Evoked Potentials - BN

09/26/2010
Brian Nichols, B.S., CNIM, REPT, RPSGT
Upper
SSEPs
Wrist to Cortex
Lower
SSEPs
Ankle to Cortex
BAERs
External Ear to Upper Brainstem

VEPs
Eyes to Occipital lobe
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Upper
SSEPs
Erbs Point, Cervical Potential, P14, N18, N20, P24

Lower
SSEPs
Pop, LP, P31, N34, P37, N45

BAERs
Waves I, II, III, IV, V

VEPs
N75, P100, N145
Polarity
convention
Types of potentials and how to record
them
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Start with electrical

stimulation
Median Nerve
Cathode 2 cm proximal
to the wrist crease
Ulnar Nerve
to the wrist crease
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The electrical impulse begins at the

cathode and moves up the nerve
toward the body.
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Impulse travels up the median

Nerve deep to the flexor muscles
of the forearm.
Impulse travels medial to

the Biceps Brachii and approaches
the Brachial Plexus.
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Impulse travels through the

Brachial Plexus.
Continues up the nerve toward the

spinal cord.
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Impulse travels up the Dorsal Nerve Root
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Impulse travels up the Dorsal nerve root
Impulse travels from the Dorsal root into

Fasciculus Cuneatus of the spinal cord.
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Impulse travels up the Fasciculus Cuneatus

of the Spinal cord.
Impulse travels up the Fasciculus Cuneatus

of the Spinal cord.
At C1-C2 the spinal cord becomes the
medulla. The lower medulla contains
the decussation of the pyramids.
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Decussation of the PyramidsLower Medulla
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Decussation of the PyramidsLower Medulla

Crossed over
Pre decussation is the spinal cord.

Post decussation is the
Medial Lemniscus
Pons
Impulse travels along the
Medial Lemniscus
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Midbrain
The Medial Lemniscus continues
carrying the impulse upward
through the Midbrain.
Thalamus
The impulse arrives at the Thalamus
where the Medial Lemniscus
terminates.
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Thalamocortical Tracts
Projections from the thalamus
Radiate outward to the
Somatosensory strip of the cortex.
Sensory Cortex
Also called the Somatosensory
strip
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Sensory Homunculus
End of Upper SSEP

pathway
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0 msec
Recording begins at stimulation
4 msec
Traveling along the median nerve
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8 msec
The impulse has reached the brachial

Plexus. As the impulse travels, the first
recording electrode at the erbs point
begins to record the propagating
Potential.
10 msec
Erbs Point: Brachial Plexus

Potential
Peripheral response recorded from the

Skin at the Supraclavicular Fossa
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13 msec
Cervical Potential: N13
The impulse has traveled through the Brachial

Plexus and converged via the dorsal nerve root
Into the spinal cord and an electrode at C5
records the potential. The N13 waveform
reflects postsynaptic activity in the cervical
spinal cord.
14 msec
Subcortical Response: P14
Reflects activity in the Caudal Medial Lemniscus

as the impulse moves through the brainstem.
Cephalic and Noncephalic recording
electrodes are used.
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18 msec
Subcortical Response: N18
The impulse continues its route along the

Medial Lemniscus and approaches the
Thalamus.
The Medial Lemniscus terminates at
the thalamus.
20 msec
Cortical Response: N20
The impulse arrives at the cortical

somatosensory region where it is processed.
The processing of this impulse by a large group
of cells, or their post synaptic activity, is what
gives us this potential.
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20 msec
Cortical Response: N20
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Start with electrical

stimulation
Tibial Nerve
Cathode is posterior to
the medial malleolus
Peroneal Nerve
to the ankle crease
Tibial nerve
stimulation provides
better waveforms
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Electrical stimulation creates an impulse that moves up the Posterior Tibial

Nerve.
The impulse continues

proximally. Note the
Post. Tib. Nerve at this
region runs deep
to the
Gastrocnemius.
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The impulse arrives

at the Popliteal
Fossa. The Post Tib
and Peroneal nerves
Soon merge to form
the Sciatic nerve.
The impulse is now

