System diseases and visual evoked potential diagnosis in neurology: changes due to synaptic malfunction

Exploring Bottom-Up Visual Processing and Visual Hallucinations in Parkinson's Disease With Dementia

Visual hallucinations (VH) are a common symptom of Parkinson's disease with dementia (PDD), affecting up to 65% of cases. Integrative models of their etiology posit that a decline in executive control of the visuo-perceptual system is a primary mechanism of VH generation. The role of bottom-up processing in the manifestation of VH in this condition is still not clear although visual evoked potential (VEP) differences have been associated with VH at an earlier stage of PD. Here we compared the amplitude and latency pattern reversal VEPs in healthy controls (n = 21) and PDD patients (n = 34) with a range of VH severities. PDD patients showed increased N2 latency relative to controls, but no significant differences in VEP measures were found for patients reporting complex VH (CVH) (n = 17) compared to those without VH. Our VEP findings support previous reports of declining visual system physiology in PDD and some evidence of visual system differences between patients with and without VH. However, we did not replicate previous findings of a major relationship s between the integrity of the visual pathway and VH.

Visual hallucinations in Parkinson's disease: clues to separate origins

Our paper discusses two experimental studies suggesting that Visual Hallucinations (VH) in Parkinson's Disease (PD) may have separate origins. The first is a prospective 8years study evaluating the appearance of VH, visual abnormalities assessed by Visual Evoked Potentials (VEPs) and REM sleep Behaviour Disorder (RBD), in 80 PD patients treated with l-Dopa and Dopaminoagonists (DA). In chronically treated, cognitively unimpaired, PD patients VH were statistically related (p=0.001) to RBD occurrence and high DA doses. Visual abnormalities were significantly reduced by l-Dopa or DA intake, and were statistically unrelated to VH. The second study involved PD patients placed in a Virtual Reality Environment, to decontextualize visual input. When motor symptoms worsened and VEP abnormalities developed patients consistently described hallucinatory dysperceptions of the virtual environment. The two studies therefore show that VH can occur in two seemingly distinct conditions, one is related to chronic treatment and to a sleep disorder frequently observed in PD, the other is probably related to a hypodopaminergic state. Our studies support a recently proposed integrative model of VH, and show that the neural circuits purported to explain VH must include the retinal dopaminergic system and the REM sleep regulatory system.

Prolonged intracortical delay of long-latency reflexes: electrophysiological evidence for a cortical dysfunction in multiple sclerosis

Convincing evidence suggests that long-latency reflexes (LLRs) are capable of testing the transcortical sensorimotor reflex arch. By subtracting the sum of the latencies of N20 (afferent branch) and transcranially elicited motor evoked potentials (MEP; efferent branch) from the LLR II latency, the cortical relay time (CRT) can also be obtained, which is alleged to represent the time required for the cortical sensorimotor integration. The aim of the present study was to investigate if a cortical dysfunction occurs in multiple sclerosis (MS). Median nerve somatosensory evoked potentials (SEPs), MEPs and LLRs were recorded from the upper limbs of 23, not severely disabled MS patients in acute phases of the disease. Eighteen age and sex matched healthy volunteers served as controls. N20, MEP, LLR II latencies were measured, and the CRT was calculated for each limb. The statistical comparison between patients and controls was only weakly significant by taking into account conduction times along either the afferent (N20) or the efferent (MEP) pathways. On the contrary, it turned out to be considerably significant if both branches of the transcortical sensorimotor reflex arch, together with the intracortical pathway, were simultaneously tested by means of the LLRs. Moreover, the patients showed a significantly higher CRT compared with that found in the control subjects. These findings are consistent with a prolonged intracortical delay of LLRs in the MS group and suggest the occurrence of conduction velocity slowing and/or synaptic transmission impairment along the sensorimotor intracortical pathway in MS.

