VEP and BAEP

Amir M. Arain, M.D.

 VEP: Modes of stimulation

• Patterned Stimulation( checkerboard):

is most commonly used
– most sensitive
• Unpatterned Stimulation( strobe):
– Less sensitive
– responses are variable.
– Information qualitative than quantitative.
 Unpatterned stimulation

• Sufficient to assess the integrity of the

visual pathway:
– following trauma
– Intraoperative
– patient unable to cooperate:
• Coma
• general anesthesia
• young infants or mentally retarded
 Visual Evoked Potentials
Full field pattern reversal
• Checkerboard pattern: TV pattern
stimulators are more commonly used

• Pattern Presentation: reversal of light

and dark elements without change in
luminance
 Dimensions of pattern

• Visual angle (function of the distance

from the subject’s eye to the pattern and
its width)
• Visual angle >8 degrees- full field
stimulation
• Visual angle > 20 degrees- partial
field stim.
 Dimensions of pattern

• Check size: smaller checks increase the

P100 amplitude
• Smaller check size have greater
sensitivity for abnormalities
– more likely to be affected by visual acuity
and luminance changes.
– at least two check sizes should be used.
Commonly 35' and 70' are used
 Characteristics of stimulus

• High contrast ( > 50%)

– Contrast <20%: delay in P100
• Check size: 35' and 70'
• Field size: 8-20 degrees
• Reversal frequency: 4Hz or less
• Reversal direction has no significant
effect
 Recording Parameters

• Filters: LFF=1 Hz HFF=100 Hz

• Sweep duration: 300- 500 msec
• Dwell time: 2 msec
• Sweep repetition: 100
– at times 200 or 500 sweep repetitions may
be necessary if responses are noisy or
unclear
 Placement and labeling of electrodes

• Recommended electrodes:
• Channel 1: Oz to reference
• Channel 2: Pz to reference
• Channel 3: L5 to reference
• Channel 4: R5 to reference
• L5 and R5 correspond to 5 cm above
and 5 cm left and right lateral to inion
respectively
 Partial-field stimulation:
Electrodes placement

• Best montage for partial-field stimulation

requires six electrodes with Fz as reference
because ears may asymmetrically active.
• Channel 1: L10 to reference
• Channel 2: L5 to reference
• Channel 3: Oz to reference
• Channel 4: R5 to reference
• Channel 5: R10 to reference
• Channel 6: Pz to reference
 VEP: Technical factors affecting results

• Luminance: P100 latency is increased with

decrease in luminance
– Pupillary diameter has an effect on retinal illumination
and so it affects P100 latency
• Contrast: Luminance difference b/w light & dark
Luminance sum (b/w light & dark)
• Decrease in contrast increases P100 latency
(stable > 40 %)
• Field size: reduces the P100 amplitude but
latency is not affected
 VEP: Technical factors affecting results

• Check size: In smaller fields, increasing

check size increases P100 latency
• Stimulator type: Increasing reversal time
increases P100 latency
• Partial Field Stimulation: (field > 20 degrees)
– Ipsilateral P100: central areas
– Contralateral negativity: Peripheral areas
– Transitional zone
 VEP: Patient factors affecting results

• Age: Check size affects the P100 latency

Amplitude stable during adult life
P100 latency changes with age, most evident after 45
yrs. Then it increases by 2-5msec/decade
• Gender: Females have a shorter P100
latency

• Visual acuity: Changes in P100 latency is

related to check size and retinal illumination
• Reliability: with observation and PERG
 VEP
Analysis of results

• Identification of waveforms, N75, P100, N145

• Measurements:
• P100 latency at Oz
• Amplitude of P100 at Oz
• Interocular latency difference (range 0-6)
• Interocular amplitude difference (range 0-5.5)
• Interocular amplitude ratio:
• Smallest amplitude x 100
Largest amplitude
 Abnormal VEPs: types
Abnormal distribution of P100

• Scotoma: removal of central-field contribution

results in peripheral field activity to predominate
Partial field stimulation can be helpful
• Lesion anterior to chiasm- differences b/w
responses from same half field in both eyes
• Lesion at chiasm--same abnormality in
different fields of both eyes (crossed
asymmetry)
• Lesion posterior to chiasm--same
abnormality in homonymous fields of both
eyes(uncrossed asym)
 Abnormal VEPs: types
Abnormal shape of P100

