BRAINSTEM AUDITORY EVOKED

RESPONSE (BAER)

Moderator: Dr. Neera

Chaudhry

What is evoked potential?

Evoked/Event related potentials (ERPs)
Time-locked brain responses to some events, which
can include acoustic, visual, or some other sensory
stimulus, eg. SSEP, BAER and VEP
Auditory evoked potentials (AEPs)
1. Form of ERP
2. Time-locked voltage changes to the presence of a
sound stimulus
3. These voltage changes are generated by auditory
system neurons, from the cochlear nerve up to the
cortex, occurring in response to a sound stimulus

INTRODUCTION
Brainstem Auditory Evoked Response (BAER)
is a neurologic test of auditory brainstem
function in response to auditory (click)
stimuli
First described by Jewett and Williston in
1971
Assesses the integrity of conduction through
the auditory pathways
Its a set of seven positive waves recorded

PHYSIOLOGY
BAER typically uses a click stimulus that
generates a response from the hair cells
of the cochlea, the signal travels along
the auditory pathway from the cochlear
nuclear complex to the inferior colliculus
in mid brain, generating waves I to V

ORIGIN OF BAEP

Recording BAER according to

ACNS GUIDELINES
After cleaning and degreasing, surface
electrodes applied with conducting jelly
Room should be quite
BAEPs can be obtained either in awake
state or sleep

Electrode placement (Montage)

1. Vertex (Cz) (recording electrode)
2. Ipsilateral ear lobule (Ai) or mastoid process (Mi)
(reference electrode)
3. Contra lateral ear lobule (Ac) (ground electrode )
Channels
. Ipsilateral ear-vertex (Ai-Cz)
. Contralateral ear- vertex (Ac-Cz)
. Rarely (Ai-Ac) is used
Impedence to be < 5Kohm

STIMULATION
Earphones which transmit broad-band
clicks (acoustic energy is spread over a
wide range of audio frequencies) are used
Contralateral ear usually masked by
continuous white noise of 60 dB to avoid
bone conduction to contralateral ear

 Stimulus Polarity
Condensation (positive pressure in
front of ear speaker)
Rarefaction (negative pressure in
front of ear speaker)
Alternate

Stimulus intensity
40-200 db
Ideally, 60-70 db preferred in all individuals
Stimulus rate
Stimulus rates of 8-10/s are used
As waves I, II, VI & VII are reduced in
amplitudes at rates higher than 10/s
Analysis time
Analysis time of 10-15 ms from stimulus onset
is suggested

IDENTIFICATION OF
WAVES
Commonly 5 peaks
Rarely peaks VI and VII seen
Upward deflection denoted as
I & Corresponding downward
deflection I
Identify wave V which is the
most persistent wave & comes
as IV-V complex, and then
wave V comes to the base line
Also observe their latencies,
eg. latency of wave I will be
less than 2mSec

NORMAL VALUES
Peak latency of a
wave = less than
the next higher no.
wave
Or just add 1 to
that wave, latency
will be less than
that
eg. Latency of wave
1 is
less than 2

CHARACTERISTICS OF WAVEFORM

MEASUREMENTS
Absolute latencies
Interpeak intervals
I-V
I-III
III-V
Right-left differences
V:I amplitude ratios

NORMATIVE DATA

INTERPRETATION
Wave I: small amplitude, delayed or absent may indicate
cochlear lesion
Wave V: small amplitude, delayed or absent may
indicate upper brainstem lesion
Prolonged I-III interval: abnormality of neural pathway
between distal VIII nerve and lower pons
Prolonged III-V interval: abnormalities in pathway
between lower pons and midbrain
Small V:I amplitude ratio: <50% suggests central
auditory pathway dysfunction

NORMAL BAER

APPLICATIONS
Hearing loss:
Identifying the hearing loss
Classification of type of deafness (conductive
or sensorineural)
Degree of hearing loss in conductive deafness
ascertained by subjective threshold of
intensity (high)

Latency of I prolonged/poor I wave in SNHL

Waves I-V interaural latency differences prolonged in SNHL, whereas they are
normal in conductive hearing loss

EVOKED RESPONSE
AUDIOMETRY
Here the evoked response is obtained with different intensities of
click stimuli
First start with a stimulus intensity of 80 dB & put the record in
memory
Change the stimulus intensity to 60 dB & put the record in memory
Continue the test with stimulus intensity of 40 dB, & 20 dB
In all these tracings identify wave V and find out its latency at all
intensities of stimuli
Plot latency intensity graph for wave V

 Normal: There is a
shaded area for the
normal person. If your
points fall in this area
then the person is having
normal hearing
Conductive Deafness: the
latency intensity graph
plotted will be above &
parallel to the shaded
area
Sensorineural Deafness:
the graph plotted will be
irregular & not forming a
curve

NEWBORN SCREENING

Several clinical trials have shown auditory

brainstem evoked response testing as an
effective screening tool in the evaluation of
hearing in newborns, with a sensitivity of
100% and specificity of 96-98%

Criteria for screening new-born babies using BERA:

1.
2.
3.
4.
5.
6.
7.
8.
9.

Parental concern about hearing levels in their child

Family history of hearing loss
Pre and post natal infections
Low birth weight babies
Hyperbilirubinemia
Cranio facial deformities
Head injury
Persistent otitis media
Exposure to ototoxic drugs

CP ANGLE TUMORS

An effective screening tool in the evaluation of

suspected retro cochlear pathology such as an acoustic
neuroma
Abnormal in >95% cases of acoustic neuroma
(Barrs et al, House et al)

BAER abnormalities in CP angle tumours:

1. Waves I - V interaural latency differences prolonged
2. Absolute latency of wave V - prolonged
3. Absence of brain stem response in the affected ear
4. Rt-left asymmetry in V latency

30 year old lady with Rt CP angle epidermoid cyst

INTRINSIC BRAINSTEM TUMOUR/ STROKE

III-V and I-V latencies prolonged

Changes may be bilateral
I-III may be prolonged in lesions
involving cochlear nucleus in pons
I- may be absent in AICA territory
infarcts with cochlear ischaemia

MULTIPLE SCLEROSIS

To document brainstem involvement

As a follow-up tool
Pattern of abnormalities:
1. Amplitude reduction/absence of V commonest
2. Prolongation of III-V
3. Decreased V:I ratio
. Less sensitive than VEP & SSEP in detecting
demyelination in MS (Purves et al)
. Yield higher in longer duration of disease

(Chiappa)

ROLE OF BAER IN COMA

Abnormal in structural diseases of brainstem

Normal in comatose patients with diffuse
supratentorial disease without herniation
Normal in toxic and metabolic encephalopathies,
even if brainstem functions clinically absent
In brain death, only I or I and II are recordable
Absence of I is inconclusive, as may reflect isolated
VIII nerve dysfunction

ROLE OF BAER IN SURGERY

For intra-operative monitoring
during microvascular decompression
of cranial nerve when decompression
is performed via the intra-cranial
posterior fossa approach
To assess recovery of brainstem
function after a lesion compressing
the brainstem has been surgically
removed.

Thank You