Auditory evoked response data reduction by PCA: development of variables sensitive to reading disability

Long latency auditory evoked responses (AER) were formed on 232 healthy normal and learning impaired subjects to tone pairs of 50 msec inter-stimulus interval (TALAER) and also to the words "tight" and "tyke" (TTAER). Both evoked potential (EP) type have been used to demonstrate differences between good readers (WIAT Basic Reading score > 115, N = 42) and poor readers (Reading score < 85, N = 42). A largely automated, hands off approach was used to reduce artifact contamination, to develop canonical measures for discriminating good from poor readers, and to predict reading scores across the entire population including intermediate (average) readers. Eye and muscle artifact were diminished by multiple regression. Substantial EP data reduction was enabled by an unrestricted use of Principal Components Analysis (PCA). For each EP type, 40 factors encompassed 70-80% of initial variance, a meaningful data reduction of about 90:1. Factor interpretation was enhanced by mapping of the factor loadings. By discriminant analysis, resulting factors predicted reading group membership with over 80% jackknifed and also split--half replication accuracy. By multiple regression, they produced a canonical variate correlating significantly (p < 0.001) with the Basic Reading score (r = 0.39). The TTAER factors were more useful than the TALAER factors. The relevance of rapid auditory processing and phonemic discrimination measurements to dyslexia is discussed.

Effects of grating spatial orientation on visual evoked potentials and contrast sensitivity in multiple sclerosis

Previous studies suggest a delay of pattern visual evoked potentials (PVEPs) in multiple sclerosis (MS) depending on grating orientation. We examined a group of 14 patients with definite MS recording PVEPs to vertical and horizontal grating and analysing latency and amplitude of P60, N70 and P100 waves. We evaluated contrast sensitivity (CS) to dark and bright bars of several spatial frequencies (SF). The aim was to evaluate the diagnostic value of evoked responses and CS in revealing involvement of cortical structures. PVEPs to 1 degrees cycle/degree (c/d) vertical bars were abnormal in 25% for P60, in 32% for N70 and in 36%, for P100; in 25%, 36% and 42% respectively at 4 c/d; as regards horizontal bars at 1 c/d we found alterations of P60, N70 and P100 in 11%, 19% and 27% respectively; at 4 c/d in 19%, 27%) and 35%. CS resulted more abnormal for vertical grating, with a maximum impairment for 3.7 c/d SF. We may conclude that the use of vertical grating in clinical routine is more reliable both for PVEPs and CS testing; in addition CS can be abnormal even with normal PVEPs: this could mean an early impairment of CS and provide useful indications about a subclinical involvement of visual cortex.

Evoked potential (EP) alterations in experimental allergic encephalomyelitis (EAE): early delays and latency reductions without plaques

Experimental allergic encephalomyelitis (EAE) in its chronic relapsing (CR-EAE), chronic progressive (CP-EAE) and acute (A-EAE) forms was obtained in 24 juvenile strain 13 guinea pigs. Visual, brainstem acoustic and somatosensory evoked potentials (EPs) were recorded in these animals prior to the sensitizing injection and during the course of the disease. Delays in the EPs appeared 15 days post-sensitization (dps), preceding or simultaneously with clinical alterations: electron microscopy revealed myelin stripping and vacuolation in the animals sacrificed 25 dps. Decreases in EP latency were recorded 32 dps; when electron microscopy revealed myelin layers indicating remyelination, whereas light microscopy showed only inflammatory changes. When confluent plaques were revealed by light microscopy 120 dps, the EP wave shapes were distorted or absent. The discussion reviews the literature on early myelin and conduction changes during central demyelination.

The duration of the movement aftereffect as an index of psychiatric illness

The duration of the movement aftereffect (MAE) has sometimes been used to make inferences about the subject's state (for example, their level of arousal). Some studies are reviewed in which visual aftereffects (including the MAE) were measured in schizophrenia, with inconsistent results. Some relevant psychopharmacological and neurological evidence is considered. It is concluded that: (i) Differences in the clinical status of the schizophrenic subjects and whether they were receiving medication, but not the method used to measure aftereffects, may underlie the interstudy disagreements. (ii) The effect of schizophrenia is to increase MAE duration, and this is not due to some peripheral artefact. (iii) Longer MAEs in the illness could result from enhanced neurally signalled contrast and/or from the increased adaptability of cortical neurons.

