Avaliação neurofisiológica por potenciais evocados sensoriais multimodais em pacientes em coma: aspectos gerais

Luccas, Francisco J. C.; Lopes, José A.; Plastino, Félix R. T.; Knobel, Elias

doi:10.1590/S0004-282X1990000300009

Resumos

Potenciais evocados sensorials (PES) são analisados pelos autores, apoiados em experiência de mais de 6 anos. É conceituado o método, orientando a obtenção à beira do leito, em UTI, em pacientes em coma. Analisa-se a execução do PE visual por flash (PEV-F), PE auditivo de tronco cerebral (PEA-TC) e PE sômato-sensitivo de nervo mediano (PESS-M), propondo-se classificação dos achados principais. É discutido o valor diagnóstico dos PES em pacientes em coma, principalmente na avaliação neurofisiológica do nível de comprometimento do sistema nervoso, cruzando-se informações obtidas por via horizontal (PEV-F), vertical (PESS-M) e do tronco cerebral (PEA-TC). Os PES podem colaborar no diagnóstico de morte encefálica e na detecção de alterações específicas a cada via. É ressaltado o valor prognóstico dos PES, em especial do PESS-M. PEA-TC anormal implica em mau prognóstico e, se normal, depende-se dos outros PE; PESS-M normal ou apenas levemente alterado indica bom prognóstico; PESS-M com ausência bilateral de componentes tálamo-corticais denuncia mau prognóstico. O PEV-F mostra comportamento similar ao do PESS-M.

Noninvasive sensory evoked potentials (SEP) performed at bedside in the Intensive Care Unit for patients in coma can be helpful in establishing both a diagnosis and a prognosis. Based on a more than 6-year experience on this subject, the authors discuss general aspects concerning these EP, their probable known generators, and propose a classification depicting different aspects observed for flash visual EP (F-VEP), brainstem auditory EP (BAEP), and median nerve somato-sensory EP (SSEP). Isolatedly, SSEP shows the best diagnostic and prognostic performance, Nevertheless, the authors consider that multimodality SEP are even better than any isolated EP study; cross-correlating information generated through a horizontal (F-VEP), a vertical (SSEP), and a pathway focusing brainstem in greater detail (BAEP) allows the neurophysiological establishment of the level of lesion in the CNS from a better perspective; besides, SEP can help setting the diagnosis of brain (encephalic) death, and the diagnosis of particular problems concerning each pathway. Notwithstanding, most important is prognosis definition, and the findings are summarized. Abnormal BAEP implies bad prognosis, as would be expected considering the severity of a brainstem lesion; on the other hand, a normal BAEP per se does not allow a precise definition, resting on other EP the role prognosis characterization. SSEP if bilaterally normal or only mildly abnormal imply good prognosis; bilateral absence of SSEP thalamocortical components has always carried a bad prognosis, since younger patients may at best evolve into a persistent vegetative state; SSEP intermediary results are more often accompanied by variable evolution. FVEP results parallel those of SSEP.

Avaliação neurofisiológica por potenciais evocados sensoriais multimodais em pacientes em coma aspectos gerais

Neurophysiological evaluation of patients in coma through multimodality sensory evoked potentials: general aspects.

Francisco J. C. Luccas^I; José A. Lopes^I; Félix R. T. Plastino^II; Elias Knobel^II

^IServiço de Neurofisiologia Clínica (SNFC) - Hospital Israelita Albert Einstein (HIAE)

^IIUnidade de Terapia Intensiva (UTI) - Hospital Israelita Albert Einstein (HIAE)

