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Module 2 Basic Instrumentation For IOM

NOTE: THE ENCLOSED INFORMATION IS A MERE SUPPLEMENT TO ALL OTHER PERTINENT INFORMATION FOUND IN JOURNAL ARTICLES, TEXTBOOKS AND OTHER PROFESSIONAL LITERATURE. THIS INFORMATION IS NOT INTENDED TO REPRESENT A COMPLETE SUMMARY OF ALL THE REQUIRED LEARNING FOR THE CNIM.

Neurocat CNIM Test Preparation Module 2 Basic Instrumentation Spring 2011

TABLE OF CONTENTS
TABLE OF CONTENTS....................................................................................................2 SECTION 1: CURRENT FLOW........................................................................................3 Fundamental of Electricity............................................................................................................3 Conductors......................................................................................................................................3 Insulators........................................................................................................................................3 Terminology....................................................................................................................................4 LESSON 2: INSTRUMENTATION....................................................................................6 Differential Amplifier....................................................................................................................6 Specifications...............................................................................................................................7 Input Impedance...........................................................................................................................7 Common Mode Rejection............................................................................................................7 Polarity.........................................................................................................................................8 Gain and Sensitivity.....................................................................................................................8 Filters...........................................................................................................................................8 Filter Slopes.................................................................................................................................9 Period of a Waveform ...............................................................................................................10 Frequency...................................................................................................................................10 Digital Filter...............................................................................................................................10 Notch (60Hz) Filter....................................................................................................................10 Analog-to-Digital Conversion...................................................................................................10 Sampling Rate............................................................................................................................10 Dwell Time................................................................................................................................11 Aliasing......................................................................................................................................12 Vertical Resolution....................................................................................................................12 Signal-to-noise Ratio.................................................................................................................14 Artifact Rejection.......................................................................................................................15 Averager.....................................................................................................................................15 Simultaneous Averaging............................................................................................................15 Multiple time bases....................................................................................................................15 Epoch ........................................................................................................................................15 Calibration..................................................................................................................................15 Replications................................................................................................................................16

Neurocat CNIM Test Preparation Module 2 Basic Instrumentation Spring 2011

SECTION 1: CURRENT FLOW


Fundamental of Electricity An understanding of the basic concepts of electricity is essential to appreciate the techniques compromising Clinical Neurophysiology. Electricity is the phenomenon of flow of electrical charge. Charge (Q) is a concept that evolved from empirical observation of electricity in nature and in experiments. Although charge can either be positive or negative, it is the flow of negative charge is the coulomb which represents the negative charge 6.35 x 1018 electrons. Because electricity represents a flow of charge, it must be directional. The direction of charge flow has been arbitrarily defined as flow from positive to negative. Current (I) is the amount of charge flow per time unit. An ampere (A) is the primary unit of current, defined as the flow of one coulomb of charge per second. Electricity flows as an electrical current in a wire. This flow is made up of electrons which are subatomic particles. It is therefore necessary to understand some basic atomic structure. An atom is made up of a nucleus which contains protons and neutrons. Electrons orbit this nucleus in so called shells. The shells or orbits do not actually exist, they represent different energy levels for the electrons. An atom always has zero charge. This means that it must have the same number of protons as electrons. If an atom looses or gains one or more electrons it forms an ion

Conductors Conductors are those substances in which the outer electrons (typically only one or two in each atom) can move freely from one atom to the next. Current flows easily through conductors. Examples of conductors include: metals such as copper, iron, aluminum, platinum and water containing dissolved minerals. The movement of electrons is current o Electrons flow from negative (-) to positive (+) o Conventional current flows from positive (+) to negative (-) Insulators Insulators are substances in which all the electrons in the atoms of the substance are tightly bound. The electrons do not easily move from one atom to the next. It is very difficult to get current to flow through
Neurocat CNIM Test Preparation Module 2 Basic Instrumentation Spring 2011

insulators. Examples of insulators include: ceramics, rubber, plastic, and surprisingly, pure water Terminology Voltage Refers to the amount of potential electrical energy between two charged points in space. Basic unit of electromotive force (E) is the Volt (V) Current Amount of charge flow per time unit Basic unit of current (I) is Ampere

Resistance Encountered when charge moves in matter Basic unit of resistance is ohm Resistors in series: R= R1 + R2 + R3 . Resistors in parallel R = 1/ (1/R1 + 1/R2+ 1/R3) Power Delivering a specific amount of current at a specific voltage Basic unit of power (P) is the watt P = (E) x (I), P + E(sq)/R, P= I (sq)

Ohms Law Ohm's law is the main basic electrical law and defines the resistance of a device to the flow of electrons. The principle by which voltage, current, and resistance are related States: Voltage (V) is equal to current (I) flowing in the circuit, multiplied by resistance (R) in the circuit V= (I) x R, or I = V/R, or V/I The letter E is sometimes used instead of V for voltage Most people can remember a picture easier than a mathematical formula. By knowing any two values you can figure out the third. Simply put your finger over the portion of the symbol you are trying to figure out and you have your formula. Electrode Impedance (Z)
Neurocat CNIM Test Preparation Module 2 Basic Instrumentation Spring 2011