Short-term neurophysiological monitoring in multiple sclerosis bouts. Evaluation of steroid treatment

Visual (VEP) and brainstem auditory (BAEP) evoked potentials (EP) were recorded in 21 multiple sclerosis (MS) patients in acute relapse before and after steroid treatment. VEPs were abnormal in 14/21 patients and BAEPs in 10/21 patients before treatment. In 4 patients with acute optic neuritis (ON), an improvement of VEPs paralleled clinical evolution in 3 cases. Substantial and contrasting changes in VEPs or BAEPs, with no clinical counterpart, were related to a spontaneous fluctuation of EPs in acute relapses of MS. These changes suggest frequent subclinical (multifocal and, possibly, sequential) central nervous system involvement in MS bouts. Group analysis showed nonsignificant changes in EP parameters before and after treatment. Our results indicate that evoked potentials (EPs) are of limited value for monitoring the short-term effect of steroid treatment in MS in bouts.

Visual evoked cortical responses and electroretinograms following implantation of human fetal mesencephalon to the right caudate nucleus in Parkinson's disease

Pattern electroretinograms and visual evoked cortical responses following flash and checkerboard pattern reversal stimulation were performed in 7 patients with advanced Parkinson's disease before and after implantation of human fetal ventral mesencephalon to the head of the right caudate nucleus. Six to nine months following surgery there was bilateral enhancement of flash-evoked response amplitudes. Electroretinogram measurements were unchanged. Individual increases in amplitude and decreases in latency were seen following pattern stimulation which were not statistically significant. A relationship between change in dyskinesia, and change in checkerboard pattern stimulation amplitude at 2.4 cycles per degree suggests that amplitude effects at this stimulus frequency are mediated via altered dopaminergic receptor status in the grafted hemisphere. This may be relevant to the mechanisms leading to generalised clinical improvements following this grafting technique.

Effects of hyperglycaemia on visual evoked potentials in insulin-dependent diabetic patients

Multimodality evoked potentials frequently reveal subclinical involvement of the central nervous system in patients with insulin-dependent diabetes mellitus. We devised this study to evaluate the possible effects of acute hyperglycaemia on visual evoked potential (VEP) parameters in type 1 diabetic patients. A hyperglycaemic clamp (250 mg/dl for 180 min) was performed in ten patients. Monocular pattern reversal VEPs (check size 15', contrast 50%) were recorded before, and every 30 min after the start of the clamp. Basal VEP latencies and amplitudes were normal bilaterally in nine patients. No significant changes in pattern reversal and flash VEP parameters were observed after the induction or during the clamp period. None of the neurophysiological parameters evaluated during the test was related to the duration of the disease, the basal VEP latency or amplitude or the presence of retinopathy. Our data suggest that the neurophysiological abnormalities detected in insulin-dependent diabetic patients are due to structural involvement of the central nervous pathways and not to functional damage induced by acute short-term hyperglycaemia.

Attenuation of the early anterior negativity of median nerve somatosensory evoked potential in the MPTP-treated monkey

Median nerve somatosensory evoked potentials (SEP) were recorded in 7 Cynomolgus monkeys, before and after the administration of N-Methyl 1,4 Phenyl 1,2,3,6 tetrahydropiridine (MPTP), a neurotoxin which induces a parkinsonian syndrome in primates. Following MPTP administration, the amplitude of the negative component recorded at 15 ms over the frontal derivations (N15) decreased by 70% or more. This amplitude reduction was not modified by administration of dopamine precursors. These findings shed light on recent findings in human parkinsonian patients.

Electrophysiological analysis of factors involved in the primary demyelinating diseases: the rabbit eye model system

This study explores the longitudinal assessment of visual evoked potentials (VEPs) in the rabbit as a method for defining factors underlying functional and structural changes associated with optic neuritis and the inflammatory demyelinating diseases. In rabbits with experimental autoimmune encephalomyelitis (EAE) induced by sensitization with guinea pig spinal cord myelin, injection of lymphokines into the posterior chamber of one eye (monocular challenge) produces an early inflammatory response in the retina and optic nerve, and an alteration in the VEP, all limited to the injected eye and its projections. The earliest changes in the timing and distribution of the cortical VEP occur within hours of ocular challenge and precede histopathological evidence of structural demyelination at the light microscope level. Prechallenge assessment allows the induced monocular prechiasmal effects to be distinguished from the more diffuse electrophysiological findings associated with EAE (i.e. those due to sensitization alone). In sensitized/challenged animals there is a clear correspondence between electrophysiological and morphological measures of dysfunction at the time points sampled. These results suggest that this model system afford an excellent opportunity to examine the precise structural correlates of the early functional changes associated with the onset of inflammatory demyelination within the CNS. Furthermore, the stability of the system provides the capacity to monitor alterations over the complete course of inflammation, demyelination and remyelination, induced by experimental manipulations.