RESUMO

Potenciais evocados sensorials (PES) são analisados pelos autores, apoiados em experiência de mais de 6 anos. É conceituado o método, orientando a obtenção à beira do leito, em UTI, em pacientes em coma. Analisa-se a execução do PE visual por flash (PEV-F), PE auditivo de tronco cerebral (PEA-TC) e PE sômato-sensitivo de nervo mediano (PESS-M), propondo-se classificação dos achados principais. É discutido o valor diagnóstico dos PES em pacientes em coma, principalmente na avaliação neurofisiológica do nível de comprometimento do sistema nervoso, cruzando-se informações obtidas por via horizontal (PEV-F), vertical (PESS-M) e do tronco cerebral (PEA-TC). Os PES podem colaborar no diagnóstico de morte encefálica e na detecção de alterações específicas a cada via. É ressaltado o valor prognóstico dos PES, em especial do PESS-M. PEA-TC anormal implica em mau prognóstico e, se normal, depende-se dos outros PE; PESS-M normal ou apenas levemente alterado indica bom prognóstico; PESS-M com ausência bilateral de componentes tálamo-corticais denuncia mau prognóstico. O PEV-F mostra comportamento similar ao do PESS-M.

SUMMARY

Noninvasive sensory evoked potentials (SEP) performed at bedside in the Intensive Care Unit for patients in coma can be helpful in establishing both a diagnosis and a prognosis. Based on a more than 6-year experience on this subject, the authors discuss general aspects concerning these EP, their probable known generators, and propose a classification depicting different aspects observed for flash visual EP (F-VEP), brainstem auditory EP (BAEP), and median nerve somato-sensory EP (SSEP). Isolatedly, SSEP shows the best diagnostic and prognostic performance, Nevertheless, the authors consider that multimodality SEP are even better than any isolated EP study; cross-correlating information generated through a horizontal (F-VEP), a vertical (SSEP), and a pathway focusing brainstem in greater detail (BAEP) allows the neurophysiological establishment of the level of lesion in the CNS from a better perspective; besides, SEP can help setting the diagnosis of brain (encephalic) death, and the diagnosis of particular problems concerning each pathway. Notwithstanding, most important is prognosis definition, and the findings are summarized. Abnormal BAEP implies bad prognosis, as would be expected considering the severity of a brainstem lesion; on the other hand, a normal BAEP per se does not allow a precise definition, resting on other EP the role prognosis characterization. SSEP if bilaterally normal or only mildly abnormal imply good prognosis; bilateral absence of SSEP thalamocortical components has always carried a bad prognosis, since younger patients may at best evolve into a persistent vegetative state; SSEP intermediary results are more often accompanied by variable evolution. FVEP results parallel those of SSEP.

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REFERÊNCIAS

1 Belsh JM, Chokroverty S - Short-latency somatosensory svoked. potentials in brain-dead patients. Electroenceph Clin Neurophysiol 68:75, 1987.

2. Bird TD, Plum F - Recovery from barbiturate overdose coma with a prolonged isoeletric electroencephalogram. Neurology 18:456, 1968.

3. Bolton CF, Gilbert JJ, Hahn AF, Sibbald WJ - Polyneuropathy in critically ill patients. J Neurol Neurosurg Psychiat 47:1223, 1984.

4. Desmedt JE, Cheron G - Prevertebral (oesophageal) recording of subcortical somatosensory evoked potentials in man: the spinal P13 component and the dual nature of the spinal generators. Electroenceph Clin Neurophysiol 52:257, 1981.

5. Eisen A, Purves S, Hoirch M - Central nervous system amplification: its potential in the diagnosis of early multiple sclerosis. Neurology 32:359, 1982.

6. Ferbert A, Buchner A, Ringelstein EB, Hacke W - Isolated brainstem death: case report with demonstration of preserved visual evoked potentials (VEPs). Electroenceph Clin Neurophysiol 65:157, 1985.

7. Goitein KJ, Fainmesser P, Sohmer H - Cerebral perfusion pressure and auditory brain-stem responses in childhood CNS diseases. Am J Dis Child 137:777, 1983.

8. Goldie WD, Chiappa KH, Young RR, Brooks EB - Brainstem auditory and short-latency somatosensory evoked responses in brain death. Neurology 31:248, 1981.

