Carlo Italo Parodi

Early trigeminal evoked potentials in tumours of the base of the skull and trigeminal neuralgia

Early scalp responses evoked by stimulation of the infraorbital nerve (W1, W2, W3) have been investigated in 23 patients affected by tumours of the base of the skull (parasellar area and cerebello-pontine angle) and in 38 patients suffering from idiopathic trigeminal neuralgia. Differences in conduction times between healthy and affected side were evaluated and confronted with data obtained from 30 normal volunteers. Alterations of the response were found in all the patients with tumours of the base of the skull who had clinical signs in the trigeminal area and in 7 of the 12 cases without such signs. The usual pattern of alteration in cases with tumours of the parasellar area was a parallel involvement of W2 and W3 (both absent or delayed to the same extent), whereas in tumours of the cerebello-pontine angle W3 was more seriously affected than W2. Wave W1 was never altered. Pre- and post-operative recording sessions in 2 patients showed definite improvement of the responses after removal of the tumour. In 9 patients suffering from idiopathic trigeminal neuralgia delays of conduction were found on the painful side, suggesting that damage to the trigeminal root, possibly at its entry zone into the pons, had taken place. Retrogasserian injection of glycerol was performed in 12 of the 38 patients with trigeminal neuralgia. Stimulation of the operated side showed disappearance of W2 and W3 in 9 cases, prolonged W1-W3 interval in 2 cases and no alterations in 1 case. The extent of response alteration usually paralleled the clinical results.

Subcortical and cortical responses following infraorbital nerve stimulation in man

Scalp responses following stimulation of the infraorbital nerve have been recorded in awake and anaesthetized subjects from non-cephalic (NCR) and vertex (VR) reference derivations. In awake subjects, after 3 very early potentials (W1, W2 and W3), 4 small components (P4, N5, P6 and N7) with widespread distribution have been constantly recorded from NCR derivations. Sometimes a further component, named N10, could be recorded in VR derivations on the scalp contralateral to the stimulus in the absence of earlier events. Large and inconstant waves were recorded following N7 in NCR and N10 in VR derivations. The muscular origin of these waves was demonstrated by simultaneous records taken from scalp and muscles. Records from NCR derivations in anaesthetized subjects showed that wave N7 was followed by a further event (N10) localized on the scalp contralateral to the stimulus and by a few slow waves. Wave N10 could also be recorded, in the absence of earlier events, from the VR derivation contralateral to the stimulus. All the responses recorded in these patients could be considered of neurogenic origin because curarization abolished any reflex activation of muscles. All the waves following W3 are of postsynaptic nature and, on the basis of their distribution and latency, we suggest that P4, N5, P6, N7 and N10 have their respective origins in the trigeminal nucleus, trigeminal lemniscus, thalamus, thalamic radiation and cortical projection of the stimulated area. It was also demonstrated that stimulation of lips and gums fails to evoke any neural event recordable from the scalp.

Early evoked potentials detected from the scalp of man following infraorbital nerve stimulation

Stimulation of the infraorbital nerve evoked a short latency scalp response characterized by a large amplitude triphasic potential (W1), followed by two smaller negative deflections (W2 and W3). All these waves were presynaptic in origin (as shown by double pulse stimulation), but appeared to be generated by separate dipoles. Short distance bipolar recording showed that W1 travelled from the zygoma to the mastoid. This wave was thought to be generated in a nearby neural structure, presumably the proximal part of the maxillary nerve, the gasserian ganglion and possibly even the trigeminal root. W2 and W3 components were probably generated by the trigeminal root fibres running through the brain-stem. Their origin from slowly conducting trigeminal fibres was ruled out by their absence in short distance bipolar records along the line from the zygomatic bone to the mastoid process, and by studies on their thresholds, which were shown to be identical to those of W1. Control experiments with concurrent facial muscle recording excluded any possible contamination of the scalp response to infraorbital nerve stimulation by electromyographic activity, and demonstrated gross muscular artefacts, picked up as far-field activity by scalp electrodes, following electrical stimulation of the upper lip.

Early scalp responses evoked by stimulation of the mental nerve in humans

In 20 subjects, we stimulated the mental nerve through needle electrodes inserted into the homonymous foramen; recording electrodes were placed on the scalp and along the jaw. Within the 1st 5 msec after the stimulus we recorded 4 constant waves, thought to reflect the afferent activity from the mandibular nerve up to the trigeminal nuclei. These waves have similar characteristics and the same high degree of reliability as those obtained after stimulation of the infraorbital and supraorbital nerves; therefore, they should be a useful complement for a complete exploration of trigeminal nerve function.