Effects of scopolamine parenteral administration on the electroretinogram, visual evoked potentials, and quantitative electroencephalogram of healthy volunteers

Single intramuscular doses of scopolamine and matching placebo were administered to young, healthy, and emmetropic volunteers. Electroretinograms and visual evoked potentials (flash and pattern stimuli) were recorded prior to and 30, 90, and 120 min after administration. The effects of scopolamine at the central nervous system level were monitored also by quantitative electroencephalographic methods. Scopolamine reduced the peak-to-peak amplitude of the late components of the flash-evoked potential without affecting latencies. A decrease of the N75 latency and increment of N175 latency of pattern-evoked potentials were observed without any apparent modification of the amplitude values. These changes were not produced by administering topical cyclopentholate. Electroencephalographic effects were apparent with a longer delay after administration than were those on the visual evoked potentials. No significant modification was observed in the electroretinogram under these recording conditions.

The use of the visual evoked potential (VEP) in delineating a state of subclinical encephalopathy. A comparison with the number connection test (NCT)

Visual evoked potential determinations and the number connection test were performed for 49 patients with stable chronic liver disease and portal hypertension but without clinical evidence of hepatic encephalopathy. The latencies of the evoked potential components N2, P2 and N3 were significantly prolonged compared to the controls. Seven patients had a prolonged N2, 10 had a prolonged P2, and 14 patients had a prolonged N3 latency. Only five of these patients had increased theta activity of the electroencephalogram. When age norms were applied, the number connection test was significantly prolonged only in the 16-36-years age group. It is concluded that the visual evoked potential identifies a group of patients with neurophysiological abnormalities and may be useful in identifying those at risk of developing overt encephalopathy.

Visual evoked cortical potentials and pattern electroretinograms in Parkinson's disease and control subjects

Parkinson's disease patients have been shown to have abnormal visually evoked cortical potentials (VEPs) to pattern stimulation. Whereas dopamine is not an important neurotransmitter in the central visual pathways, the retina is rich in dopamine and, together with previous animal and human studies, this suggests that the abnormal VEPs in Parkinson's disease patients may be due to a biochemical and electrophysiological disorder in the retina. This hypothesis has been examined by studying the VEPs and pattern electroretinogram (PERG) of Parkinson's disease patients and matched control subjects. The amplitudes of the cortical and retinal evoked potentials were significantly reduced in Parkinson's disease patients compared with the control subjects and this could not be attributed to any particular feature of the disease or its treatment. There was a significant relationship between the VEP P100 latency and the PERG amplitude. Moreover for those subjects in whom there was an interocular difference in both cortical and retinal evoked potentials, the abnormality was more commonly found in the potentials from the same eye. These findings suggest that the abnormality of the VEP in Parkinson's disease patients is, at least in part, secondary to an abnormality of the retina itself.

Visual evoked potentials in parkinsonism and dopamine blockade reveal a stimulus-dependent dopamine function in humans

VEPs were recorded with three different spatial frequencies of stimulation in patients affected by idiopathic Parkinsonism and by Parkinsonian syndromes. The detection of VEP abnormalities in Parkinson's disease was dependent on the spatial frequency of the visual stimulus (a vertical square wave grating). The VEP latency was normal in Parkinsonian syndrome patients (except in one patient affected by familial Parkinsonism). Dopamine precursor therapy differently reduced the VEP latency, depending on the spatial frequency of the visual stimulus. These findings suggest that the dopaminergic mechanism involved in the generation of VEP delays is sensitive to stimulus spatial frequency. The study of VEPs before and after the administration of haloperidol confirmed this hypothesis. VEP latency did not correlate with the major clinical symptoms of Parkinson's disease and could not predict the results of chronic dopaminergic therapy.