9. Greenberg RP, Mayer DJ, Becker DP, Douglas Miller J - Evaluation of brain function in severe human head trauma with multimodality evoked potentials: I. Evoked brain-injury potentials, methods and analysis. J Neurosurg 47:150, 1977.

10. Guerit JM, Mahieu P, Meulders M, Tremouroux J - Visual and brainstem evoked potentials in comatose patients. Proc Symposium Intensive Care and Emergency Medicine. Brussels, 1981, 43 a-d.

11. Hansotia PL - Persistent vegetative state: review and report of electrodiagnostic studies in eight cases. Arch Neurol 42:1048, 1985.

12. Hume AL, Cant BR, Shaw NA - Central somatosensory conduction time in comatose patients. Ann Neurol 5:379, 1979.

13. Luccas FJC, Manzano GM, Ragazzo PC - Potencial evocado: generalidades. Arq Bras Neurocir 2:65, 1983.

14. Luccas FJC, Manzano GM, Ragazzo PC - Potencial evocado auditivo de tronco cerebral: estudo normativo. Arq Bras Neurocir 2:71, 1983.

15. Moller AR, Jannetta PJ, Burgess JE - Neural generators of the somatosensory evoked potentials: recording from the cuneate nucleus in man and monkeys. Electroenceph Clin Neurophysiol 65:241, 1986.

16. Regan D, Regal DM, Tibbies JAR - Evoked potentials during recovery from blindness recorded serially from an infant and his normally sighted twin. Electroenceph Clin Neurophysiol 54:465, 1982

17. Reilly EL, Kondo C, Brunberg JA, Doty DB - Evoked potentials during hypothermia and prolonged circulatory arrest. Electroenceph Clin Neuropsysiol 45:100, 1978.

18. Ropper AH, Miller DC - Acute traumatic midbrain hemorrhage. Ann Neurol 18:80, 1985.

19. Slimp JC, Tamas LB, Stolov WC, Wyler AR - Somatosensory evoked potentials after removal of somatosensory cortex in man. Electroenceph Clin Neurophysiol 65:111, 1986.

20. Spehlman R - Evoked Potential Primer. Butterworth, Boston, 1985, pg 400.

21. Starr A - Auditory brain-stem responses in brain death. Brain 99:543, 1976.

22. Trojaborg W, Jorgensen EO - Evoked cortical potentials in patients with isoeletric EEGs. Electroenceph Clin Neurophysiol 35:301, 1973.

23. Whyte HE, Taylor MJ, Menzies R, Chin KC, MacMillan LJ - Prognostic utility of visual evoked potentials in term asphyxiated neonates. Pediatr Neurol 2:220, 1986.

Dr. Francisco J, C. Luccas - Hospital Israelita Albert Einstein - Av. Albert Einstein 627 -05652São Paulo SP - Brasil.

