Evoked

Potentials
FUNCTIONAL
FUNCTIONALDIAGNOSTICS
DIAGNOSTICS
Copyright MFD 2001 - Any kind of reproduction is prohibited

NEURODIAGNOSTICS

Evoked Potentials

(EP)

Dawsons averager, first demonstrated in 1951,

formed a new area in clinical neurophysiology,
- the area of Evoked Potentials.
Links between Evoked Potentials and clinical
practice are firmly established in neurology,
neurosurgery, ophtalmics, otology, pediatrics,
psychiatry and urology.

SEP Somatosensory EP
VEP Visual EP
AEP Auditory EP
BAEP Brain stem (short latency)
AEP Central pathway (middle & long latency)

ERP Event-Related Potentials

CNV Contingent Negative Variation
P300 Cognitive Potential
MRP Motor Related Potentials
FUNCTIONAL DIAGNOSTICS
NEURODIAGNOSTICS

Evoked Potentials

General Remarks

Recording potential on Spinal Cord and/or Cortex

issued from Somatosensory, Auditory or Visual stimulation

Averager is needed to extract small potentials from

Spinal and/or Cortex noise

Amplitude of signal 0.1 to 5 V

Form and latency depend on EP and recording site

FUNCTIONAL DIAGNOSTICS
NEURODIAGNOSTICS

Averager
Used to extract a
revealed potential
buried in an activity
(EEG or Muscle
noise) 1000 times
greater or more.

(A.V.G.)

Direct Signal
AVG Group I
AVG Group II
AVG I + II

Averaged Signal

Amplified

FUNCTIONAL DIAGNOSTICS
NEURODIAGNOSTICS

Evoked Potentials

Recording & Latencies

Recording sites are identified by

Active Electrode

Cpz

(anatomic abbreviations)

Reference Electrode

Cpz - FPz

Fpz

SEP

Tibial nerve

P40

Marker latencies are identified by

N145

Peak orientation

Negative

N75

N..
P..

Positive
Normal latency value

P40
P100

Value around 40 ms
Value around 100 ms

Oz- Cz
P100

VEP

FUNCTIONAL DIAGNOSTICS
NEURODIAGNOSTICS

Somatosensory EPs
Thalamocortical
potentials
Cervicomedullary
potentials
Brachial Plexus
potentials

Cauda Equina
- Lower Cord
potentials

Somatosensory Eps offer a look at

physiologic anatomy. They provide a
sensitive tool for assessment of spinal
cord and brainstem posterior columns and
medial lemniscal tracts and nearby
structures.

Somatosensory Eps are used to test:

the PNS (nerves and roots)
the large-fiber sensory tracts in the CNS

PNS: Peripheral Nervous System

CNS: Central Nervous System

FUNCTIONAL DIAGNOSTICS
NEURODIAGNOSTICS

Somatosensory E.P.
N 7 cm
Fpz
Fz

C5S

Lower Extremities

Tibial Nerve

Cz

AVERAGING

CPi-Fpz

5 cm
P37

2 cm
CPi CPz CPc
T12S

CPz-Fpz

P37
N34

IC

P31

Fpz-C5S

Stim. Freq.: 3 Hz
Intensity:

Threshold

LP
T12S-IC

Averaging: 200 - 500

AVG Sens.: 2 - 5 V/D
Stim.

20

40

60 ms

FUNCTIONAL DIAGNOSTICS
NEURODIAGNOSTICS

Somatosensory E.P.
N 7 cm
C5S
Epc

Epi

C3

Median Nerve
N19

Fpz
Fz

Upper Extremities

R
C4

CPc-CPi

5 cm
2 cm

CPi

Stim.

CPc

N18

CPi-Epc

P14
N13
C5S-Epc

EP

Stim. Freq.: 3 Hz
Intensity: Threshold

Epi-Epc

Averaging: 200 - 500

AVG Sens.: 2 - 5 V/D

10

20

30

ms

FUNCTIONAL DIAGNOSTICS
NEURODIAGNOSTICS

SEP Normal Values

Latency ms
Mean
SD
Range

Amplitude V
Mean
SD
Range

9.6
13.2
18.9

0.7
0.8
1.0

5.4
2.9
2.8

10.8
33.5
36.3

0.9
1.5
2.4

Median Nerve
EP
N13
N19

2.5
1.3
1.6

Tibial Nerve
LP
N34
P37

8.6-13.1
30.3-41.3
30.5-41.7

FUNCTIONAL DIAGNOSTICS
NEURODIAGNOSTICS

Visual E.P.