• W, or bifid pattern produced by:

• 1. Upper visual field contributes -vity to the
inion and this may be shifted in latency
resulting in two peaks. This can be corrected
by stimulating only the lower visual field
• 2. Visual field defects( scotoma) the -vity
recorded over contralateral scalp, contributed
by peripheral field, may intermix with inion
+vity resulting in two peaks. This can be
corrected by recording from more lateral
electrodes
 Abnormal VEPs
Clinical correlation
• Optic neuritis
PSVEP abnormal in 90% pts.
More sensitive than MRI in a study 0f 37
patients
(Miller et al 1986)
• Prognosis can be studied by doing PERG.The
abnormalities in PERG predict permanent visual
defect
• 17 eyes permanent reduction -- poor outcome
• 29 eyes PERG normal – good outcome
(Kaufman et al 1988)
 Abnormal VEPs
Clinical correlation

• Multiple sclerosis:
Detect silent lesions: No clinical evidence of
optic neuritis - 50% abnormal PSVEP
• In transverse myelitis PSVEP is abnormal in
only 10% compared to progressive
myelopathy (35-70%)
• Combined Evoked Potential studies: have a
higher yield in diagnosing MS (Noseworthy
et al)
• Yield for diagnosis of MS:
SSEP>PSVEP>BAEP
 Abnormalities in MS

• The most sensitive abnormality on VEP

with optic neuritis is interside P-100
amplitude difference
• In clinical practice the most useful
abnormality to be detected on VEP with
optic neuritis is interside P-100 latency
difference
 Abnormal VEPs
Clinical correlation

• Compression produce PSVEP waveform

distortion and loss of amplitude but less
latency delay
Brainstem Auditory Evoked
Potentials
 Definition- BAEP

• “Electrical events generated by neural

elements along the auditory pathway in
response to an auditory stimulus.”
– A sensitive tool for assessment of brainstem
auditory tracts and nearby structures
– Allows localization of conduction defects within
a centimeter
– Resistant to systemic effects but not structural
pathology
 Clinical applications

• Hearing assessment in infants.

• Determining hearing loss in
uncooperative adult patients.
• Diagnosing cerebellopontine angle
tumors
• Evaluating brainstem function in
suspected MS.
• Evaluating neuro-otological disorders.
• Intraoperative monitoring.
 Short Latency AEP

• Short latency AEP(BAEP):

-occurring within the 1st 10
msec. following the
stimulus.
-amplitude ~ 0.2 µv.
-generated in the brainstem.
 ANATOMY- BAEP

NEURAL ELEMENTS

I. PERIPHERAL
COCHLEA
SPIRAL GANGLION
EIGHTH NERVE
 General principles of BAEP recording

• Subject: comfortable, recline in chair or

lies in bed, relax neck muscles by placing
pillows under the head.
• Quiet room.
• Earphones applied cautiously in children
to avoid collapse of the outer ear canal.
• Subjects encouraged to sleep.
• May need using sedatives (infants and
young Children).
 Recording parameters- BAEP

• Filter settings: low frequency cutoff 100 Hz,

and the high frequency cutoff is 3000 Hz.
• Amplification: potentials are amplified
between 0.5 & 1 million times and averaged.
• Sweep length: at least 15 msec.
• Averaging: to obtain clean recordings, 1000-
4000 trials should be averaged. At least 2
waveforms should be obtained using the
same stimulation conditions to check for
reproducibility.
 Stimulation Methods- BAEP

• Earphones: most commonly used.

• Loudspeakers: used only rarely for acoustic
stimulation. This method does not allow
testing of monaural AEPs except in patients
with unilateral deafness and in recording the
Electrocochleogram (EcochG).
• Bone stimulation: not used routinely but may
be helpful when air stimulation cannot be
used (ex: intraoperatively, in cases of
malformations of the external ear…).
 Stimulus Types- BAEP
• Most AEPs are produced by Clicks or by Tone pips.
• Clicks: (delivering an electrical square wave of 100-200 msec
duration to an audiologic earphone):
-very satisfactory for neurological studies because they produce
sudden excitation resulting in a well defined EP.
-Not very suitable for audiological studies, because they contain a
wide range of tone frequencies, mainly high frequency content , and
do not test lower frequency range, which is important for speech.
- stimulation with Tones (sine wave) are desirable for audiological
studies.