Represents the combined effects of resistance, capacitive reactance and inductive reactance that occurs in AC circuits. Impedance for scalp electrode should be between 1,000 5,000 ohms Very low impedance (Less than 1,000) may short circuit the amplifier input (e.g., sweat or salt bridges) Impedance of the stimulating electrode has a direct and severe affect on the output to the nerve.
Note: Electrode resistance Electrode impedance - opposition to direct current flow - opposition to alternating current flow

Capacitance A capacity is defined as an electrical circuit element used to store a charge temporarily, consisting in general of two metallic places separated by a dielectric Capacitance is the ratio of charge to potential of an electrically charged, isolated conductor The unit of capacitance is farad. Capacitors block direct current but pass alternating current

Inductance The property a circuit possesses that cause voltage to be induced in the circuit when there is a variation in current flow Inductance opposes any change in current The unit of inductance is the Henry (H) Current Leakage Defined as the low value electrical current that inherently flows (leaks) from the energized electrical portions of an instrument to the metal chassis. All electrically operated equipment has some leakage current. For equipment where patients have direct contact, leakage current must not
Neurocat CNIM Test Preparation Module 2 Basic Instrumentation Spring 2011

exceed 100 A Artifact Defined as unwanted signal that contaminates recordings Four basic sources of artifact include: 1) Patient or unshielded electrodes can act as an antenna 2) Recording electrodes connected to other recording equipment act as conductors 3) The recording leads or cables connecting the patient with the recording equipment conduct magnetic field artifacts 4) Interference leaks into the amplifiers from the power lines Keeping electrode impedances as low and evenly match as possible helps eliminate in-phase artifacts Stimulus artifact is a specific type of artifact. It occurs early in the recording and is caused by free electrons from the stimulus charge reaching the recording electrodes. The standard for setting up any stimulus/recording array is to place ground halfway between the stimulus and recording site. The ground will draw off the electric charge before it reaches the recording site.

LESSON 2: INSTRUMENTATION
Differential Amplifier
Neurocat CNIM Test Preparation Module 2 Basic Instrumentation Spring 2011

Specifications

Noise level of the amplifier must not exceed 2 uV rms with the inputs connected to neutral and with a bandpass of 0.1 to 5000 Hz Meet specification in presence of a sustained 300 mV offset applied differentially
Input Impedance

Electrical impedance of the amplifier input must be high compared with that of the recording electrodes High input impedance insures against a loss of amplitude of signals recorded The input impedance of the amplifiers should be 10 M ohm or more
Common Mode Rejection

Differential amplification rejects signals of identical potentials, these potential changes are said to be common mode The ability to reject common mode signals is called the common mode rejection ratio (CMMR) Defined as the ratio of the amplification of the signals that are different in the two inputs of an amplifier, to the amplification of the signals that are the same in the two inputs. CMRR for EP amplifiers should be 10,000 to 1, i.e., 80 dB or more CMRR is facilitated by impeccable electrode application technique that insures that the 60 Hz is picked up at the same amplitude and phase in all electrodes

Page 36 of the Concise Handbook: Often the CMRR is given in decibel (dB). A number can be converted to decibels by first taking the logarithm in base 10 of the number and then multiplying by 20. CMRRdb = 20 x log10(CMRR) LOG (1000) LOG (10000) LOG (100000) LOG (1000000) =3 =4 =5 =6 multiplied by 20 multiplied by 20 multiplied by 20 multiplied by 20 = = = = 60 db 80 db 100 db 120 db

Neurocat CNIM Test Preparation Module 2 Basic Instrumentation Spring 2011

Polarity

There is no universally accepted polarity convention for EP recordings Two polarity conventions exist for differential amplifiers Either: 1) Or 2) A positive potential at input I causes a downward deflection at the output and; A positive potential at input II produces an upward output deflection A positive signal at input I produces an upward deflection at the output and; A positive signal at input II causes a downward output deflection

The deflection (up or down) presentation of the waveform is dependent on the EP instrument. The polarity of the event is event/generator specific and cannot be changed The term active electrode is usually used to indicate the electrode that is closer to the generator as compared to the reference electrode which would be farther away.
Gain and Sensitivity

Gain should be adjustable in steps of not more than 2.5 to 1 Gain and Sensitivity are terms which manufactures use for similar functions. The key terms which will differentiate one from the other are as follows: SENSITIVITY Is the number of micro-volts represented by a specified distance (e.g., division) A larger number will result in smaller waveforms (less sensitive) (e.g., 50 mV/div versus 20 mV/div) GAIN Is the ratio of voltage or power out to the voltage or power in A larger number will result in larger waveforms

Filters
Neurocat CNIM Test Preparation Module 2 Basic Instrumentation Spring 2011

A filter is a circuit that is designed to pass a specific band of frequencies while attenuating (blocking) all signals outside this band. Filter networks may be either active or passive. Passive filters networks contain only resistors, inductors, and capacitors. Active filters employ amplifier circuits such as transistors or operational amplifiers plus resistors, inductors, and capacitors. Band-pass filters pass only a band of frequencies while attenuating all frequencies out the band. Low Frequency Filter (LLF) (High pass filter) Reduce the amplitude of slow waves without attenuating faster waves Excessive low-frequency filtering will cause a peak or valley to appear earlier, leading to possible falsely normal results High Frequency Filter (HFF) (low pass filter) Reduce the amplitude of waves of high frequency and let waves of low frequency pass without attenuation Excessive high-frequency filtering will delay (prolong) a peak or valley leading to a possible falsely abnormal study.