Optic Nerves & Stimulus

Pattern: Checkers - Bares

Optic Nerve
Optic tract
Lateral geniculate
body

Goggles

Occipital lobe
Flash
FUNCTIONAL DIAGNOSTICS
NEURODIAGNOSTICS

Visual E.P.
VER Right Eye

Cz
O'z
A1

O1 Oz O2

AVERAGING

N145

O'1-Cz

70 cm

N75
O'z-Cz

P100

Stim.: Checker
Checker size: Visual angle *
Stim. Freq.: Max. 2 Hz
Dark room
Averaging: 200 - 300
AVG Sens.: 0.5 to 2 V/D
* See next slide

O'2-Cz

Cz-A1

N100

100

200 ms

FUNCTIONAL DIAGNOSTICS
NEURODIAGNOSTICS

Visual

Angle Calculation
d = Screen diagonal
L = 4d / 5 H = 3d / 5

H
n = Number of Checks in H
h = H/n

a = Screen Angle
b = Check Angle

Calculation
Example: d = 15" (38 cm)

D = 55cm

n = 46

aRadian = ATan 3d/5D

aRadian = 0.39

a = aRadian (180/3.14)

a = 23

bRadian = ATan 3d/5nD

bRadian= 0.01

b = bRadian (180/3.14)

b = 0.5
b = 30

FUNCTIONAL DIAGNOSTICS
NEURODIAGNOSTICS

VEP Normal Values

(P100)

Full-field, screen size 9, check size 26

Mean

Range

SD

P100 Latency ms

102.3

89-114 5.1

Latency diff. between two eyes

1.3

0-6

2.0

P100 Amplitude V

10.1

3-21

4.2

Amplitude diff.

1.6

0-5.5

1.4

FUNCTIONAL DIAGNOSTICS
NEURODIAGNOSTICS

Auditory E.P.

Brain Stem
V
IV
III
II

VI

VI
V II

VII

IV V
III
II

Stimuli

Stimulation:
Threshold + 70 dB peSPL
Unfiltered Click 50 - 100 s
Above 120 dB peSPL
Max.: 132 dB peSPL

Distal spiral ganglia and auditory nerve

II

Proximal auditory nerve (cochlea nucleus)

III

Ventral cochlear nucleus in pons

IV

Inferior lateral lemiscus in pons

Lateral lemiscus in lower mid brain

VI

Medial geniculate nucleus (upper mid-brain)

VII Primary auditory cortex

FUNCTIONAL DIAGNOSTICS
NEURODIAGNOSTICS

Sound Pressure Variation

Atmospheric Pressure 105 Pascal

Sound Pressure Variation

Loud-Speaker
Atmospheric Pressure
Modulation

Hearing limit at 1 KHz

1 KHz

2 Pascal

20 x 10-6 Pascal = 0 dB peSPL

20 log

2
= 100 dB peSPL
20 x 10-6

FUNCTIONAL DIAGNOSTICS
NEURODIAGNOSTICS

Hearing Sensitivity
Hearing Level depends
on sound frequency (A)

10

In Audiometry
0 dB 30 dB peSPL
is called dB OHL

194

Atmospheric Pressure

104

174

Wegels Curves (1922)

103

Increasing sound
intensity (dB or
Pressure). We do not hear
the sound, but get a pain
sensation. That is the
dangerous level (B)

Decibel dB

Pressure Pascal

154

102
10

n
Da

ous
ger

Lev

el

134
114
94

1
10-1

10-2

dB

10-3

74

nH
L

54

0 dB OHL

10-4

34
14

0 dB peSPL = 20.10 -6 Pascal

10-5

16

32

64

128

256

512

1024 2048 4096 8196 16384

Freq. Hz

Frequency band
used in Audiometry

FUNCTIONAL DIAGNOSTICS
NEURODIAGNOSTICS

Sound Level in decibel (dB)

dB peSPL Sound Pressure Level,
0 dB = 20.10-6 Pascal at 1 KHz

(sound pressure variation)

