Utility and Uncertainties of Evoked Potential Monitoring in the Intensive Care Unit

  • F. Mauguière
  • L. Garcia Larrea
  • O. Bertrand


Patients admitted to a neurological intensive care unit (ICU) often undergo sudden variations of their homeostasis which may lead to important changes in their clinical status and probability of survival. Up to now most studies aimed at evaluating the prognostic significance of single or daily recordings of early somatosensory (SEPs) or brainstem auditory (BAEPs) evoked potentials in coma. Electrophysiological assessment of comatose patients with EP techniques is peculiarly needed in head-injured patients receiving continuous infusions of short-acting barbiturates which modify brainstem reflexes and EEG activity with little or no effect on early SEPs or BAEPs14, 20, 31, 32, 42, 45, 46 A finding common to most of these investigations was that outcome is invariably poor in comatose patients with abnormal BAEP waves or bilateral absence of the contralateral parietal N 20 evoked by median nerve stimulation6, 9, 17, 18, 27, 29, 36, 38, 39, 47, 51. However, several investigators have pointed out that in many cases the information provided by a single EP recording might not be of prognostic significance in the ICU setting, especially when responses are normals 1, 9, 11, 39. This statement is illustrated by our SEP data. from a series of 53 comatose patients (Glasgow score < 7) as shown in Table 1. This table shows that a poor outcome is to be expected when the contralateral N 20 component of the SEP is absent bilaterally after stimulation of the median nerve; but it also demonstrates that a poor outcome may occur in patients with normal N 20 on both sides.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Anderson DC, Scott B, Rockswold GL (1984) Multimodality evoked potentials in closed head trauma. Arch Neurol 41: 369–374PubMedCrossRefGoogle Scholar
  2. 2.
    Artru F, Jourdan C, Ferry M, Montarry M, Roche P, Deleuze R (1986) Protection cérébrale par perfusion continue de lidocaine. In: Les Comas (Soc de réanimation de Langue Française Bruxelles, May 29th-31st), pp 75–79Google Scholar
  3. 3.
    Bertrand O, Garcia Larrea L, Artru F, Mauguière F, Pernier J (1987) Brainstem monitoring: a system for high rate BAEP sequential monitoring and feature extraction. Electroencephalogr Clin Neurophysiol 68: 433–445PubMedCrossRefGoogle Scholar
  4. 4.
    Bobbin RP, May JG, Lemoine RL (1979) Effects of pentobarbital and ketamine on brain-stem auditory potentials. Arch Otolaryngol 105: 467–470PubMedCrossRefGoogle Scholar
  5. 5.
    Boston JR, Deneault LG (1984) Sensory evoked potentials: a system for clinical testing and patient monitoring. Int J Clin Monitoring and Computing 1: 1319CrossRefGoogle Scholar
  6. 6.
    Brewer CC, Resnick DM (1984) The value of BAEPs in assessment of the comatose patient. In: Nodar RH, Barber C (eds) Evoked potentials II. Butterworths Publishers, Boston, pp 578–581Google Scholar
  7. 7.
    Brodal A (1969) Neurological anatomy. Oxford University Press, New York London TorontoGoogle Scholar
  8. 8.
    Brunko E, Delecluse F, Herbaut AG, Levivier M, Zegers de Beyl D (1985) Unusual pattern of somatosensory and brain-stem auditory evoked potentials after cardio-respiratory arrest. Electroencephalogr Clin Neurophysiol 62: 338342Google Scholar
  9. 9.
    Cant BR, Hume AL, Judson JA, Shaw NA (1986) The assessment of severe head injury by short latency somatosensory and brain-stem auditory evoked potentials. Electroencephalogr Clin Neurophysiol 65: 188–195PubMedCrossRefGoogle Scholar
  10. 10.
    Chiappa KH (1982) Brainstem auditory evoked potentials in clinical neurology. In: Courjon J, Mauguière F, Revol F (eds) Clinical applications of evoked potentials in neurology. Raven Press, New York, pp 169–175Google Scholar
  11. 11.
    Chiappa KH (1983) Brainstem auditory evoked potentials. Interpretation. In: Evoked potentials in clinical medicine. Raven Press, New York, pp 145–189Google Scholar
  12. 12.
    Desmedt JE (1962) Auditory evoked potentials from cochlea to cortex as interferenced by activation of the efferent olivo-cochlear bundle. J Acoust Soc Am 1478–1496Google Scholar