1 Belsh JM, Chokroverty S - Short-latency somatosensory svoked. potentials in brain-dead patients. Electroenceph Clin Neurophysiol 68:75, 1987.
2. Bird TD, Plum F - Recovery from barbiturate overdose coma with a prolonged isoeletric electroencephalogram. Neurology 18:456, 1968.
3. Bolton CF, Gilbert JJ, Hahn AF, Sibbald WJ - Polyneuropathy in critically ill patients. J Neurol Neurosurg Psychiat 47:1223, 1984.
4. Desmedt JE, Cheron G - Prevertebral (oesophageal) recording of subcortical somatosensory evoked potentials in man: the spinal P13 component and the dual nature of the spinal generators. Electroenceph Clin Neurophysiol 52:257, 1981.
⁵
Eisen A, Purves S, Hoirch M - Central nervous system amplification: its potential in the diagnosis of early multiple sclerosis. Neurology 32:359, 1982.
6. Ferbert A, Buchner A, Ringelstein EB, Hacke W - Isolated brainstem death: case report with demonstration of preserved visual evoked potentials (VEPs). Electroenceph Clin Neurophysiol 65:157, 1985.
⁷
Goitein KJ, Fainmesser P, Sohmer H - Cerebral perfusion pressure and auditory brain-stem responses in childhood CNS diseases. Am J Dis Child 137:777, 1983.
8. Goldie WD, Chiappa KH, Young RR, Brooks EB - Brainstem auditory and short-latency somatosensory evoked responses in brain death. Neurology 31:248, 1981.
⁹
Greenberg RP, Mayer DJ, Becker DP, Douglas Miller J - Evaluation of brain function in severe human head trauma with multimodality evoked potentials: I. Evoked brain-injury potentials, methods and analysis. J Neurosurg 47:150, 1977.
¹⁰
Guerit JM, Mahieu P, Meulders M, Tremouroux J - Visual and brainstem evoked potentials in comatose patients. Proc Symposium Intensive Care and Emergency Medicine. Brussels, 1981, 43 a-d.
11. Hansotia PL - Persistent vegetative state: review and report of electrodiagnostic studies in eight cases. Arch Neurol 42:1048, 1985.
12. Hume AL, Cant BR, Shaw NA - Central somatosensory conduction time in comatose patients. Ann Neurol 5:379, 1979.
13. Luccas FJC, Manzano GM, Ragazzo PC - Potencial evocado: generalidades. Arq Bras Neurocir 2:65, 1983.
¹⁴
Luccas FJC, Manzano GM, Ragazzo PC - Potencial evocado auditivo de tronco cerebral: estudo normativo. Arq Bras Neurocir 2:71, 1983.
15. Moller AR, Jannetta PJ, Burgess JE - Neural generators of the somatosensory evoked potentials: recording from the cuneate nucleus in man and monkeys. Electroenceph Clin Neurophysiol 65:241, 1986.
16. Regan D, Regal DM, Tibbies JAR - Evoked potentials during recovery from blindness recorded serially from an infant and his normally sighted twin. Electroenceph Clin Neurophysiol 54:465, 1982
17. Reilly EL, Kondo C, Brunberg JA, Doty DB - Evoked potentials during hypothermia and prolonged circulatory arrest. Electroenceph Clin Neuropsysiol 45:100, 1978.
¹⁸
Ropper AH, Miller DC - Acute traumatic midbrain hemorrhage. Ann Neurol 18:80, 1985.
19. Slimp JC, Tamas LB, Stolov WC, Wyler AR - Somatosensory evoked potentials after removal of somatosensory cortex in man. Electroenceph Clin Neurophysiol 65:111, 1986.
20. Spehlman R - Evoked Potential Primer. Butterworth, Boston, 1985, pg 400.
21. Starr A - Auditory brain-stem responses in brain death. Brain 99:543, 1976.
²²
Trojaborg W, Jorgensen EO - Evoked cortical potentials in patients with isoeletric EEGs. Electroenceph Clin Neurophysiol 35:301, 1973.
23. Whyte HE, Taylor MJ, Menzies R, Chin KC, MacMillan LJ - Prognostic utility of visual evoked potentials in term asphyxiated neonates. Pediatr Neurol 2:220, 1986.

Datas de Publicação

Publicação nesta coleção
26 Maio 2011
Data do Fascículo
Set 1990

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1 Belsh JM, Chokroverty S - Short-latency somatosensory svoked. potentials in brain-dead patients. Electroenceph Clin Neurophysiol 68:75, 1987.

[2] 2. Bird TD, Plum F - Recovery from barbiturate overdose coma with a prolonged isoeletric electroencephalogram. Neurology 18:456, 1968.

[3] 3. Bolton CF, Gilbert JJ, Hahn AF, Sibbald WJ - Polyneuropathy in critically ill patients. J Neurol Neurosurg Psychiat 47:1223, 1984.