dB nHL

Normal Hearing Level - depends on frequency

dB SL

Sensation Level, Auditory Threshold

dB OHL

Objective Hearing Level, 0 dB 30 dB peSPL

FUNCTIONAL DIAGNOSTICS
NEURODIAGNOSTICS

Stimulus Patterns
50

100
10 Hz

Normal
1000 Hz 3 c/s

Hanning
1000 Hz 3 c/s

Hamming
1000 Hz 3 c/s

Gauss
1000 Hz 3 c/s

Blackman
1000 Hz 3 c/s

Tone Burst
500 Hz 1 c/s
Plat. 500ms
R/F 10%

Click
50 or 100 s

Full frequency band, used in BAEP

Normal
125 Hz - 10 KHz

Click with specific frequency

Hanning
125 Hz - 10 KHz
Hamming
125 Hz - 10 KHz

Generally used for Auditory Threshold

Gauss
125 Hz - 10 KHz
Blackman
125 Hz - 10 KHz
Plateau

Used to evaluate peripheral hearing

disorders

Tone Burst
125 Hz - 10 KHz
Rising/Falling Time

FUNCTIONAL DIAGNOSTICS
NEURODIAGNOSTICS

Stimulus Polarity
Condensation

Headset
Membrane

Positive pressure
on tympanum

Rarefaction

Ear

Negative pressure
on tympanum

Alternative
Condensation/Rarefaction

Coil
FUNCTIONAL DIAGNOSTICS
NEURODIAGNOSTICS

Auditory E.P.
Stim.:

BAEP

Click 50 s BAERs Right

IV

Averag.: 2000 - 4000

Cz
A1

AVG Sens.: 0.1 V/D

I

A2

Left

III
II

AVERAGING
V
VI

A2-Cz

Right

Normal Values

Latences

Peaks

ms

SD

SD

1.7

0.15

0.28

0.14

II

2.8

0.17

0.23

0.12

III
IV

3.9
5.1

0.19
0.24

0.25
0.40

0.12
0.13

V
VI

5.7
7.3

0.25
0.29

0.47
0.43

0.16
0.16

(Click 90 dB SPL)

Amplitudes

Run
2
Superimposition

5
10
ms
FUNCTIONAL DIAGNOSTICS
NEURODIAGNOSTICS

Latency - Intensity Function (LIF)

Normal Subject
Click:
80 to 20 dB OHL
Duration: 100 s
Rate:
13/sec
Polarity: Rarefaction

80
10

V
60

Notice: as stimulus
intensity decreases, the
amplitude of wave V
decreases and latency
increases.

Normal values in gray

area.

LIF
11

Wave V ranges from

5.64 to 8.28 ms

Wave V, LIF plotted

from the intensity series.

dB OHL

40

20

0.25 V

Latency to Wave V (ms)

OHL

10

ms

20

40

60

80

dB OHL

FUNCTIONAL DIAGNOSTICS
NEURODIAGNOSTICS

100

Infant Normative Data

(60 dB OHL)

Latency ms
10
9
8
7

Wave V

6
5
4
3
2

Wave I

1
29-30 31-32 34-34 35-36 37-38 39-40

Weeks

4-9

9-14 14-19

Age

19-24 24-29 29-34

Months

Adult

FUNCTIONAL DIAGNOSTICS
NEURODIAGNOSTICS

Event-Related Potentials

(ERP)

Parietal Cortex
P300
Frontal Cortex
N100 & P200
Thalamus

Auditory Cortex
P80

Relationship between
middle latency AEP (auditory cortex),
long latency AEP (frontal cortex) and
cognitive potentials (parietal cortex).
FUNCTIONAL DIAGNOSTICS
NEURODIAGNOSTICS

CNV

Contingent Negative Variation

Application:
Primary degenerative senile dementia

- 20

- 10

Electrodes: Cz-M1 or Cz-A1

Recording: SS 5, LF 0.1Hz, HF 0.1KHz
Stimulation: Binaural
S1: Click 1000Hz, 80 dB SPL, duration 100ms
S2: Burst 500Hz, 80 dB SPL, stopped by patient
Interval: 1000ms
Rate:
Random 5 to 60s (manually)
AVG:
30 epochs (S2)
Reaction Time: Measured with an handheld switch

0
+ 10
+ 20

2000
V

- 20

0
+ 10
+ 20

B
C

2000
V

- 20

Normal young subject (30-50)

