Anatomic origin of P13 and P14 scalp far-field potentials.

After median nerve stimulation, noncephalic or earlobe reference montages enable one to record over the scalp a well-defined, positive far-field response, which has been labeled the P14 or P13-P14 complex. It has been ascertained that this wave is generated in the caudal brainstem. Its use is reliable and sometimes mandatory in assessing a number of diseases that affect primarily the brainstem, such as multiple sclerosis or coma. Because of its complex shape as well as discrepant findings in the literature, it is still debated whether this potential is produced by a single or by multiple serial generators. The authors present these different views and summarize the different recording methods, while bearing in mind that some recording techniques are more suitable for routine purposes and others are preferred in selected cases, when more information regarding caudal brainstem function is required.     

short-latency somatosensory evoked potentials to median nerve stimulation: components N 13-P 13, N 14-P 14, P 15, P 16 and P 18 with different recording methods

Summary Comparative recordings of short-latency somatosensory evoked potentials with midfrontal (Fz), ear and non-cephalic reference electrodes were obtained in 12 normal subjects to define the site of the generators of the different components and the spatial distribution and interference of the different components recorded at the neck and scalp. Such investigations provide the basis for identical investigations in patients with focal lesions of the central nervous system. The N 13 recorded from the neck (C 2-Fz) and the inconsistently recorded component N 14 were quite similar in latency to the far-field potentials P 13 and P 14 recorded at the scalp (C₃, C₄—ear or hand). The component P 15 was clearly visible only in scalp-Fz leads and occurred 0.2–0.9 ms (mean 0.5 ms) later than P 14 in ear or hand reference recordings. This is evidence against the identity of these two components proposed by others. In a larger group of 48 subjects, using an exclusive Fz-reference lead, normal values were established of the components P 15, P 16 and P 18, as well as their scalp distribution.

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Zusammenfassung An 48 Normalpersonen wurden die Normalwerte der spinalen und subkortikalen SEP-Komponenten (einschließlich P 16 und P 18) nach Medianus-Stimulation am Handgelenk ermittelt, wobei eine frontomediane Referenz (Fz) gewählt wurde. Bei einem Teil der Probanden (n=12) erfolgten zusätzliche Ableitungen der Reizantworten gegen eine Ohr- sowie eine extrakephale (Hand-) Referenz, um die Beziehungen der hierbei registrierbaren positiven Far-field-Potentiale zu den einzelnen Komponenten des Nacken-SEP zu klären. Die von der oberen Nackenpartie (C 2-Fz) abgeleiteten Komponenten N 13 und N 14 stimmten in ihrer Latenz mit den von der Kopfhaut abgeleiteten Komponenten P 13 und P 14 überein, wobei ein Teil der Probanden anstelle zweier deutlich unterscheidbarer P 13- und P 14-Komponenten lediglich eine positive Potentialschwankung aufwies. Die bei frontomedianer Referenz konstant sichtbare P 15-Komponente wies bei allen Untersuchten eine 0,2–0,9 ms längere Latenz auf als das mit extrakephaler Referenz registrierte Far-field-Potential P 14, was gegen die von anderer Seite vermutete Identität dieser beiden Komponenten spricht. Die klare gegenseitige Abgrenzung der frühen somatosensiblen Reizantworten nach Medianusstimulation bei Wahl unterschiedlicher Referenzorte ist Voraussetzung für eine verfeinerte Lokalisationsdiagnostik innerhalb des lemniskalen Systems der Somatosensorik.

     

Neural generator of P14 far-field somatosensory evoked potential studied in a patient with a pontine lesion

Somatosensory evoked potentials (SEPs) to electrical stimulation of the right and the left median nerves were studied in a patient with a pontine lesion. At first there was mainly right medial lemniscus involvement. Four months later the left medial lemniscus was found to be also involved. SEPs to stimulation of the right median nerve had normal wave forms and latencies while N20 was lacking and P14 was abnormal after stimulation of the left median nerve in the first SEP record. N20 and P14 were absent with preservation of P9 and P11 after stimulation of both left and right median nerves in the second SEP record. Therefore the P14 component has been found abnormal, then absent, in a patient with a pontine lesion.     

