BAER

Dr.G.Ranjith
References :

 1.UK misra and J Kalita.

 2.John S. Ebbersole

 3. American clinical neurophysiology society.

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Introduction :
 AEP – Stimulation of auditory system.

AEP

Short
latency(SLAEP) Medium latency Late latency
<10ms 10-50ms >50ms

1.EcochG
2.BAEP

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Anatomy : Sound

Hair cell activation.

Auditory nerve activation.( Vestibulo cochlear nerve)

Ventral and caudal dorsal cochlear nuclei

(rostral medulla)

50% fibers decussate(trapezoid body ventral pons).

Superior olivary complex.

(L/leminiscus)

Inferior colliculus(midbrain)

Medial geniculate body

Superior temporal gyrus(primary auditory cortex)

( b/l representation)

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Wave form generators :

 5 wave forms.

 Recording montage : Cz-A1 and Cz-A2.

 Reference - auricular and active – central.

 Labeled according to their sequence.

 Many structures contribute to each wave form.

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 Wave form Localisation

I Distal auditory nerve Near field Negitive

(Reference
electrode)
II Proximal auditory nerve Far field Positive
and cochlear nucleus

III Superior olivary complex Far field Positive

IV Lateral leminiscus Far field Positive

V Inferior colliculus Far field Positive

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Methodology :

 Stimulation

Effect BAEP interpretation.

 Recording

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Stimulation :

1.Patient-related factors.

2.Delivery technique :

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3.Characteristics of the stimulus :

 Broadband clicks - 100 μs pulses - wide band of frequencies.

 It is their high- frequency content that produces the BAEP.

 Useful for neurological assessments not for audiological assessment.

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 Intensity of stimulation : Actual stimulus intensity compared with a reference value.

 BAEP stimulus intensity is expressed as “dBnHL”.

 Stimulus intensity -d/p- amplitude and morphology.

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 Stimulation rates :

 Slow and fast stimulation rates can be used.

 Slow rates, between 8 and 12 per second, are used most often.

 Slow rate : Better morphology and short latency.

 Fast rate : Prolonged latencies and lower amplitudes.

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 Stimulus polarity

Based on initial

movement of diaphragm

Condensation(Towards)
Refraction (Away)

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 Masking white noise : 40 db less than that used for stimulation.

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Recording :

Channel 1 CZ-Ai

Channel 2 Cz-Ac

Channel 3 Ai-Ac

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 BAEP polarity convention is the opposite.

 All BAEP components are displayed upward.

 Filter setting for BAEP : 10- 3,000 Hz.

 Repitions : 2000 (KMC lab)

 Must be replicated atleast once.

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 Interpretation :

 Indentification of wave forms.

 I,III,V- Obligate wave forms.

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 Neither on the Latency or sequence.

 First : Identification of wave V.

 Peak that precedes most significant negitive potential.

 Aprox latency- 5.5 ms.

 May be fused with wave IV – Better seperated in Cz-Ac

 Most robust - Decreasing the rate intensity and increasing the rate frequency.

 Click polarity may alter the prominance.

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 Second : Identification of wave I

 Early wave forms.(1.4ms latency)

 Polarity does not change with change in polarity of stimulus.

 Wave I is absent in the Cz-Ac derivation .

 It is more prominent in Ai-Ac derivation.

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 Third step : Indentification of wave III.

 Well seen in Cz-Ai may be fused in Cz-Ac.

 In contralateral ear this wave may be smaller and earlier.

 Wave II : Easy to make out in contralateral ear.

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Peak and inter peak latencies :

 Absolute latencies of waves I, III, and V are determined.

 IPL : I–III, III–V, or I–V are also determined .

 VC is better than V.

 Amplitudes of waves I, IV, and V are also determined.

 Amplitude ratio of V/I.

 Comparision should be done between the ears and side to side.

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KMC lab reference values :

 I-III IPL – 1.9 to 2.3

 III-V IPL – 1.8 to 2.2

 I-V IPL - 3.7 to 4.3

 Absolute Wave 1 latency : 1.3 – 1.9.