Helpful tip: The bigger the number in (Hz) on the filter, the shorter the latency

Filter Slopes

Low Frequency Filters Roll-off slopes should not exceed 12 dB octave If a frequency is reduced by 50%, it is said to have change by one octave High-Frequency Filters Roll-off slopes should not exceed 24 dB octave (HFF) The time required for a sudden input voltage to rise to 63% of its peak voltage equals: T=R, C in an RC filter With each reduction of the input frequency by one octave, the output amplitude typically will be reduced by 50%. This is called the roll-off LLF is usually a passive filter made of a capacitor in series and resister in parallel to the signal path. The cutoff is usually defined as 3 dB point (or the frequency at which the signal at the filter output is reduced to 3 dB or 30 percent)

Neurocat CNIM Test Preparation Module 2 Basic Instrumentation Spring 2011

Time constant may be determined by measure the time interval between the onset of the sustained calibration pulse and the point at which its amplitude has dropped to 37%
Period of a Waveform

The period of a waveform is the time required for completing one full cycle. It is measured in seconds
Frequency

The frequency of a waveform is the number of cycles that is completed each second. It is measured in Hertz (Hz)
Digital Filter

Operates on digitized responses to eliminate components of low or high frequency with very high cutoffs and without phase shift Digital filtering causes no temporal distortion of EP waveforms
Notch (60Hz) Filter

Most common cause is unequal electrode impedance Greatly reduce waves of frequencies in a very narrow band concentrated around 60 Hz. Affects the most common artifact from power-line interference of 60 Hz May distort EP waveforms
Analog-to-Digital Conversion

Continuous voltage changes of the data are converted into a sequence of numbers (digital format) This display is displayed as a sequence of illuminated dots The degree of similarity between the analog signal and its digital counterpart is dependent of each of the items listed below. Several Important Rules exist that must be followed when digitally sampling physiologic signals: 1. Amplifiers must have sufficient sensitivity and CMRR to detect and amplify the signal 2. The A-D converters must have a liner response over the dynamic range of the signal 3. The A-D converters must have an adequate sampling rate and resolution to faithfully reproduce the signal.
Sampling Rate
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Sampling rate is defined as the number of points per second that a computer is using to digitize the response on the horizontal axis Sample rate and dwell time define the horizontal resolution or time (frequency) resolution. Horizontal Resolution is dependent upon 1) Analysis time required to do the test 2) Number of points selected 3) Horizontal resolution of 20 sec/address/channel is preferred Sampling rate (in Hz) is calculated as:
# sampling points analysis time (sec)

Dwell Time

Dwell time is the inter-sample interval or the space between each point. Dwell time is calculated as follows:
analysis time # of points

Most instruments allow the user to define sampling rate or number of sampling points. Dwell time will change with an edit of either of these options.

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Nyquist Frequency Defined as: the sampling frequency should be at least twice as fast as the highest frequency being recorded. If not, aliasing could occur. For example, to duplicate the standard EEG frequency range of 0.1 Hz to 70 Hz, each channel must be sampled digitally at 140 Hz Example: What can you say about a system trying to resolve a 40 S sine wave with a sampling rate of 40 kHz? 1. 2. 3. 4. No aliasing will occur Aliasing will occur Aliasing may or may not occur depending on the bits Aliasing may or may not occur depending on the Nyquist frequency

Nyquist Frequency: Defined as: the sampling frequency should be at least twice as fast as the fastest frequency being recorded. Therefore, at a sampling rate of 40 kHz, the fastest waveform that can be resolved is 20 kHz. At 40 us (0.04 ms) sine wave has a frequency 1000 ms/.04 = 25000 Hz, or 25 kHz. Aliasing WILL occur because the sine wave of 25 kHz is GREATER than the maximum frequency of the waveform that can be resolved which is 20 kHz.
Aliasing

Aliasing is the computer induced artifact which is present when the sampling rate is too slow Aliasing may appear as corruption in both frequency and amplitude presentation
Vertical Resolution

Size of A/D converter Sizes range for 4-12 bit Most resources state that the most common is 8 bit, however with the advent of the digital EEG, the most common is now an 11-16 bit converter 8 bit allows for 256 unique voltage values (+/-)
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Excessive amplification will result in clipping of the waveform and corrupt amplitude values Insufficient amplification results in waveform flattening and corrupt amplitude values Number of trials, sweeps, epochs Amplitude resolution is improved by increasing the number of trials (improving signal to noise ratio) Vertical resolution is controlled by the number of bits in the A-D converter. The larger the # of bits the larger the unique voltage values that can be stored the greater the vertical resolution. The +/- voltage range associated with the A to D converter, unique points in that range and modality being recorded.

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Signal-to-noise Ratio

Defined as the ratio of the amplitude of the stimulus locked components (signal) to the amplitude of the unrelated components (noise) This ratio improved with the number of responses averaged. The noise decreases by the square root of the number of averages. Typical CNIM Question: If an evoked response of 5 uV occurs in EEG activity of 20 uV, how many responses need to be average to obtain a signal to noise ratio of 2:1? 1. 8 2. 16 3. 64 4. 128 IMPORTANT: You must know that the signal-to-noise ratio will improve with SQUARE ROOT of the number of trials. There are different ways of answering this but here is one: Signal-to-Noise = SNR SNRnew = SNRold multiplied by SQUARE ROOT (Number of trials) From the question above SNRnew = 2:1 SNRold = 5:20 SQUARE ROOT (Number of trials) = X Plug these values into the equation: 2/1=5/20 multiplied by X Solve for X, using basic algebra X = (2 x 20)/5 X=8 8 represents the SQUARE ROOT of the number of trials so you must SQUARE X to determine the number of trials. Therefore, 8 x 8 = 64.
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The answer is 64 trials.