Noise:
Not used as a stimulus, but is delivered to the nonstimulated ear as a
masking sound to reduce spread of stimulus sound delivered to the
opposite ear, so that the stimulation is not bilateral
 BAEP montage- ACNS

• Electrode placement
– A1 left earlobe / behind the left ear
– A2 right earlobe / behind the right ear
– Cz vertex (10-20 system)
Montages and polarity convention-
BAEP
• Dual-channel recordings are preferred
for BAEP: A1-Cz, and A2-Cz.
• A ground electrode placed on the head
or other body parts, and connected to
the amplifier ground.
• Polarity Convention: most laboratories
record the BAEPs so the deflection
indicates increased positivity at the
vertex electrode. This makes the
relevant peaks convex upwards.
• Wave I:
-appears more than 1.5 msec
after the stimulus.
-in contrast to cochlear
microphonics, does not
reverse with reversal of
click polarity.
-decreasing click intensity
leaves wave I as the last
peak in this area.
 Cochlear microphonic

• The cochlear microphonic is a receptor

potential believed to be generated
primarily by outer hair cells of the organ
of Corti.
• Its detection in surface recordings has
been considered a distinctive sign of
outer hair cell integrity in patients with
auditory neuropathy.
• Wave V:
-most prominent peak after 5.5
msec.
-starts above the baseline.
-the immediately following trough
is maximum below the baseline.
-is the last peak visible in this
area.
* Waves IV & V interact to
present a variety of
patterns.
• Wave III:
-appears between I & V, ~
equidistant unless
abnormalities are present.
-the last wave present in this
area with decreasing click
intensities.
 Click intensity- BAEP

• Changes in click intensity produce marked

changes in the absolute latency and
amplitude of all BAEPs.
• All BAEP peak latencies decrease as the click
intensity increases ( 0.03 ms/db).
• However, because all of the BAEPs waves
latencies shift by roughly the same amounts,
there is very little changes in the interpeak
latencies.
• Amplitude: with decreasing the click, all peaks
except I, III, and V, tend to disappear.
 Intensity-latency curves
• Recording at multiple
intensities (stepwise decrease
of latency by 20 dB increase in
intensity.
• Wave V is the last waveform
to disappear at lower
intensities
- Identify wave V and confirm
abnormalities.
- Evaluate sensorineural
hearing loss: abrupt drop in III-
V slope at lower intensities.
- Evaluate conduction hearing
loss: prolonged or absent I
with normal III-V slope.
 Click rate- BAEP

• Increasing the click rate increases

absolute latency of all BAEP waves and
decreases amplitude.
• Interpeak latencies (IPL) increase
slightly at higher stimulus rates.
• Clicks are delivered at a rate of 8-10 Hz,
allowing reproducible identification of all
waves.
 Stimulus polarity- BAEP

• Condensation clicks: click stimuli may

be produced by electric pulses , which
causes an initial deflection of the
earphone membrane toward the
eardrum (condensing the air or
compressing the air in the ear canal),
generating condensation or
compression click.
 Stimulus polarity- BAEP

• Rarefaction clicks: the polarity of

electric pulse is reversed, so the pulse
produces an initial deflection of the
membrane away from the eardrum,
rarefying the air in the ear canal.
• BAEPs to R clicks are used more often,
because they have shorter latency and
clearer definition than BAEPs to C click.
• Ideally, all patients should have BAEPs
to alternating C and R clicks.
 BAEP stimulus mode: Monaural
only
- A normal response generated by a
good ear will mask abnormal responses
from a bad ear, resulting in significant
loss of the test sensitivity.
- Masking noise to contralateral ear
 BAEP patient variable: age

• absolute and peak latencies increase with

increasing age after childhood.
• Older subjects have greater increase in IPL
when stimulus intensity decreased.
• Infants: waveforms are often higher in
amplitude due to smaller head size, greater
proximity of the recording electrodes to BAEP
generators.
• Waveforms have a simpler appearance in
prematures and neonates, and an adult
configuration reached by 3-6 months of age.
 BAEP patient variable: body
temperature
• An increase in absolute and IPLs with
progressive lowering of body
temperature.
• Below 32.5 C, the values are abnormal.
• Below 27 C, waveforms become difficult
to identify or disappear.
• Changes in BAEPs with hypoglycemia
probably result from changes in body
temperature.
BAEP patient variable: peripheral
hearing disorder
• Patients with hearing loss needs
audiological examination to investigate
the peripheral or central causes:
• Peripheral hearing loss: increase BAEP
peak latencies rather than IPL, and
therefore do not necessarily preclude
the identification of central lesions.
 Drug effects on BAEP