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 Latencies Significance Lateralisation
Wave I absolute latency Measure of peripheral Ipsi
auditory pathway upto distal
auditory nerve.

I to III IPL From auditory nerve to Ipsi or contralateral

superior olivary complex.

III to V From superior olivary complex Ipsi or contralateral

to inferior colliculus.

I to V Entire pathway. Ipsi or contralateral

• The wave IV– V/I amplitude ratio should be at least 0.5. (not lateralising)
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 Absence of obligate waveforms :

 Most severe type of abnormality.

 Can be due to severe hearing loss.

 Severe brain stem dysfunction.

 Absent wave V – Severe midbrain dysfunction.

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 Interpeak latency :

 I to V IPL :

 Conduction from VIII to midbrain.

 Typical IPL is 4.5 ms.

 Right to left asymmetry < 0.5ms.

 Examples : Demyelination, ischemia , hypoxic insult , tumors.

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 I-III IPL :

 Conduction from VIII into subarachnoid space to the core of lower pons.

 Prolongation : Lower brain stem lesion.

 Prolongation : CP angle tumors, meningitis , SAH. , GBS.

 Upper limit – 2.5 ms.

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 III-V IPL:

 Isolated prolongation is not abnormal.

 Should be associated with prolongation of I-V.

 Upper limit - 2.4ms

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 Wave V / I :

 Normal range 50 to 300 %.

 < 50% - Central impairment.

 > 300% - Peripheral impairment.

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 Pediatric Considerations :
 Used for evaluation of brain stem and evaluation of hearing.

Age Waves

Term I,III,V are present.

3 to 4 months All five waves

Half the amplitudes as adult.

One year Almost adult like.

4 to 5 years Amplitudes matches to adults.

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 Age Latencies

At birth Wave I and V latencies are prolonged.

At 2 months Wave I latency reaches adult level.

At 2 years Wave V latency reaches adult level

From 2 months to 2 years I to V latency decreases.

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 Interpretation is similar as in adults from the age of 2 years.

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Clinical Correlations :

 Tests functional integrity of auditory pathway.

 Neurologic and hearing problems can result in BAEP changes.

 Hearing screening : latency/intensity (L/I) –Latency of wave V on different stimulus

intensities.

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 CP angle tumours :

 Ex : Acoustic neuroma.

 Prolonged I-III and 1-V IPL.

 Only wave one recordable.

 Unrecirdable BAEP.

 Right to left assymetry in wave V latency > 0.5 ms.

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 BAEP in multiple sclerosis :

 Prolongation of III to V IPL.

 Prolongation of I-V IPL.

 Reduction of V/I ratio.

 Absence of wave III.

 BAEP is consistently abnormal in various leukodystrophies.

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 Coma :

 Absence of waves III and V are associated with poor prognosis.

 Metabolic and toxic coma does not effect BAEP.

 Coma due to brain stem stroke : absent II to V waves- Poor prognosis.

 Meningitis : V/I amplitude was reduced.

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 Brain death :

 Regardless of etiology and depth of the coma

Normal BAEP – recovery

Absent baep indicates death.

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 Pediatric conditions :

 Presence of wave I and V are considered normal.

 Done at 30 decibels.

 Hyperbilirubinaemia.

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 Bacterial meningitis.

 Hypoxic ischemic insult.

 Low birth wt.

 Rubella infections

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Criteria for clinically significant abnormality (ACNS)

1. Absence of all BAEP waves.

2. Absence of all waves following I,II,III.

3. Abnormal prolongation of I-III , III-V intervals.

4. Abnormal dimunition of IV,V/I.

5. Abnormal increase in interaural interpeak latencies.

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 Conclusion :

 IPL are most important.

 Useful in MS leukodystrophies.

 Prognostication of coma patients.

 CP angle tumours.

 Meningitis .

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 Thank you

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