Haemorrhages in spinal cord with syringomyelia in a patient with haemophilia

Summary A 21-year-old man, with non-hereditary haemophilia on the basis of a deficiency of anti-haemophilic factor, was affected by a banale infection accompanied by cervical pain, which three days later progressed to a paraplegia. Neurological, roentgenological and neurosurgical findings showed that there was a haematomyelia. Anatomical examination showed in addition to the recent massive haemorrhages, iron pigment, cavitation extending over the entire length of the spinal cord, and new tissue formation such as is considered to be characteristic of syringomyelia.

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Résumé Un jeune homme de 21-ans atteint d'hémophilie non héréditaire (manque du facteur anti-haemophilique) tombait malade d'un rhume vulgaire avec complaints de douleur cervicale. Après 3 jours il se développait une paraplégie. Examinations neurologiques, roentgenologiques et la biopsie de neurochirurgien démonstraient l'existence d'une hématomyélie.L'anatomie-pathologique fournait l'évidence d'une hémorragie massive très récente, d'hémorragies anciennes avec accumulation de pigment de fer et d'une cavitation dans le centre de la moëlle épinière avec formation de tissu glial (comparer avec une formation neurofibromateuse).Coincidence rare d'une hématomyélie et d'une syringomyélie.

     

Absent median nerve P14 far-field somatosensory evoked potential with persistent tibial nerve P30 component in a patient with ischemic pontine lesion

In a patient with an ischemic lesion of the right paramedian region of the pons, somatosensory evoked potential (SEP) recording to median nerve stimulation showed an absent P14 response with still preserved P13 and N18 potentials. The tibial nerve P30 and N33 SEP components were normal. Our results suggest that the median nerve P14 potential, absent in our patient, has a different origin from the tibial nerve P30 response, normal in the present case.     

Posterior spinal fusion for severe kyphoscoliosis in a Loeys-Dietz syndrome patient with a large syringomyelia

Spinal deformity is a characteristic feature of Loeys-Dietz syndrome (LDS). Surgical correction in LDS is indicated when the deformity is progressive to avoid neurological deficits, respiratory impairment, and back pain. However, few reports exist on the surgical treatment of spinal deformity in LDS, and no therapeutic standards have been established. We described the clinical and radiological outcomes of a patient with LDS receiving surgery for severe kyphoscoliosis.A 21-year-old male patient with LDS underwent posterior spinal fusion with an all-pedicle screw construct from T10 to L5 for a preoperative main curve Cobb angle of 70 degrees and kyphotic angle of 49 degrees. The postoperative Cobb angle of the main curve and kyphotic angle improved to 36 and 8 degrees, respectively. Correction surgery was performed with frequent motor evoked potential testing, taking care not to cause motor paralysis. Ameliorated low back pain and improvements in clinical questionnaire scores were noted at 21 months after surgery. No perioperative complications were reported.Based on the present case, posterior spinal fusion represents a good correction option for severe spinal deformity in LDS with syringomyelia. Careful preoperative examination and treatment for neurovascular and neurological lesions is advised to prevent severe complications.     

Scalp recorded P13 and spinal recorded N13 in short latency somatosensory evoked potentials

Using non-cephalic reference and by median nerve stimulation, P 13 component and N 13 component are recorded on the scalp (scalp P 13) and the posterior neck (spinal N 13), respectively, in the short latency somatosensory evoked potentials (SSEP). The purpose of this study is to disclose the origin, characteristics and clinical significance of these two components. Ten healthy volunteers served for normal subjects. Ten patients with pontine lesion or brain death were studied. The effect of barbiturate was also studied in additional 5 patients during anesthesia for cranioplastic surgeries. Electrical stimuli of 0.2 msec square wave pulse were used in routine examination. To confirm the effects of stimulation frequency, 3, 6, 9, 12, 15, 18, 21, 24 and 27 Hz were also used in normal subjects. Recording electrodes were placed in the following sites. (1) Scalp electrode at the Shagass' point contralateral to the stimulated side (Par.). (2) Posterior neck electrode on the spinous process of the fifth cervical vertebrae (Cv5), (3) Anterior neck electrode on the thyroidal cartilage (Ant. C). (4) Erb's electrode just above the mid-clavicular point ipsilateral to the stimulation. Erb's electrode contra-lateral side of stimulation was used as a reference. Spinal N 13 on posterior neck reversed its polarity into P 13 (spinal P 13) on the anterior cervical electrode. A study with different stimulus rates revealed that the latency of scalp P 13 significantly prolonged at 24 Hz stimulation. On the other hand, the latency of spinal N 13-P 13 easily prolonged even at 18 Hz. This suggested that spinal N 13-P 13 were generated polysynaptically.(ABSTRACT TRUNCATED AT 250 WORDS)     