  13. 13.
    Doyle DJ (1975) Some comments on the use of Wiener filtering for the estimation of evoked potentials. Electroencephalogr Clin Neurophysiol 38: 533534Google Scholar
  14. 14.
    Drummond JC, Todd MM, U HS (1985) The effect of high dose sodium thiopental on brain stem auditory and median nerve somatosensory evoked responses in humans. Anesthesiology 63: 249–254PubMedCrossRefGoogle Scholar
  15. 15.
    Fischer C, Blanc A, Mauguière F, Courjon J (1981) Apport des potentiels évoqués auditifs précoces au diagnostic neurologique. Rev Neurol 137: 229240Google Scholar
  16. 16.
    Fisher C, Mauguière F, Echallier JF, Tommasi M, Courjon J (1982) Brainstem acoustic evoked potentials in vascular and tumoral lesions of the brainstem. In: Courjon J, Mauguière F, Revol F (eds) Clinical applications of evoked potentials in neurology. Raven Press, New York, 32, pp 177–186Google Scholar
  17. 17.
    Facco E, Martini A, Zuccarello M, Agnoletto M, Giron GP (1985) Is the Auditory Brainstem Response (ABR) effective in the assessment coma? Electroencephalogr Clin Neurophysiol 62: 332–337PubMedCrossRefGoogle Scholar
  18. 18.
    Goldie WD, Chiappa KH, Young RR, Brooks EB (1981) Brainstem auditory and short-latency somatosensory evoked responses in brain death. Neurology 31: 248–256PubMedCrossRefGoogle Scholar
  19. 19.
    Hacke W (1985) Neuromonitoring. J Neurol 232: 125–133PubMedCrossRefGoogle Scholar
  20. 20.
    Hall JW (1985) The effects of high-dose barbiturates on the acoustic reflex and auditory evoked responses. Acta Otolaryngol 100: 387–398PubMedCrossRefGoogle Scholar
  21. 21.
    Hall JW, Mackey-Hargadine JR, Kim EE (1985) Auditory brainstem responses in determination of brain death. Arch Otolaryngol 111: 613–620PubMedCrossRefGoogle Scholar
  22. 22.
    House JW, Brackmann DE (1979) Brainstem audiometry in neurotologic diagnosis. Arch Otolaryngol 105: 305–309PubMedCrossRefGoogle Scholar
  23. 23.
    Javel E, Mouney DF, McGee JA, Walsh EJ (1982) Auditory brainstem responses during systemic infusion of lidocaine. Arch Otolaryngol 108: 71–76PubMedCrossRefGoogle Scholar
  24. 24.
    Jewett DL, Romano MA, Williston JS (1970) Human auditory evoked potentials. Possible brainstem components detected on the scalp. Science 167: 1517–1518Google Scholar
  25. 25.
    Jones TA, Weidner WJ (1986) Effects of temperature and elevated intracranial pressure on peripheral and brainstem auditory responses in dogs. Exp Neurol 92: 1–12PubMedCrossRefGoogle Scholar
  26. 26.
    Kaga K, Takamori A, Mizutani T, Nagai T, Marsh RR (1985) The auditory pathology of brain death as revealed by auditory evoked potentials. Ann Neurol 18: 360–364PubMedCrossRefGoogle Scholar
  27. 27.
    Kallwellis G, Roder H, Rabending G (1980) Auditory evoked brainstem potentials in patients in coma and brain death. Electroencephalogr Clin Neurophysiol 50: 100 PGoogle Scholar
  28. 28.
    Karnaze DS, Weiner JM, Marshall LF (1985) Auditory evoked potentials in coma after closed head injury. A clinical-neurophysiological coma scale for predicting outcome. Neurology 35: 1122–1126Google Scholar
  29. 29.
    Lindsay KW, Carlin J, Kennedy I, Fry J, McInnes A, Teasdale GM (1981) Evoked potentials in severe head injury. Analysis and relation to outcome. J Neurol Neurosurg Psychiatry 44: 796–802Google Scholar
  30. 30.
    Maresch H, Pfurtscheller G (1983) Simultaneous measurement of auditory brainstem potentials and EEG spectra. Electroencephalogr Clin Neurophysiol 56: 531–533PubMedCrossRefGoogle Scholar
  31. 31.
    Mauguière F (1982) Brainstem auditory and short-latency somatosensory evoked responses in coma and brain death. In: Touraine JL, Traeger J (eds) Transplantation and clinical immunology. Excerpta Medica, Amsterdam, 14, pp 238–250Google Scholar
  32. 32.
    Mauguière F, Grand C, Fischer C, Courjon J (1982) Aspects des potentiels évoqués auditifs et somésthésiques précoces dans les comas neurologiques et la mort cérébrale. Rev EEG Neurophysiol 12: 280–286Google Scholar
  33. 33.
