-latency auditory evoked potentials. American Clinical
Neurophysiology Society (2008).
• Eggermont (2019). Auditory brainstem response. Handbook of Clinical Neurology Vol 160
(3rd series)
• Van Pesch, Hantson (2013). Brainstem somatosensory and auditory evoked responses in
central pontine myelinolyosis. Acta Neuroligica Belgica
• Raudzens, Shetter (1982). Intraoperative monitoring of brain-stem auditory evoked potentials.
Journal of Neurosurgery.
Thank you