Artifact Rejection

Characteristic of EP instruments whereby artifact-contaminated trials can be Achieved by rejecting those trials that exceed the limits of the A-D converter or some adjustable percentage thereof. Most commonly set to 90-98% of the dynamic range of the A-D Setting a percentage of A-D converter is one means for artifact rejection. The other is to have an addition uV detection level that will eliminate individual trials.
Averager excluded from the average

Time resolution should be 20 us/data point or less Amplitude resolution of the A-D converter should be at least 8 bits 500 address of memory should be available for each channel Allow for averaging of at least 4000 trials

Simultaneous Averaging

Averaging multiple modalities at the same time It is usually interlaced and asynchronous. For example, averaging left upper SSEP, right upper SSEP, left lower SSEP and right lower SSEP Alternatively, running synchronous. For example, both upper and/or both lowers stimulated together.
Multiple time bases

Able to display and/or record the same modality in different time bases. For example, BAERs using 1 msec and 2 msec on the same data.
Epoch

Is the total amount of time, starting either pre-stimulus or at the start of the stimulus, to the end of the data collection
Calibration

Injecting into the input jacks of each channel rectangular pulses of appropriate amplitude, usually 0.5-100 uV, time-locked to the onset of the sweep.
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Calibration pulses must be amplified and average and their amplitude measured in conditions identical to those to be employed for the recording of the evoked potential under study
Replications

Replication of the response is imperative to demonstrate that clinically evoked responses are consistently repeatable and therefore are of neural and not artifact in origin. Replication is demonstrated by the consistency of latency and amplitude measure of evoked potential components recorded in successive averages. Latency replication within 1.0 % of the total sweep time and amplitude replication within 15% of the peak-topeak amplitude can usually be achieved. Poor replication may be caused by: unusually low (but not necessarily abnormal) amplitude responses excessive artifact insufficient number of responses in the average

CNIM Preparation Basic Instrumentation Questions & Answers


1. A differential amplifier records: a. Only the first two inputs b. The second half of the two inputs c. The power of the sum of the two inputs d. The difference between the two inputs Nuwer (1983) page 15 ref # 11 1. To accurately represent the amplitude of an EP waveform a match must be made between the: a. Signal size and the vertical capacity of the digitizer b. High-frequency noise and smoothing operation of the instrument c. Dwell time and sampling rate d. Horizontal resolution and signal size Misulis (1994) page 32 ref # 9 Due to a smaller surface area, sub-dermal needle electrodes will have an impedance that is: a. Lower than disk electrodes b. Increased with improper insertion c. Improved by cleansing the skin with an abrasive gel d. Higher that surface electrodes Tyner (1983) page 130 -- ref # 15 16

1.

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The difference between the voltage in input 1 and input 2 will make the display of the amplifier move: a. Ina sinusoidal pattern b. Up c. Either up or down d. Down Misulis (1994) page 16 ref # 9 In order to stimulate both tibial nerves asynchronously, you need: a. To delay the first stimulator b. To delay the second stimulator c. A positive trace delay d. A negative trace delay Nuwer (1986) pages 30 and 31 ref # 11 The input impedance of a differential amplifier must be at least: a. <5 K ohms b. 10 megohms c. 100 megohms d. <10 megohms AEEGS (1994) pages 42 ref # 1 An EP recording system should allow averaging of: a. 600 trials or more b. no more than 500 trials c. a maximum of 2000 trials d. at least 4000 trials AEEGS (1994) page 42 ref # 1

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24886. Signal-to-noise ratio relates to which of the following? a. The amplitude of the evoked response components to the amplitude of the unrelated components. b. The ability of the instrument to resolve data and noise vertically. c. Two inputs of a differential amplifier with like negativity d. Sensitivity scaling Misulis (1994) page 28 ref # 9 1. Electrode impedance is defined as opposition to: a. direct current flow b. alternating current flow c. different current flow d. 60 Hz artifact Misulis (1994) page 14 ref # 9 A constant voltage stimulator: 17

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Neurocat CNIM Test Preparation Module 2 Basic Instrumentation Spring 2011

a. Varies the current in order to maintain a preset voltage level b. Maintains a constant voltage of 100 volts c. Varies the output in order to maintain a preset current level d. Maintains a current level of 10 mA Loftus (1994) page 158 ref # 8 1. The sound stimulus intensity at the tympanic membrane depends on the: a. Acoustic coupling between the sound stimulus generator and the ear b. Relation between SPL (dB) and the inverse peak equivalent SPL (dB) c. Relation between SPL (dB) and peak equivalent SPL (dB) d. Patient s hearing threshold (dB) Misulis (1994), page 119 For the intraoperative recording of EEG the impedance of a scalp electrode should range from: a. 250 to 500 ohms b. 500 to 1000 ohms c. 1000 to 5000 ohms d. 5000 to 10,000 ohms Misulis (1994) page 14 ref # 9