• IPL of BAEPs are not significantly affected by

therapeutic doses of CNS depressants.
• small but statically significant increases in
IPLs with high doses of thiopental infusions.
(and also decrease in amplitude).
• BAEP abolition with high doses of Lidocaine
and thiopental ( reversible).
• Alcohol intoxication may increase BAEP
latencies.
 Normal BAEP parameters- VUMC

Male Female
Wave I 2.10 ms 2.10 ms
I-III 2.55 ms 2.40 ms
III-V 2.35 ms 2.20 ms
I-V 4.60 ms 4.45 ms
V/I AMP 0.5 0.5
I-V inter-ear 0.5 ms 0.5 ms
 Latency abnormalities (Data
analysis)
• Abnormal I-III IPL: conduction defect in the
brain stem between the 8th nerve close to the
cochlea and the lower pons. The lesion may be
either in the nerve or in the brainstem (most
common in acoustic neuroma).
• Abnormal III-V IPL: conduction defect between
the lower pons and the midbrain.
• Absent wave I, and the III-V separation is
normal: usually due to a peripheral hearing
disorder.
• Increased I-III & III-V IPL: lesions affects
the brainstem at and above the caudal
pons with or without involvement of the
acoustic nerve.
• Absence of III with normal I & V: normal.
• Absence of V with normal I & III: indicates
a lesion above the caudal pons.
 Multiple Sclerosis

• Chiappa found 1006 patients with varying

classifications of MS and 466 (46%) had
abnormal BAEPs.
• Most frequent abnormalities:
-decreased amplitude or absence of wave V
(80% of MS patients with abnormal BAEPs).
-increased III-V IPL in 1/3 of MS patients with
abnormal BAEPs.
-less frequent: absence of wave III.
-Chiappa recorded normal BAEPs in ~ 50% of
patients with MS and INO.
 Multiple Sclerosis- BAEP

• BAEP are useful in evaluating the

patients in which MS is entertained:
-patients without signs or symptoms
suggesting brain stem involvement.
-provide objective evidence of brainstem
involvement in patients with equivocal
findings on clinical examination.
-can be used to monitor effectiveness of
an experimental therapy.
 Acoustic Neuromas- BAEP

• BAEPs are extremely sensitive in

detecting acoustic neuromas:
- Sensitive for lesions of > 2 mm.
- Distinguishes from patients with
cochlear loss such as Meniere’s
disease and labyrinthine disease who
have normal BAEPs.
 Acoustic Neuromas: BAEP
findings
-ipsilateral I-III and I-V IPL delay (one of the most sensitive
screening tests for acoustic neuromas), seen in 1/3 of
patients.
-ipsilateral absence of all peaks following wave I( tumor of
sufficient size to produce a conduction block at the
compression point), seen in 1/3 of the patients.
-ipsilateral absence of all components including wave I. This
most likely because tumor compromised the internal
acoustic artery which also runs in the acoustic canal, and
supplies the origin of wave I of the BAEPs.
-contralateral BAEPs are usually normal, except when the
tumor is large and displaces the brainstem (if abnormality
seen, usually III-V prolongation).
 Coma and Brain death- BAEP

• Toxic-metabolic coma: normal BAEPs.

• Brain death:
-Absence of BAEPs waves II through V despite
a normal I wave indicates a significant lack of
function of in the brain stem auditory tracts.
-without wave I present, no inferences can be
made as to the localization of the interruption
of the auditory signal since the integrity of the
peripheral apparatus in any individual patient
is often not known.
 Conclusion- BAEP
• Commonly indicated in evaluation of
suspected acoustic neuroma or Multiple
sclerosis and intraoperative monitoring.
• Identification of correct waveforms is
critical for interpretation
• BAEPs are the most sensitive screening
test when small acoustic neuroma is
suspected
• The most common BAEP abnormality in
patients with CNS disease is a prolonged
I-V interpeak latency.