Multiple intracranial enterogenous cysts

The case of a 40-year-old woman with increasing ataxia is described. Although the clinical presentation and evoked response studies raised the possibility of multiple sclerosis, further investigation revealed multiple cystic intracranial lesions. Surgical excision of one of the lesions relieved the patient's symptoms. Histological examination revealed that this was an enterogenous cyst. Although single cysts of this type have rarely been reported occurring in the posterior cranial fossa, the occurrence of multiple lesions, some in the supratentorial compartment, appears to be unique.

How might demyelinating disorders and glaucoma modify synaptic function?

Latencies of visually evoked potentials (VEPs) tend to be abnormally long in multiple sclerosis (MS). Similar VEP delays are seen in glaucoma. Such delays could result in part from reduced intensities of synaptic inputs at post-retinal synaptic relays, and defects of axoplasmic transport might be one cause for this. The effective rate of synaptic activation of a given postsynaptic neuron can be decreased either by reducing the arrival-rate of presynaptic action potentials (e.g., by complete or partial blockage of conduction in some presynaptic axons), or by reducing the quantity of neurotransmitter released per action potential (e.g., as a consequence of presynaptic neurotransmitter depletion). It is proposed that in both glaucoma and MS, delayed VEPs may result from either or both of these mechanisms. Firstly, loss and functional impairment of optic nerve axons occurs in each disorder. Secondly, in glaucoma the increased intraocular pressure tends to block the rapid anterograde axoplasmic transport (RAAT) which brings neurotransmitter supplies to the axon terminals. This could result in neurotransmitter depletion in the lateral geniculate relay, decreased synaptic effectiveness of remaining normally-conducting optic nerve axons, and thereby increased VEP latencies. RAAT is also blocked by demyelinated lesions that have been produced experimentally by injection of diphtheria toxin. If it is impaired by the demyelinated plaques of multiple sclerosis, then VEP slowing by a similar presynaptic depletion mechanism could ensue.

Pattern-reversal visual evoked potential in a case of nitrous oxide abuse and recovery

Pattern reversal visual evoked potentials were recorded in a dentist who had abused nitrous oxide while he showed neurologic impairment and during recovery. The latency of the major positive peak (P100) remained constant during both phases. However, the amplitude of this peak was markedly reduced during the stage of neurologic involvement, and increased during recovery after withdrawal. The clinical significance of this is discussed.

Visual evoked potential: a diagnostic tool for the assessment of hepatic encephalopathy

Visual evoked potential recordings were examined in 45 liver cirrhosis patients with (n = 29) and without (n = 16) encephalopathy, in 15 normal volunteers, and in one patient with an opioid induced stupor state. Visual evoked potential parameters were classified on the basis of EEG recordings. Plasma concentrations of amino acids, octopamine, and ammonia were assayed in order to document the metabolic change of hepatic encephalopathy. Latencies and wave patterns recorded after flash stimulation differentiated the four degrees of the coma one from another according to EEG classification in the 29 patients with encephalopathy. In the group of 16 patients without clinical and EEG evidence of encephalopathy the visual potential recordings discriminated a group of patients (n = 10) in a preclinical stage of encephalopathy. Biochemical parameters and subsequent clinical observation of patients confirmed our judgement of a preclinical stage of encephalopathy. These results suggest that visual evoked potentials are a simple, suitable and objective method for differentiating the degrees of encephalopathy and for identifying the preclinical stage of encephalopathy.

The effect of contrast and spatial frequency on the visual evoked potential of the hooded rat

Transient and steady-state visual evoked potentials, obtained with counterphase modulated grating patterns, were recorded through chronically implanted electrodes in lightly anesthetized and unanesthetized hooded rats. As a function of spatial frequency, the latency of the major positive wave (P1) of the transient VEP was minimal with a 0.1 cycles per degree (cpd) grating as stimulus. The amplitude of the P1-N2 component remained constant from 0.04 to 0.20 cpd and then decreased with higher spatial frequencies. The function relating amplitude of steady-state VEP to spatial frequency at high contrast depended on temporal frequency: It had a band-pass form at 5.0 Hz and a low-pass form at 8.4 Hz. As a function of contrast, the latency of the P1 wave linearly decreased and its amplitude increased with increments of contrast up to 55%. The contrast function of the amplitude of the second harmonic of the steady-state VEP (8.4 Hz) showed two linear segments: one for low contrasts with a shallow slope and one for high contrasts with a steep slope, suggesting two distinct contrast mechanisms.