[4] 4. Desmedt JE, Cheron G - Prevertebral (oesophageal) recording of subcortical somatosensory evoked potentials in man: the spinal P13 component and the dual nature of the spinal generators. Electroenceph Clin Neurophysiol 52:257, 1981.

[5] ⁵
Eisen A, Purves S, Hoirch M - Central nervous system amplification: its potential in the diagnosis of early multiple sclerosis. Neurology 32:359, 1982.

[6] 6. Ferbert A, Buchner A, Ringelstein EB, Hacke W - Isolated brainstem death: case report with demonstration of preserved visual evoked potentials (VEPs). Electroenceph Clin Neurophysiol 65:157, 1985.

[7] ⁷
Goitein KJ, Fainmesser P, Sohmer H - Cerebral perfusion pressure and auditory brain-stem responses in childhood CNS diseases. Am J Dis Child 137:777, 1983.

[8] 8. Goldie WD, Chiappa KH, Young RR, Brooks EB - Brainstem auditory and short-latency somatosensory evoked responses in brain death. Neurology 31:248, 1981.

[9] ⁹
Greenberg RP, Mayer DJ, Becker DP, Douglas Miller J - Evaluation of brain function in severe human head trauma with multimodality evoked potentials: I. Evoked brain-injury potentials, methods and analysis. J Neurosurg 47:150, 1977.

[10] ¹⁰
Guerit JM, Mahieu P, Meulders M, Tremouroux J - Visual and brainstem evoked potentials in comatose patients. Proc Symposium Intensive Care and Emergency Medicine. Brussels, 1981, 43 a-d.

[11] 11. Hansotia PL - Persistent vegetative state: review and report of electrodiagnostic studies in eight cases. Arch Neurol 42:1048, 1985.

[12] 12. Hume AL, Cant BR, Shaw NA - Central somatosensory conduction time in comatose patients. Ann Neurol 5:379, 1979.

[13] 13. Luccas FJC, Manzano GM, Ragazzo PC - Potencial evocado: generalidades. Arq Bras Neurocir 2:65, 1983.

[14] ¹⁴
Luccas FJC, Manzano GM, Ragazzo PC - Potencial evocado auditivo de tronco cerebral: estudo normativo. Arq Bras Neurocir 2:71, 1983.

[15] 15. Moller AR, Jannetta PJ, Burgess JE - Neural generators of the somatosensory evoked potentials: recording from the cuneate nucleus in man and monkeys. Electroenceph Clin Neurophysiol 65:241, 1986.

[16] 16. Regan D, Regal DM, Tibbies JAR - Evoked potentials during recovery from blindness recorded serially from an infant and his normally sighted twin. Electroenceph Clin Neurophysiol 54:465, 1982

[17] 17. Reilly EL, Kondo C, Brunberg JA, Doty DB - Evoked potentials during hypothermia and prolonged circulatory arrest. Electroenceph Clin Neuropsysiol 45:100, 1978.

[18] ¹⁸
Ropper AH, Miller DC - Acute traumatic midbrain hemorrhage. Ann Neurol 18:80, 1985.

[19] 19. Slimp JC, Tamas LB, Stolov WC, Wyler AR - Somatosensory evoked potentials after removal of somatosensory cortex in man. Electroenceph Clin Neurophysiol 65:111, 1986.

[20] 20. Spehlman R - Evoked Potential Primer. Butterworth, Boston, 1985, pg 400.

[21] 21. Starr A - Auditory brain-stem responses in brain death. Brain 99:543, 1976.

[22] ²²
Trojaborg W, Jorgensen EO - Evoked cortical potentials in patients with isoeletric EEGs. Electroenceph Clin Neurophysiol 35:301, 1973.

[23] 23. Whyte HE, Taylor MJ, Menzies R, Chin KC, MacMillan LJ - Prognostic utility of visual evoked potentials in term asphyxiated neonates. Pediatr Neurol 2:220, 1986.