Neural generators of N18 and P14 far-field somatosensory evoked potentials studied in patients with lesion of thalamus or thalamo-cortical radiations

Somatosensory evoked potentials (SEPs) to electrical stimulation of the right or left median nerve were studied in 4 patients with hemianesthesia and a severe thalamic or suprathalamic vascular lesion on one side. The SEPs were recorded with a non-cephalic reference. The normal side of each patient served as his or her own control. The lesion consistently abolished the parietal N20-P27-P45 and the prerolandic P22-N30 SEP components. It did not significantly affect the P9-P11-P14 positive far fields, nor the widespread bilateral N18 SEP component. This allowed N18 features to be studied without interference from cortical components. It is proposed that N18 reflects several deeply located generators in brain stem and/or thalamus whereas N20 represents the earliest cortical response of the contralateral post-central receiving areas.     

The subcortical generated somatosensory evoked potentials in non-cephalic,cephalic, and anterior neck referenced recordings in a patient with a cervico-medullary lesion: a clue to the identification of the P14/N14 and N13 generators

Summary Median nerve somatosensory evoked potentials (SEPs) were studied in a patient before and after the development of a cervico-medullary lesion. The first examination demonstrated normal subcortical generated potentials N13 and N14. The second examination, following a subarachnoid haemorrhage at the cervico-medullary junction, displayed a delayed and reduced amplitude P14/N14 peak on both sides. P14/N14 showed the same latency in all montages, using noncephalic, cephalic and anterior neck references. The N13 component was not significantly changed in latency compared with the first examination. The latencies of the N13 peak were variable in the different montages. They increased from the lower (C7) to the upper (C2) neck, whereas the latency of the N13 onset was identical in all montages. This alteration might be caused by a delayed near-field activity at C2 overlapping the N13 component. These results fit the hypothesis of two major generators responsible for subcortical SEPs; a near-field N13 component at the level of the lower neck and a far-field P14 component arising from the level of the cervico-medullary junction. An additional minor near-field activity generated by the cuneate nucleus is suspected.     

Origin of scalp far-field N18 of SSEPs in response to median nerve stimulation.

To identify the origin of scalp-recorded far-field negativity of short-latency somatosensory evoked potentials to median nerve stimulation (designated N18), direct records were made from the thalamus and ventricular system during 4 stereotaxic and 3 posterior fossa operations. In the thalamus a negative potential with almost the same latency as the scalp N18 was restricted to the Vim nucleus, but there was a large positive potential in the VC nucleus and medial lemniscus. Vim negativity increased in amplitude when high frequency stimulation was given to the median nerve, indicative of a facilitation effect. In contrast, the amplitude of scalp N18 decreased at high frequency stimulus. Direct recordings made through the medulla oblongata to the mid-brain showed a negative potential with gradually increasing latency. Above the upper pons, there was stationary negativity with no latency shift. The similarity between this negative potential and N18 is shown by their having the same latency and same response to the amplitude reduction and latency prolongation produced by high frequency stimulus. Our data suggest that scalp N18 comes from brain-stem activity between the upper pons and the mid-brain rather than from the thalamus.     

