Visual evoked potentials, intracranial pressure and ventricular size in hydrocephalus

Clinical electrophysiology of the optic nerve and retinal ganglion cells

Clinical electrophysiological assessment of optic nerve and retinal ganglion cell function can be performed using the Pattern Electroretinogram (PERG), Visual Evoked Potential (VEP) and the Photopic Negative Response (PhNR) amongst other more specialised techniques. In this review, we describe these electrophysiological techniques and their application in diseases affecting the optic nerve and retinal ganglion cells with the exception of glaucoma. The disease groups discussed include hereditary, compressive, toxic/nutritional, traumatic, vascular, inflammatory and intracranial causes for optic nerve or retinal ganglion cell dysfunction. The benefits of objective, electrophysiological measurement of the retinal ganglion cells and optic nerve are discussed, as are their applications in clinical diagnosis of disease, determining prognosis, monitoring progression and response to novel therapies.

Visual evoked potentials show strong positive association with intracranial pressure in patients with cryptococcal meningitis

OBJECTIVE

To verify the relationship between intracranial pressure and flash visual evoked potentials (F-VEP) in patients with cryptococcal meningitis. Method The sample included adults diagnosed with cryptococcal meningitis admitted at a reference hospital for infectious diseases. The patients were subjected to F-VEP tests shortly before lumbar puncture. The Pearson’s linear correlation coefficient was calculated and the linear regression analysis was performed.

RESULTS

Eighteen individuals were subjected to a total of 69 lumbar punctures preceded by F-VEP tests. At the first lumbar puncture performed in each patient, N2 latency exhibited a strong positive correlation with intracranial pressure (r = 0.83; CI = 0.60 - 0.94; p < 0.0001). The direction of this relationship was maintained in subsequent punctures.

CONCLUSION

The intracranial pressure measured by spinal tap manometry showed strong positive association with the N2 latency F-VEP in patients with cryptococcal meningitis.

Flash visual evoked potentials are unreliable as markers of ICP due to high variability in normal subjects

BACKGROUND

Previous publications have suggested a high correlation between flash visual evoked potential (F-VEP) N2 peak latency and intracranial pressure. This would enable F-VEP to be used as a non-invasive and inexpensive method to estimate ICP in a number of settings. However, basic knowledge about variability across subjects and test-retest properties of the F-VEP is lacking.

METHODS

Fifteen healthy adult subjects were tested on three different occasions. F-VEP responses were recorded using international standards.

FINDINGS

For the tested population, mean N2 latency was 65.7 ms (SD 10.7 ms) and the range was 48-110 ms. Intra-individual variability was high, in four of the 15 subjects more than 15 ms between testing sessions. The same was found for P2 latency and for N2 and P2 amplitudes. The response waveform was very variable and unambiguous marking of peaks was often difficult. One out of the 15 subjects had a very poorly developed F-VEP response, but a normal pattern-reversal VEP response.

CONCLUSIONS

F-VEP has a wide range of latency, amplitude and waveform across normal subjects. A large proportion of subjects also had a high intra-individual variability over time. This variability makes F-VEPs unreliable as a marker for intracranial pressure, and caution in interpreting F-VEP changes in clinical work is advised.

Neuropathology and structural changes in hydrocephalus

In the context of spina bifida, hydrocephalus is usually caused by crowding of the posterior fossa with obstruction to cerebrospinal fluid flow from the forth ventricle, and less often by malformation of the cerebral aqueduct. Enlargement of the cerebral ventricles causes gradual destruction of periventricular white matter axons. Motor, sensory, visual, and memory systems may be disturbed through involvement of the long projection axons, periventricular structures including the corpus callosum, and the fimbria-fornix pathway. Secondary changes occur in neuronal cell bodies and synapses, but there is minimal death of neurons. The clinical syndrome of hydrocephalic brain dysfunction is thus due to subcortical disconnection. Some of the brain dysfunction is reversible by shunting, probably through restoration of cerebral blood flow and normalization of the extracellular environment. However, destroyed axons cannot be restored.