Moving up the sciatic
nerve toward the
spinal column.
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The sciatic nerve moves up the leg,

eventually separates and merges
with other nerves to form the
LumboSacral plexus.
The LumboSacral Plexus
innervates L4-S3
Arriving at the Sacral Plexus
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The nerves that are encased in the vertebral

column are considered the Cauda Equina
At T12, the
cauda equina
becomes the
Spinal Cord
at a region
known as the
Conus
Medullaris.
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The impulse has traveled up

The spinal cord and arrives
At the lower brainstem where
The crossover takes place.
The impulse is now

contralateral to the side of
stimulation and is traveling
up the Medial Lemniscus.
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Traveling the Medial Lemniscus.
Continuing along the Medial Lemniscus.

To the Thalamus.
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Passing through the thalamus and

traveling via thalamocortical tracts to
the sensory cortex.
Impulse is processed in the

somatosensory cortex.
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The Sensory Homunculus.
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0 msec
Recording begins at stimulation
6 msec
Impulse travels Posterior Tibial nerve
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10 msec
Peripheral response recorded at the popliteal fossa
15 msec
Impulse passes popliteal fossa and moves up sciatic
nerve toward the next recording electrode at T12.
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17 msec
Impulse moves up Sciatic Nerve, through the
lumbosacral plexus and Cauda Equina toward
the next recording
electrode at T12.
20 msec
Impulse arrives at the Conus Medullaris where the
Cauda equina synapses with the spinal cord. The
Post synaptic activity creates a potential that is
recorded by an
electrode placed at the
T12 region.
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25 msec
Impulse travels up the spinal cord.
31 msec
Impulse reaches the lower brainstem, crosses over
and begins its route up the medial lemniscus
Cephalic and
noncephalic
Recording Electrodes
are used.
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32 msec
Impulse moves up through the medial lemniscus.
34 msec
Impulse reaches the thalamus where the medial
lemniscus terminates.
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35 msec
Impulse passes thalamus and via thalamocortical tracts
it is moving toward the somatosensory strip.
37 msec
Impulse has reached the somatosensory strip. Cephalic
electrodes are used to record the response.
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Start with audible tone

clicks
Ear inserts
Headphones
Soundwave enters ear canal
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Soundwave arrives at the tympanic

Membrane, also called the eardrum.
The eardrum vibrates causing
Movement in the ossicles (bones of
Middle ear). The ossicles send the
vibrations into the Cochlea where tiny
hair cells convert the physical
movement into an electrical sensory
impulse.
Wave I: Distal Auditory nerve
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Wave II: Proximal Auditory nerve
Wave III: Superior Olivary Complex
At the junction of the Pons

and Medulla Oblongata.
This is the beginning of the
Lateral Lemniscus.
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Wave IV: Lateral Lemniscus
The Lateral Lemniscus

travels upward through the
pons and terminates at the
Inferior Colliculus
Wave V: Inferior Colliculus
Located in the midbrain.

Acts as a relay station to
send the sensory impulse
to the correct area in the
brain.
End of the Lateral
Lemniscus.
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Start with
checkerboard pattern
reversal.
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Waveforms
N75
P100
N145
N100
The waveforms N75 and
P100 are generated in
the primary visual cortex.
Note the Left retina halves of each eye are processed in the left lobe.
And vice versa. The right retina halves of each eye are processed in the
right lobe.
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Polarity Convention: How the waveforms are displayed are based on the
polarity of the impulse and what amplifier input is recording that impulse.
Waveforms with an N are

negative. i.e. N20, N18
Waveforms with a P are
positive. i.e. P14, P31
Peripheral and spinal
potentials are negative.
In BAERs, Wave 1 is negative
and waves II through V are
positive.
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Keep in mind, both amplifier inputs (Active(-) and Reference(-)) record data.
The polarity convention applies to each of the 2 inputs separately. Then the
data from each input is combined and we see the final waveform.
Using the properties of polarity convention, well

look at 2 different types of potentials, and how they
are displayed
1. Propagating
2. Stationary
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A moving potential that travels along a nerve.