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The use of the 60 Hz notch filter is discouraged while recording because it can: a. Produce a risk to the patient b. Produce ringing activity that can contaminate the appearance of the response c. Cause the recording electrodes to form a salt bridge d. Filter slow activity distorting the response AEEGS (1994) PAGE 43 REF # 1 The gain of an amplifier set to give an output signal of 1 volt for an input signal of 10 uV is: a. 100 b. 1,000 c. 10,000 d. 100,000 Misulis (1994) page 35 ref # 15 The following are examples of good insulating materials, inhibiting current flow; a. silicon and germanium b. silver and copper c. glass and rubber d. gold and platinum Tyner (1983) page 35 ref # 15

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26758. In selecting the horizontal parameters of analysis the


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a. Sampling rate should be at least two times greater than the highest frequency in the signal b. Sampling rate should be the equivalent of the highest frequency in the signal c. Analysis period should be at least twice the Nyquist frequency d. Analysis period should approach the Nyquist frequency Misulis (1994) page 30 ref # 9 17. The phenomenon called aliasing a. may be avoided by proper placement of the ground and stimulating electrodes. b. Is common during intraoperative recording of evoked potentials c. Refers to an erroneous representation of an analog signal by digital values d. Occurs when the analysis period is more than twice the Nyquist Frequency Misulis (1994) page 30ref # 9 Brain activity recorded directly from the cortex (ECoG) is very high in amplitude and usually requires sensitivities in the range of: a. 10 to 50 V/mm b. 40 to 100 V/mm c. 100 to 150 V/mm d. 200 to 300 V/mm ASET (1998) page 210 ref # 5

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The assumption that responses of excessive amplitude are likely to contain artifact forms the basis for: a. Digital filtering b. Dwell time c. Artifact rejection d. Digital averaging Misulis (1994) page 33 ref # 9 20. A capacitor is an electronic device used to: a. Store electrical energy b. Stop current flow when some critical power level is exceeded c. Enhance current flow d. Measure electrode impedance at the scalp Tyner (1983) page 44 -- ref # 15 21. Pre-stimulus triggering a. presents a positive signal to the averager prior to initiating the display b. includes a period of recording before the stimulus c. eliminates the problems associated with recording the stimulus artifact d. delays the synchronizing pulse to the computer Misulis (1994) page 27 ref # 9
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The horizontal resolution of an evoked potential system: a. Should be 20 microseconds per data point or less b. Has no effect on the aliasing properties of the instrument c. Should be greater than 30 milliseconds per data point d. Is one half the Nyquist frequency AEEGS (1994) page 42 ref # 1 23. A unit of resistance is symbolized by: a. A b. c. d. E Tyner (1983 page 35 ref # 15 24. SSEP recordings typically require a wide bandpass of: a. .5 Hz to 200 Hz b. 1 Hz to 1,000 Hz c. 5 Hz to 3,000 Hz d. 5 Hz to 5,000 Hz Misulis (1994) page 169 ref # 9

1. Given an electrical circuit with a resistance of 1,000 ohms and a voltage of 10 volts, the current flow will be: a. .01 A b. .10 ohms c. 10 A d. 100 volts Tyner (1983) page 35 to 37 ref # 15 26. The common mode rejection ratio of amplifiers used for EP recording should be at least: a. 100:1 b. 1,000:1 c. 10,000:1 d. 100,000:1 Misulis (1994) page 18 ref # 9 27. Spectral edge is a function of: a. Beta and alpha vs. time b. Amplitude and latency vs. time c. Power and frequency vs. time d. Zero crossing intervals
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ASET (1996b) page 110 ref # 4 57. With a sampling rate of 10 kHz the shortest sine wave resolved would be: a. 2 msec b. .2 msec c. .4 msec d. .02 msec Misulis (1994) page 30 ref # 9 58. If you have a signal to noise ratio of 1:2 averaging 64 responses will: a. reduce the noise by 50% b. Not change the ratio c. Improve the ratio to 8:1 d. Improve the ratio to 4:1 Misulis (1994) page 28 ref # 9 59. A Condensation click: a. delivers loudest sounds to the tympanic membrane b. cause the tympanic membrane to move out ward c. causes the headphone diaphragm to displace toward the tympanic membrane d. causes the headphone diaphragm to move away from the tympanic membrane Russell (1995) page 141 ref-- # 14