Normative data on scalp responses evoked by infraorbital nerve stimulation

Normative data concerning the waves W1, W2, W3, P4, N5, P6 and N7 recorded from the scalp after stimulation of the infraorbital nerve have been collected from 96 healthy subjects, selected according to age and sex. Peak latency, inter-peak intervals, side-to-side asymmetry of inter-peak intervals, amplitude, amplitude ratio of some components versus W1 and side-to-side asymmetry of such ratio have been analysed as functions of age and sex. None of these parameters appeared to be affected by sex; computation of the correlation coefficient showed a significant (P less than 0.01), though slight, increase of value of the inter-peak intervals W1-W2 and W1-W3 with age. This increase was partially confirmed by analysis of variance. However, such differences are too small to be useful for practical applications, so only a single normative value is proposed for each parameter. The influence of stimulus strength on the amplitude of the W1 component has been studied in 10 more subjects; amplitude saturation of this wave has been found to take place at intensities between 4 and 6 times the sensory threshold. Increasing the stimulus rate from 1 to 3 pulses/sec did not affect any of the components. It is remarked that components W1, W2, W3 and, to a lesser extent, P4 are the ones to be considered useful in clinical practice.

Migraine Treatment with Nicardipine

A novel calcium entry blocker, nicardipine, has been tested using a dosage of 20 mg twice a day against placebo on 30 patients suffering from migraine without aura, according to a double-blind, cross-over design; overall duration of the study was four months (two with nicardipine and two with placebo). Migraine parameters such as monthly frequency, mean intensity and mean duration of attacks were monitored. Two indexes were also calculated: index A (monthly frequency x mean intensity) and index B (monthly frequency x mean intensity x mean duration). All the parameters considered and the two indexes showed a marked and significant improvement after nicardipine treatment in comparison to both placebo and pre-study scores. Detailed analysis of the cross-over results showed that improvement obtained with nicardipine lasted some time after the drug was discontinued. Nicardipine did not alter the blood and attention tests performed and caused few side effects.

Early scalp responses evoked by stimulation of the supraorbital nerve in man

In 25 healthy volunteers the supraorbital nerve was stimulated and evoked potentials were recorded. Leads were placed on the scalp and along the ipsilateral eyebrow-mastoid line and were either referred to a non-cephalic reference (on the neck, or Cv7) or linked to form bipolar derivations. As template wave form was chosen the one obtained from derivation Cz-Cv7, which had an initial triphasic component with negative (SW1a), positive (SW1b), negative (SW1c) polarity (mean latencies 0.63, 0.95 and 1.43 msec), followed by 2 negative waves (SW2 and SW3, mean latencies of 2.20 and 2.89 msec). A final positive wave could be observed in most cases (SP4, mean latency of 4.08 msec). The records collected from the various derivations showed that each component (SW1, SW2, SW3 and SP4) had a different behaviour, thus suggesting separate origins. SW1 would originate from a volley travelling from the point of stimulation towards the mastoid, probably across the ophthalmic branch of the trigeminal nerve. The subsequent components would be generated by deeply situated structures: double pulse stimulation suggests that SW1, SW2 and SW3 are generated before the first synapse, whereas SP4 is a postsynaptic event. A strong similarity exists between the components evoked by stimulation of the supraorbital and the infraorbital nerves. Local anaesthetic block of the frontal nerve on the stimulated side and monitoring of the EMG activity of m. orbicularis oculi and m. frontalis ruled out any muscle contamination of the responses described in this paper.

Evoked potentials directly recorded from the trigeminal root in man

The paper by Macon and Poletti published in Vol. 31 of this journal [7] reports on short and long latency trigeminal evoked potentials directly recorded from the root during radiofrequency lesions for treatment of trigeminal neuralgia. The authors claim that the deflections recorded originate from fibres conducting at different conduction velocities, the slowest of which would conduct at about 1.4 m/set, thus falling in the range of unmyelinated fibres. According to the authors these late components, whose presence is correlated with pain perception, are affected by heat and lidocaine block more than the early components. They may, therefore, be of use in monitoring differential destruction of pain conducting fibres as performed in trigeminal rhizotomy. However, the assumption about the origin of the components recorded, both early and late, can be questioned. Since 1981, when the first written communication of these authors appeared, they