Latency and amplitude abnormalities of the scalp far-field P14 to median nerve stimulation in multiple sclerosis. A SEP study of 122 patients recorded with a non-cephalic reference montage

The frequency and characteristics of P14 abnormalities were investigated in 122 patients with probable (68), or definite (54) multiple sclerosis by recording SEPs to median nerve stimulation with a non-cephalic reference montage. The most frequent SEP abnormality found in our series (62% of abnormal results) combined latency increase and amplitude reduction of P14. Interindividual variability, inherent in absolute amplitude measurements, was by-passed by calculating the ratio between the amplitudes of far-field P9 and P14 components, which proved to be normally distributed in controls. In spite of the strong association (P much less than 0.001) between the P9-P14 interpeak interval (IPL) and the P9/P14 amplitude ratio in MS patients, the latter parameter was found to be the only abnormality in 12 patients whose P9-P14 and P14-N20 IPLs were normal. Also IPLs were increased in 12 patients with normal P14 amplitudes. These results suggest that adding the P9/P14 amplitude criterion to standard IPL data might be useful to detect conduction troubles in MS patients.     

Amplitude abnormalities in the scalp far-field N18 of SSEPs to median nerve stimulation in patients with midbrain-pontine lesion.

Various amplitude ratios were measured in 20 normal controls and 36 patients with midbrain-pontine, thalamic or putaminal lesions in order to evaluate the amplitude abnormalities in scalp far-field N18 following median nerve stimulation. A study of normal controls showed that the distributions of P9/N18, P14/N18 and N18/P14 + N18 resembled a gaussian distribution and could be used as criteria for determining the decrease in N18 amplitude in each patient. There was a decrease in N18 amplitude, or the absence of N18, in patients with midbrain-pontine lesions, but not in those with thalamic or putaminal lesions. Nine amplitude ratios (P11/P9, P14/P9, N18/P9, P9/P11, P9/P14, P9/N18, N18/P14, P14/N18 and N18/P14 + N18) were compared statistically for normal controls and 3 groups of patients based on non-parametric, Wilcoxon's non-pairs and signed-rank tests. A decrease in N18 amplitude in midbrain-pontine lesion was shown by significant changes in N18/P9, P9/N18, N18/P14, P14/N18 and N18/P14 + N18, no amplitude decreases in P11 and P14 being found from the amplitude ratios of P11/P9, P9/P11, P14/P9 and P9/P14. No significant changes were seen in any of the 9 amplitude ratios when the normal controls and patients with thalamic and putaminal lesions were compared. The amplitude ratios of N18 can be used to detect a decrease in N18 amplitude in patients with midbrain-pontine lesions. The data obtained support the hypothesis that N18 originates in the midbrain-pontine region and that neither the thalamus nor thalamocortical radiation make major contributions to the formation of the N18 peak.     

Secondary holocord syringomyelia with spinal hemangioblastoma: a report of two cases

Intramedullary spinal hemangioblastoma is well known to be accompanied by syringomyelia. However, holocord secondary syringomyelia is uncommon. We present 2 cases of spinal hemangioblastoma, one in the conus medullaris and the other in midthoracic region, accompanied by holocord syrinx. In both the cases the secondary syrinx resolved following successful total tumor excision with good neurological recovery.     

Spine and scalp somatosensory evoked potentials in normal subjects and patients with spinal cord disease: evaluation of afferent transmission

Spine and scalp somatosensory evoked potentials (SEPs) to peroneal nerve stimulation were recorded from 20 normal subjects using 1 restricted and 3 open frequency filter bandpasses. Spine to spine and spine to scalp propagation velocities were calculated. Of those recording parameters investigated, optimal recordings were obtained using an open bandpass (5-1500 or 30-1500 Hz) and recording from 3 surface spine bipolar channels and 1 scalp bipolar channel. This method was then investigated in 40 patients with disease of the spinal cord and peripheral nervous system. Focal spinal cord compressive lesions generally resulted in slowing of spine to spine and spine to scalp propagation velocities. Diffuse or multifocal lesions of the spinal cord generally resulted in the absence of scalp responses. Although there was no consistent correlation of the SEP findings with the sensory exam, there was a correlation of the SEP findings with the clinical prognosis.