60. Reduction of the high frequency filter: a. Has no effect on evoked potential latency b. Has an unpredictable effect on evoked potential latency c. Increases evoked potential latency d. Decreases evoked potential latency Misulis (1994) page 169 ref # 9 61. The duration of a monophasic rectangular pulse used for somatosensory stimulation should be: a. 0.05 ms b. 0.2ms c. 0.5ms d. 1 ms AEEGS (1994) page 82 ref # 1 62. The sensitivity setting on a amplifier set to produce a vertical deflection of 1 cm with an input of 10 mV is: a. 1 mV/mm b. 1mV/cm
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c. 10mV/mm d. 20mV/cm Misulis (1994) page 19 ref # 9 63. A rarefaction click occurs when the: a. Initial movement of a transducer diaphragm is towards the tympanic membrane b. Initial movement of a transducer diaphragm is away from the tympanic membrane c. Movement of a transducer diaphragm alternates in polarity relative to the tympanic membrane every second trail rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr. Movement of a transducer diaphragm alternates in polarity relative to the tympanic membrane on a random basis Misulis (1994) page 122 ref # 9 64. All of the following are true of magnetic stimulation except: a. An electrical stimulator is required to pace the stimulus b. The stimulation is not perceived as painful c. Pulses of current are delivered through a coil of wire d. The magnetic field created causes movement in cortical neurons. Misulis (1995) page 222 ref # 9 65. An after-discharge can occur on the cortical EEG recording following: a. A seizure recorded in the operating room b. Electrical stimulation of the exposed cortex c. The introduction of 60 Hz artifact d. Electrocautery. Russell (1995) page 200 -- ref #14 66. To minimize pain from stimulation during the recording of SSEPs, the contact impedance should be: a. Less than 50 kiloOhms b. More than 10,000 ohms c. Less than 5,000 ohms d. Less than 10 megohms AEEGS (1994) page 66 ref # 1 67. The recommended filter settings for the facial nerve CMAP are: a. 1-1.5 kHz
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b. 1-15 kHz c. 10 1.5 kHz d. 10-15 kHz AEEGS (1994) page 841 ref # 1 68. Spinal cord evoked potentials are best recorded using a low frequency filter setting of 100 Hz. This setting is preferred because relative to cortical somatosensory evoked potentials spinal cord potentials are: a. of relatively short duration b. less affected by changes in anesthesia c. subject to 60 Hz interference d. an extremely low voltage response EEGS (1994) page 83 ref # 1 69. In the operating room, the stimulus intensity for activating a sensory nerve: a. should be set at double the sensory threshold b. should be set for two to three times the motor threshold c. does not have an established boundary d. is set slightly above motor threshold AEEGS (1994) page 82 ref # 1 70. The suggested rate of stimulation for intraoperative posterior tibial nerve evoked potential monitoring is: a. 30 to 40 per second b. 20 to 30 per second c. 10 to 20 per second d. 2 to 10 per second AEEGS (1994) page 84 ref # 1 71. The effect of pharmacological or surgical manipulations can be mimicked by the inappropriate manipulation of: a. The stimulus rate b. The stimulus intensity c. Filter settings d. The group electrode AEEGS (1994) pages 79 and 83 ref # 1 72. Direct focal electrical stimulation of a peripheral nerve lesion will a. Define epileptiform activity generated in the lesion b. Identify begin masses versus malignant tumor masses c. Be of no value d. More precisely localize the distribution of intact conducting nerve fibers Loftus (1994) page 279 ref #8 73. For stimulation in spinal cord motor evoked potential (MEP) studies, the anode should be placed:
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a. Rostral to the cathode b. Caudal to the cathode c. Medial to the cathode d. Lateral to the cathode Russell (1995) page 165 ref #14 74 . When monitoring Somatosensory evoked potentials during a critical moment in an intraoperative study, changing the setting of the high-frequency filter: a. Will be of limited consequence to the outcome of the study b. May help isolate a true signal from background noise c. May increase the number of single trial events required to resolve the evoked response d. May lead to a false interpretation of the data AEEGS (1994) page 83 ref # 1 74. A stimulus pulse width that would tend to excite a larger population of motor fibers than sensory fibers is: a. 0.05 ms b. 0.2 ms c. 0.5 ms d. 1 ms 75. When using constant voltage for facial nerve stimulation and the nerve becomes bathed in CSF what will occur after the area is suctioned? a. The output voltage will vary to maintain a preset current level b. The current flow will vary in order to maintain the present voltage level c. No change will occur d. The stimulator will stop Kartush (1992) page 104ref # 7 76. Chassis leakage for evoked potential equipment used in the operating room should be less than: a. 1 micro amp b. 10 milliamps c. 10 micro amps d. 100 micro amps AEEGS (1994) page 43 ref # 1 77. The type of artifact most likely associated with blood warming equipment is: a. Baseline away b. 60Hz c. popping electrodes d. increased stimulus artifact ASET (1996a) page 103 ref # 3 78. The purpose of isolated amplifier inputs is to:
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a. Allow only the high voltage biological signs to pass b. Restrict current flow to the instrument c. Restrict current flow to ground at 20 uA d. Prevent a flow of stray currents through connecting lines to the patient AEEGS (1994) page 78 ref # 1 Tyner (1983) page 77 ref # 15 79. Common sources of nonphysiologic artifact in the operating room include: a. Oxygenation, ventilation, and body temperature b. Operating microscope, x-ray view boxes and heating devices c. Movement in the room VCR monitors and surgical instruments d. The surgeon anesthesiologist and neurophysiologist Russell (1995) page 243 ref # 14 80. Although the use of electrical cautery can obliterate EP waveforms intraoperative monitoring should be continued: a. Because the average will store the reliable waveforms b. By averaging the saturated waveforms c. By monitoring the raw (unaveraged) data d. Whenever the audible sound of the cautery is present ASET (1996a) page 60 ref # 3 81. Stimulus artifact during SSEPs can be decreased by: a. Keeping the instrument away from florescent lights and video monitors b. Using enough muscle relaxant c. Separating stimulating cable from cable of other equipment d. Lowering the impedance of ground electrodes ASET (1996a) page 103 ref # 3 82. According to current OSHA standards needle electrodes should: a. Be reused whenever possible b. Not be soaked in a sodium hypochlorite solution c. Be recapped before discarding d. Not be handled with tongs or forceps while cleaning ASET 91995) page 164 ref # 2