The light-flash-evoked response as a possible indicator of increased intracranial pressure in hydrocephalus

Surgical treatment of infantile hydrocephalus by shunt implantation may result in suboptimal intracranial pressure. Major neurological impairments and death are usually prevented by shunt treatment, but minor sequelae may persist or develop. The introduction of adjustable shunts has improved the possibilities of optimizing shunt function and minimizing the risk of such impairments. However, it is still impossible to determine the intracranial pressure without invasive measurements. Clinical findings and procedures such as computed tomography (CT) are not always enough to allow a conclusion as to whether a child's signs and symptoms are the result of suboptimal intracranial pressure (shunt dysfunction) or are of another etiology. With the aim of reducing the number of invasive pressure measurements and CT scans, we investigated the effect of increased intracranial pressure on the visual evoked response (VER). Binocular light flash stimuli of supramaximal intensity were used and VER recordings were performed from Oz and Cz. The VER results from a group of 31 infants and children with hydrocephalus and 2 children with pseudotumor cerebri were compared with responses from a control group of 35 healthy children. The results show that a subpotential, P' (P-prime), usually just preceding P1 (P100), had an increased latency ( > 96 ms) in all hydrocephalic children before surgery. The P' latency in this group was usually even above 110 ms. The latencies of other VER potentials were also increased but not as consistently as P'. After surgical intervention the VER latencies decreased and usually normalized. The P' latency in four children in the control group was just above the borderline latency, but was less than 110 ms.(ABSTRACT TRUNCATED AT 250 WORDS)

Visual evoked responses as a monitor of intracranial pressure during hyperosmolar blood-brain barrier disruption

Intracarotid mannitol (HBBBD = hyperosmotic BBB disruption) as a method of transiently increasing solute/drug delivery to brain parenchyma has been associated in animals with a 1-2% increase in brain water and an increase in cisternal ICP. To determine whether these changes are clinically significant, we investigated ICP changes associated with HBBBD in 33 patients with malignant brain tumor utilizing flash VERs in which the N2 latency correlates well with ICP (N2 > 80 ms linearly corresponds to ICP > 20 cm H2O). VERs were obtained prior to, 4 and 24 h after 114 HBBBD/chemotherapy procedures. Additionally, in 10 patients (37 HBBBDs), VER monitoring was performed during the procedure. In 112/150 (75%) HBBBDs, good barrier opening was obtained (radionuclide brain scan). Postoperative mean N2 latencies did not differ significantly from pre-HBBBD values (N2 = 86 +/- 3.3 pre, 90 +/- 3.0/4 h, 87 +/- 3.6/24 h); there was no significant difference in N2 latencies in those patients with good vs poor BBBD. In the 10 patients monitored during HBBBD, peak N2 latency = 94.9 +/- 1.6, however, was significantly above pre- and post-HBBBD values (p < 0.04). We conclude that flash VERs are a useful noninvasive measure of ICP, and that HBBBD is associated with mild transient increase in ICP which is not clinically detrimental.

Automated evoked potential monitoring

We have developed a computer system for use in the operating room and intensive care unit for the automated acquisition and classification of flash evoked potentials. The project goals were to: (1) acquire evoked potentials without user intervention; (2) recognize, label, and trend important parameters; and (3) alarm if parameters deviate too far from normal. The system consists of a Nicolet Pathfinder, programmed for periodic flash visual evoked potential acquisition and a personal computer for analysis. Analysis software utilizes the C+ +language. The system has been tested on sixteen cases, determinations of specific waveforms were validated ex post facto by two experts. Three parameters in each of three channels were correctly recognized in more than 87% of all waveforms acquired. No signals at all were obtained in only 0.8% of all samples.

Visual and auditory evoked potential correlates of cerebral malformations

To date there are no systematic studies of the evoked potential correlates of cerebral malformations. A total of 109 sensory evoked potential studies (20 ERGs, 61 VEPs and 28 ABRs) were performed in 27 children with defined cerebral malformations. Diagnoses were confirmed by CT scan, supplemented by MRI, cranial ultrasound, or neuropathological examination. Sensory evoked potential studies were abnormal in over half of patients studied, but the VEP was unable to identify or distinguish specific supratentorial cerebral malformations. ABR abnormalities were documented in cases of holoprosencephaly, lissencephaly, pachygyria and generalized megalencephaly. ABR abnormalities were not observed in septo-optic dysplasia or focal dysplasia of the cerebral cortex. We conclude that evoked potentials are not a diagnostic criterion of severe dysplasias, but rather serve as a supplementary tool for detecting the variable associated abnormalities of brain development that may affect visual and central auditory pathways or their cerebral cortical or brainstem targets.