- 10

4000 ms

4000 ms

- 10
0

Non-demented old subject (70-80)

Old subject with primary degenerative
senile dementia

+ 10
+ 20

2000

4000 ms

FUNCTIONAL DIAGNOSTICS
NEURODIAGNOSTICS

P300

In Myotonic Dystrophy - Active P300

Application:
Alteration of cognitive functions

Normal Patient
N1
N2

BAEP

Cz-A12

SW
P80

Electrodes: Cz-A1+A2
Recording: SS 1
LF 0.1Hz, HF 0.05KHz
Stimulation: Binaural - 70 dB SPL
Std: Burst (10/100/10 ms) 1000Hz, 80%
Odd.: Burst (10/100/10 ms) 2000Hz, 20%
Rate: 0.5Hz
AVG: 20-30 epochs

P2

P3

Myotonic Dystrophy
N1
N2

Cz-A12
P2

Reaction Time could be measured with

handheld switch (SW)

6 V

-100

N1 and P2 are not affected (exogen).

N2 and P3 are significantly disturbed.

SW

P3

Oddball Traces
500

ms

P80: Middle latency N1, P2: Long latency responses

P3: P300 Cognitive response

FUNCTIONAL DIAGNOSTICS
NEURODIAGNOSTICS

P300

In Post-anoxic Coma - Passive P300

Application:
Coma Evolution

P300
Standard

Electrodes: Cz-A1+A2
Recording: SS 1
LF 0.1Hz, HF 0.05KHz
Stimulation: Monaural - Alternative
Std: Click 1000Hz, 80 dB SPL - 80%
Odd.: Click 2000Hz, 80 dB SPL - 20%
Rate: 0.5Hz
AVG: 20-30 epochs

Cz-A12

Cz-A12

Oddball

N2
540 ms
P2

3 V

P3
-100

N1 and P3 presence can

evaluate the degree of chance
for re-awakening of the patient.

N1

250

500

750

1000 ms

Anoxic Patient: Awaked D20

FUNCTIONAL DIAGNOSTICS
NEURODIAGNOSTICS

MRP

Motor Related Potentials

Application:
Skilled Performance Tasks

MRP

Electrodes: Cz-A1+A2
Recording: SS 1
LF 0.1Hz, HF 0.05KHz
Cz-A12
Stimulation: Binaural - 70 dB SPL
Std: Burst (10/100/10 ms) 1000Hz, 80%
Odd.: Burst (10/100/10 ms) 2000Hz, 20%
Rate: Random 3 to 10s (manually)
Patient Reaction: Switch (Hit) the
Oddball Tones.
AVG only Hits: 20-30 epochs
RP:
MCP:
P200:
SPP:

Readiness Potential
Motor cortex potential
Decline of EMG
Skilled performance positivity

MCP
RP

10 V

P200
SPP

EMG
Anterior
forearm

100 V

-1200

-800

-400

400

FUNCTIONAL DIAGNOSTICS
NEURODIAGNOSTICS

800 ms

Settings
SEP

S / N: Surface or Needle

Rec. Sites
Electrodes

AEP

Cortex Other
S/N
S

BAEP

P300

Cortex
S/N

Cortex
S /N

High FQ (KHz)
Low FQ (Hz)

1
0.5

3
20

2
50

Sensitivity V/Div
Input
AVG

5
0.5

5
2

5
0.1

Sweep Speed
ms/Div
Stim. Intensity
Duration ms
Frequency c/s

Upper
Lower

5
10

Threshold

0.2
3

VEP

0.05
0.1

0.5
0.5
5
1

100

Threshold + 60 dBSPL

0.05
10-15

Cortex
S/N

30
1-3

FUNCTIONAL DIAGNOSTICS
NEURODIAGNOSTICS

Pitfalls
Stimulation Frequency too high (SEP, AEP & VEP)
Stimulus intensity too high (SEP & AEP)
Electrode impedance too high
Patient not relaxed (muscle activity)
Eye movement
Too much light in the room (VEP)
Too much noise in the room (AEP)
Confusion between dBSPL and dBOHL (AEP)
Interference with other instruments (artifact)
FUNCTIONAL DIAGNOSTICS
NEURODIAGNOSTICS

!
s
k
n
a
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FUNCTIONALDIAGNOSTICS
DIAGNOSTICS
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