83. A term used to describe very low currents that may be lethal to patients with indwelling devices is: a. Macroshock b. Ground loop c. Short circuit d. Microshock Tyner (1983) page 76 ref # 15
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84. A recommendation to minimize stimulus artifact while recording BAEPs intraoperatively is to: a. Use alternating clicks b. Use larger sized headphones c. Use rarefaction clicks d. Decrease the impedance of your stimulating electrodes AEEGS (1994) page 79 ref # 3 85. To reduce artifact from electrode wire movement during surgery it is best to a. Use long wire and tuck them under the patient b. Braid the wires c. Loop the wires under the patient head d. Use only paste and gold disc electrodes ASET 91996a) page 51-- Ref # 3 86. Electrical hazards that exist for patients attached to medical equipment include all of the following except: a. Ground faults b. Leakage current c. Needle sticks d. Indwelling electrodes Tyner (1983) page 81 ref # 15 87. An example of nonphysiologic artifact would be: a. High levels of muscle tension b. Electrical interference c. The ECG signal d. Slow signal due to perspiration ASET (1996a) page 102 ref # 3 88. Electrode lead wires used in the operating room suite must be converted to safety connectors (female electrodes) by: a. June, 1999 b. May, 2000 c. January, 1997 d. January, 2005 ASET (1998) page 211 ref # 5 89. A ground loop is created when: a. Two separate devices are attached to the same patient and have two separate grounding connections b. Two recording electrodes are connected to two separate input box of the same instrument c. The patient is grounded by the large electrocautery ground that resembles a loop d. Separate equipment attached to the same patient have current-limiting grounds
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Russell (1995) page 60 ref # 3 90. One function of the circuitry in an isolated input board is to protect the patient from electrical shock by limiting the current flow to at least: a. 100 uA b. 20uA c. 60 uA d. 10uA Tyner (1983) pages 77- ref #15 91. A grounding device must be available so that under normal conditions no voltage greater than ______________ is measured across an impedance of 1000 ohms: a. 60 mV ms at 50 Hz b. 20 mV ms at 60 Hz c. 50 mV ms at 60 Hz d. 10 mV ms at 50 Hz AEEGS (1994) page 78 ref # 1 92. If the monitoring instrument develops an inability to average, steps to take would include all of the following except: a. check electrode impedance b. check that all cable are round separately c. insure that the stimulus rate is not a multiple of the interference frequency d. consult with the anesthesiologist regard anesthesia change ASET (1996a) page 106 ref # 3 93. Both SSEP and BAEP waveforms can be affected by structural manipulation using: a. Retractors b. grounding pads c. suction d. blood pressure transducers ASET (1996a) page 220 ref # 3 ASET (1996b) page 101 ref # 4 94. The term broadband click refers to a: a. Peak acoustic power of 2-4 kHz b. Short peak acoustic power of 1-2 kHz c. Broad peak acoustic power of 1-5 kHz d. A peak acoustic power of 500Hz to 2kHz Misulis (1994) page 120 ref # 9 95. Which of the following is not related to Ohms law? a. Electromotive force b. Impedance c. Voltage
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d. Phase e. Current Ibid, page 5 96. Ohms law is: a. E=IR b. I-ER c. R=Ei d. 2I=E/Z e. Z+EI Ibid, page 5 97. Input impedance should: a. be very high b. be very low c. Equal the common mode rejection ratio d. Affect low frequency activity e. Increase signal distortion Kiloh, Mccomas and Osselton, Clinical Electroencephalography, Third Edition, Butterworths, 1972 page 36 98. Gain is: a. The ratio of output signal to input signal b. The same as sensitivity c. Always less than 100:1 e. Expressed in dB f. Expressed in microvolts Niedermeyer, E, and Lopes da Silva F Electroencephalography, Urban & schwarzenber, 1982, page 53. 99. In a differential amplifier, the common mode rejection of in phase signals is typically: a. 100:1 b. 500:1 c. 5:1 d. 10,000:1 e. 10:1 Ibid, page 59

100. Common mode rejection is: a. The ability of an amplifier to cancel out ECG artifact b. The characteristic of an amplifier that rejects external interference
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c. The same as input impedance d. Controlled by the 60 cycle notch filter e. Same as sensitivity Ibid, page 58 101. The ratio of input voltage to output pen deflection is: a. sensitivity b. input impedance c. gain d. common mode rejection e. filter Niedermeyer E, and Lopes da Silva F Electroencephalography, Urban & Schwarzenberg, 1982 page 53 102. In a differential amplifier, if input one received a voltage of 65 uV and input two a voltages of 30 uV, the output voltage seen would be _________uV and the pen would move ___________>: a. 35 uV, upward b. 95 uV, downward c. 95 uV upward d. 35 uV downward e. 65 uV, upward Clenney S., and Johnson, S Back to Basics, Beckman instruments, Inc., 1983 page 86 and 87.

