Motor and somatosensory evoked potentials in coma: analysis and relation to clinical status and outcome

Abstract

Central sensory and motor conduction were studied in 23 comatose and three brain-dead patients. Motor evoked potentials (MEPs) to transcranial magnetic (magMEP) and electrical (elMEP) stimulation were recorded from the hypothenar muscle, and somatosensory evoked potentials (SEPs) were recorded after median nerve stimulation. Comparison of clinical with evoked potential (EP) findings revealed: 1) a painful stimulus applied to the skin of the arm lowered excitation threshold to cortical stimulation and was a prerequisite to obtain MEPs in 14 instances; 2) only in braindead patients were all EPs abolished simultaneously and bilaterally; 3) MEPs (p less than or equal to 0.05, chi 2-Test), but not necessarily SEPs (p greater than 0.1) were preserved in the arms that showed normal motor reaction during clinical examination; 4) no correlation was found between EP findings and the Glasgow Coma Scale (GCS). The results of clinical and EP testing were examined in the light of the patient's outcome 10 months later: 1) fatal outcome was predicted by a GCS of three (38% of cases, p less than or equal to 0.05, Fisher's exact test), abolished brainstem- or papillary reflexes (38%, p less than or equal to 0.05), the combination of these clinical signs (54%, p less than or equal to 0.01), bilateral abolition of elMEPs (38%, p less than or equal to 0.05), magMEPs (38%, p less than or equal to 0.05), or SEPs (23%, p greater than 0.1), or a combination of clinical and EP data (85%, p less than or equal to 0.0005); 2) good outcome was predicted by a GCS of greater than or equal to 8 only in post-traumatic coma, and EPs did not help to predict fatal outcome of coma; 1) if this appears impossible on the basis of clinical data alone; 2) if a second indicator is needed to confirm a clinical impression; 3) SEPs may be first evaluated during the acute stage of coma treatment, because they can be recorded in the presence of anaesthetic or relaxant agents; 4) MEP may be studied if outcome prediction remains ambiguous, and if the clinical situation allows for discontinuation of these agents.