    Maynard DE, Jenkinson JL (1984) The cerebral function analyzing monitor. Anesthesia 39: 678–690CrossRefGoogle Scholar
  34. 34.
    Nagao S, Roccaforte P, Moody RA (1979) Acute intracranial hypertension and auditory brainstem responses (parts I and II). J Neurosurg 51: 669–676PubMedCrossRefGoogle Scholar
  35. 35.
    Nagata K, Tazawa T, Mizukami M, Araki G (1984) Applications of brainstem auditory evoked potentials to evaluation of cerebral herniation. In: Nodar RH, Barber C (eds) Evoked potentials II. Butterworths Publishers, Boston, pp 183–193Google Scholar
  36. 36.
    Ottaviani F, Almadori G, Calderazzo AB, Frenguelli A, Paludetti G (1986) Auditory brain-stem and middle-latency auditory responses in the prognosis of severely head-injuries patients. Electroencephalogr Clin Neurophysiol 65: 196–202PubMedCrossRefGoogle Scholar
  37. 37.
    Prichep LS, John ER, Ransohoff J, Cohen N, Benjamin V, Ahn H (1985) Real-time intraoperative monitoring of cranial nerves VII and VIII during posterior fossa surgery. In: Morocutti C, Rizzo PA (eds) Evoked potentials: neurophysiological and clinical aspects. Elsevier, Amsterdam, pp 193–202Google Scholar
  38. 38.
    Rosenberg C, Wogensen K, Starr A (1984) Auditory brainstem and middle and long-latency evoked potentials in coma. Arch Neurol 41: 835–838PubMedCrossRefGoogle Scholar
  39. 39.
    Seales DM, Rossiter VS, Weinstein ME (1979) Brainstem auditory evoked responses in patients comatose as a result of blunt head trauma. J Trauma 19: 347–352PubMedCrossRefGoogle Scholar
  40. 40.
    Sohmer H, Gafni M, Havatselet G (1984) Persistence of auditory nerve response and absence of brain-stem response in severe cerebral ischemia. Electroencephalogr Clin Neurophysiol 58: 66–72CrossRefGoogle Scholar
  41. 41.
    Starr A (1976) Auditory brainstem responses in brain death. Brain 99: 543554Google Scholar
  42. 42.
    Starr A, Achor J (1975) Auditory brainstem responses in neurological disease. Arch Neurol 32: 761–768PubMedCrossRefGoogle Scholar
  43. 43.
    Starr A, Hamilton AE (1976) Correlation between confirmed sites of neurological lesions and abnormalities of far-field auditory responses. Electroencephalogr Clin Neurophysiol 41: 595–608PubMedCrossRefGoogle Scholar
  44. 44.
    Stockard JJ, Rossiter VS (1977) Clinical and pathological correlates of brainstem auditory response abnormalities. Neurology 27: 316–325PubMedCrossRefGoogle Scholar
  45. 45.
    Stockard JJ, Stockard JE, Sharbourgh FW (1980) Brainstem auditory evoked potentials in neurology: Methodology, interpretation, clinical application. In: Aminoff MJ (ed) Electrodiagnosis in clinical neurology. Churchill-Livingstone, New York, pp 370–413Google Scholar
  46. 46.
    Sutton LN, Frewen T, Marsh R, Jaggi J, Bruce DA (1982) The effects of deep barbiturate coma on multimodality evoked potentials. J Neurosurg 57: 178–185PubMedCrossRefGoogle Scholar
  47. 47.
    Tsubokawa T, Nishimoto H, Yamamoto T, Kitamura M, Katayama Y, Moriyasu N (1980) Assessment of brainstem damage by the auditory brainstem response in acute severe head injury. J Neurol Neurosurg Psychiatry 43: 1005–1011PubMedCentralPubMedCrossRefGoogle Scholar
  48. 48.
    Uziel A, Benezech J (1978) Auditory brainstem responses in comatose patients: Relationship with brainstem reflexes and levels of coma. Electroencephalogr Clin Neurophysiol 45: 515–524Google Scholar
  49. 49.
    Walter DO (1969) “A posteriori” Wiener filtering of average evoked responses. Electroencephalogr Clin Neurophysiol [Suppl] 27: 61–70Google Scholar
  50. 50.
    De Weerd JPC, Martens WLJ (1978) Theory and practice of “a posteriori” Wiener filtering of average evoked potentials. Biol Cybernetics 30: 81–94CrossRefGoogle Scholar
  51. 51.
    De Weerd AW, Groeneveld C (1985) The use of evoked potentials in the management of patients with severe cerebral trauma. Acta Neurol Scand 72: 489–494PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Wien 1988

Authors and Affiliations

  • F. Mauguière
    • 1
  • L. Garcia Larrea
    • 1
  • O. Bertrand
    • 2
  1. 1.EEG Department, Hõpital NeurologiqueLyonFrance
  2. 2.INSERM Unité 280LyonFrance

Personalised recommendations