103. Which of the following is attenuated by time constant of .03 seconds? a. .10 Hz b. 15 Hz c. 25 Hz d. 3 Hz e. 60 Hz Ibid, page 97 104. Which of the following is most attenuated by high frequency filter setting of 35Hz? a. 10 Hz b. 25 Hz c. 15 Hz d. 35 Hz e. 45 Hz Ibid, page 48

105. Which of the following is attenuated by a high pass filter of 5Hz: a. 1 Hz


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b. 10 Hz c. 15 Hz d. 20 Hz. e. 25 Hz Ibid page 101 106. The accepted limit allowed for leakage current from chassis of an evoked potential machine is: a. 1 amp b. 10 milliamps c. 100 microamps d. 100 amps e. none is allowed American Electroencephalographic Society, Guidelines for Clinical Evoked Potential Studies, J. Clin Neurophysiol 1:3-53, 1984 page 8 107. The most practical method to assure the integrity of an average is to demonstrate_____________ of independently collected averages: a. Polarity b. Raw data c. Latency d. Replication e. Amplitude Ibid page 9 108. Which of the following recording parameters can affect waveform morphology, latency and amplitude of evoked potentials: a. High pass filters b. Low pass filters c. 60 Hz filter d. notch filter e. all of these Ibid page 9 109. Signal averaging tends to increase time-locked events while random activity tends to zero. This is known as: a. Signal to noise ratio b. A/D conversion c. Band pass d. Noise to noise ratio e. Signal to signal ratio American Journal of EEG Technology, Book (Evoked Responses, 2 volumes), selected reprints, ASET Executive Office Vol. 1, page 14 110. A signal averager should have horizontal resolution of:
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a. 5 s b. 5 us c. 50us d. 50ms e. 10us American Electroencephalographic Society, Guidelines for Clinical Evoked Potentials, J. Clin Neurophysiol 1:3-53 page 8 Grass Ellen R. and Johnson, Edmund, Evoked Reponses Signal Averaging, Grass Instrument Co., page 14 & 15 111. Among the measurement taken from an evoked potential waveform the most clinically useful is: a. Amplitude b. Latency c. Morphology d. Interpeak latency e. B and d Chiappa, K., Evoked Potentials in Clinical Medicine, Raven Press, 1983 page 18-21 112. The square root of the arithmetic average of the squares of the deviation from the mean is known as: a. Mean b. Median c. Mode d. Standard deviation e. Tolerance limit Dictionary; Intro. to Evoked Potential Instrumentation, Nicolet Instrument Corporation, 1979 113. It is acceptable to use published normative date from another center for the analysis of evoked potentials when: a. Stimulus, recording and other conditions are compatible b. The other centers normal values are closely matched to your select (at least 20) normal subjects c. Any published data is acceptable d. No published data is acceptable e. A and b only American Electroencephalographic Society, Guideline for Clinician Evoked Potential Studies, J. Clin Neurophysiol 1:3-53 1984, page 11 114. Which of the following filter bandwidths will affect the latency and/ or amplitude of the brainstem auditory evoked potential? a. 100-3k b. 100-10k c. 100-1k d. 30-3k
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115. What affect does increasing stimulus rate have on the BAEP? a. Latencies are prolonged b. Amplitudes of waves I, II and III are attenuated c. Amplitudes of wave Vi is attenuated d. All of the above e. A & b only American Journal of EEG Technology, Book IV (evoked Response, 2 volumes) selected reprints, ASET Executive Office 116. Noise masking: a. To prevent bone conduction of the stimulus to the other ear not being tested b. A white noise, usually about 60 dB SPL (30 db NHL) c. Delivered to the contralateral (non-stimulated) ear d. Should be done routinely e. All of the above American Electroencephalographic Society, Guidelines for Clinical Evoked Potential Studies, J. Clin Neurophysiol 1:3 53, 1984 117. Stimulus intensity should be adjusted to: a. 10mA b. 20mA c. produce pain then reduce 3mA d. sensation level e. produce a minimal movement at the joint involved Chiappa K., Evoked Potentials in Clinical Medicine Raven Press 1983 pg. 222 118. The optimal filter bandpass settings for recording PREPs is: a. 10-50 b. 1-200 c. 1-50 d. 10-200 e. 100-3,000 American Electroencephalographic Society Guidelines for Clinical Evoked Potential Studies J. Clin Neurophysiol 1:3-53, 1984 pg 24 119. The optimal filter settings for recording a somatosensory evoked potential of the upper extremity is: a. 5-1000 b. 150-3000 c. 1-200 d. 5-500 e. 20-3000 Ibid page 42

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120. Artifact rejection is designed to: a. Limit unwanted signals from entering the average b. Reject voltages exceeding the sensitivity setting c. Improve the quality of the average d. Count all average within amplitude boundaries selected e. All of these Spehlmann, Ranier, Evoked Potential Primer, Butterworth Publishers, 1985 pages 47-48 121. When recording Evoked Potentials the phase shift caused by high and low frequency filter affects? a. Latency b. Amplitude c. Latency and amplitude equally d. Time locking e. None of the above Tyner, Knot and Mayers Fundamentals of EEG Technology Vol I, Raven Press 1983 122. 60 HZ filters cause a change of latency by a: a. phase shift b. decrease in amplitude c. frequency of waves d. frequency response curve e. ringing effect Ibid. 123. The number of grounds placed on the patient is only important when recording: a. Somatosensory evoked potentials b. Visual evoked potentials c. Auditory evoked potentials d. Dermatones e. All of the above Ibid. 124. The use of extension cords is discouraged because: a. Increased leakage current b. Decrease in power supply to the machine c. The ground may not be intact d. Patients can trip over them e. A and C Ibid.

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