Examples: Erbs point, Pop Fossa
Occurs on peripheral nerves.
Polarity is negative
Active electrode records at a volley or where the
nerve becomes superficial.
Reference electrode
records from an area
where there is little
contamination from
muscle and away
from potential. Also
called a quiet area.
Propagating Potential
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A potential generated at a specific point after the impulse

stops at a relay station along a nerve route.
Examples: Cervical and lumbar potentials
As the nerve cells are transmitting the impulse across
a synapse, or connection between 2 nerve cells, a
potential is created
Polarity is negative
Active electrode records where the potential is most
superficial.
Reference electrode records from an area where
there is little contamination from muscle and away
from the potential. Also called a quiet area.
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Near
field- Potential lies close to the

surface of the brain.
Potential is higher amplitude because the field
Is generated near the recording electrode.

Far
field- Potential lies deep within the

brain
Potential is lower amplitude because the field
Is generated far from recording electrode.
Example of a potential being recorded at CP3.

The negative potential is
recorded by the active (-)
input thus creating an upward
deflection at CP3. The
reference (+) CP4 is
in a quiet area and does
not record the potential.
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Example of subcortical potential being recorded at CP3.

Requires cephalic to non-cephalic channel.
The negative potential is
recorded by the active(-)
input thus creating an upward
deflection at CP3. The
Reference(+) A2 is in a quiet
area off the head and does
not record the potential.
Why cephalic to cephalic montage does not work to obtain

far field responses.
Example of CP3-CP4
montage
This is why you can record
a cortical potential and not
have it contaminated with a
Subcortical potential.
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References:
Spehlman, R., 1985, Evoked Potential Primer: Visual, Auditory, and
Somatosensory Evoked Potentials in Clinical Diagnosis
Chiappa K., 1983, Evoked Potentials in Clinical Medicine
American Clinical Neurophysiology Society Guidelines
Thank You.
48

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09/26/2010

Brian Nichols, B.S., CNIM, REPT, RPSGT

External Ear to Upper Brainstem

Eyes to Occipital lobe

Erbs Point, Cervical Potential, P14, N18, N20, P24

Pop, LP, P31, N34, P37, N45

Waves I, II, III, IV, V

N75, P100, N145

Start with electrical

The electrical impulse begins at the

Impulse travels up the median

Impulse travels medial to

Impulse travels through the

Continues up the nerve toward the

Impulse travels up the Dorsal Nerve Root

Impulse travels up the Dorsal nerve root

Impulse travels from the Dorsal root into

Impulse travels up the Fasciculus Cuneatus

Impulse travels up the Fasciculus Cuneatus

Decussation of the PyramidsLower Medulla

Decussation of the PyramidsLower Medulla

Pre decussation is the spinal cord.

End of Upper SSEP

Recording begins at stimulation

Traveling along the median nerve

The impulse has reached the brachial

Erbs Point: Brachial Plexus

Peripheral response recorded from the

Cervical Potential: N13

The impulse has traveled through the Brachial

Subcortical Response: P14

Reflects activity in the Caudal Medial Lemniscus

Subcortical Response: N18

The impulse continues its route along the

Cortical Response: N20

The impulse arrives at the cortical

Cortical Response: N20

Start with electrical

Electrical stimulation creates an impulse that moves up the Posterior Tibial

The impulse continues

The impulse arrives

The impulse is now

The sciatic nerve moves up the leg,

Arriving at the Sacral Plexus

The nerves that are encased in the vertebral

The impulse has traveled up

The impulse is now

Traveling the Medial Lemniscus.

Continuing along the Medial Lemniscus.

Passing through the thalamus and

Impulse is processed in the

The Sensory Homunculus.

Recording begins at stimulation

Start with audible tone

Soundwave enters ear canal

Soundwave arrives at the tympanic

Wave I: Distal Auditory nerve

Wave II: Proximal Auditory nerve