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Brainstem auditory evoked responses in palatal myoclonus.

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Brainstem Auditory
Evoked Responses
in Palatal Myoclonus
Charles M. Epstein, MD, Richard Stappenbeck, MD,
and Herbert R. Karp, MD
A 30-year-old laborer in good health had acute onset of
vertigo, vertical diplopia, left-sided sensory loss, and rightsided incoordination. He developed palatal myoclonus at
120 per minute, awake and asleep, with synchronous rotatory nystagmus and overflow to the neck and diaphragm.
%ght hemiataxia and left hemisensory loss to pain and
temperature persisted. Over the course of a year, two C T
scans, an isotope brain scan, vertebral angiography, and visual evoked responses were normal. Cerebrospinal fluid
glucose, protein, cell count, IgG, and electrophoresis were
unremarkable. Brainstem auditory evoked potentials were
recorded by the method of Stockard et al [51 using Grass
P S l l J preamplifiers and a Nicolet 1172 signal averager
(Figure). With right ear stimulation, waves I, 11, 111, and V
showed normal configuration [2], amplitude, and interpeak
latencies. With left ear stimulation, waves 1-111 were well
defined but wave V was obliterated.
An isolated abnormality of wave V indicates a lesion
between the rostra1 pons and inferior colliculus [4].Within
this region the spinothalamic tract, superior cerebellar
peduncle, central tegmental tract, and lateral lemniscus lie
only a few millimeters apart. The clinical findings place the
lesion unequivocally o n the right side of the brainstem; yet
the evoked potential abnormality occurs only o n stimulation of the left ear. This result, which is in accord with the
traditional view of auditory conduction [4],suggests that
the majority of fibers have crossed to the contralateral side
by the time they ascend to the upper pons or collicular
level. Similar results have been reported in experimental
animals [ 11 but have rarely been so clearly demonstrated in
human patients. Though the concept of auditory crossing
in the human brainstem has recently been challenged [3],
592 Annals of Neurolom
Vol 7
No 6 June 1980
Brainstem auditory evoked potentials recorded with stimulation of (A) right ear and (B) left ear, using rarefaction clicks
at 10.3 per second (averages of 2,000 stimuli; time lines at 2,
4, and 6 msec). A rhythmic muscle artifact was present
throughout. The stimulus artifact waJ electronically edited
prior to transcription. In B, Ycmay represent a delayed wave
V recorded from the contralateral ear. No peak corresponding to
waue V can be identifed in the ipsilateral ear.
cases such as this suggest that it should not be lightly abandoned.
Department of Neurology
Emory University School of Medicine
Atlanta, GA 30322
1. Buchwald JS, Huang CM: Far-field acoustic response: origins in
the cat. Science 189:382-384, 1975
2. Chiappa KH, Gladstone KJ, Young RR: Brainstem auditory
evoked responses. Studies of waveform variations in 50 normal
human subjects. Arch Neurol 3681-87, 1979
3. Oh SJ,Kuba T, Choi IS, et al: The lateralization of brainstem
lesion by the brainstem auditory evoked potentials (BAEPs)
(abstract). ElectroencephalogcClin Neurophysiol (in press)
4. Stockard JJ, Stockard JE, Sharbrough W Detection and localization of occult lesions with brainstem auditory responses.
Mayo Clin Proc 52:?61-769, 1977
5. Stockard JJ, Stockard JE, Sharbrough Fw: Non-pathologic
factors influencing brainstem auditory evoked potentials. Am J
EEG Techno1 18:177-209, 1978
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response, palatal, auditors, myoclonus, brainstem, evoked
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