BAER - brainstem auditory evoked response

(BAER) is a test to measure the brain wave activity that occurs in response to clicks or certain tones.
How the Test is Performed
You lie on a reclining chair or bed and remain still. Electrodes are placed on your scalp and on each earlobe. The earphones give off a brief
click or tone. The electrodes pick up the brain's responses to these sounds and record them. You do not need to be awake for this test.
How to Prepare for the Test
You may be asked to wash your hair the night before the test.
Young children often require some type of sedation (medicine to relax them) so they remain still during the procedure.
Why the Test is Performed
The test is done to:
Help diagnose nervous system problems and hearing loss (especially in newborns and children)
Determine how well the nervous system works
This test may also be performed during surgery to decrease the risk of injury to the hearing nerve and brain.
Normal Results
Normal results vary, and depend on the patient and the instruments used to perform the test.
What Abnormal Results Mean
Abnormal test results may be a sign of hearing loss, multiple sclerosis, acoustic neuroma, or stroke.
Abnormal results may also be due to:
Brain injury
Brain malformation
Brain tumor
Central pontine myelinolysis
Speech disorders
Alternative Names
Evoked auditory potentials; Brainstem auditory evoked potentials; Evoked response audiometry; Auditory brainstem response; ABR; BAEP

The hearing test known as the brainstem auditory evoked response (BAER) or brainstem auditory evoked potential (BAEP)
detects electrical activity in the cochlea and auditory pathways in the brain in much the same way that an antenna detects radio
or TV signals or an EKG detects electrical activity of the heart. The response waveform consists of a series of peaks numbered
with Roman numerals: peak I is produced by the cochlear nerve and later peaks are produced within the brain. The response
from an ear that is deaf is an essentially flat line. In the sample recordings shown below, Puppy 1 heard in both ears, Puppy 2
was deaf in the left ear, Puppy 3 was deaf in the right ear, and Puppy 4 was deaf in both ears. Because the response amplitude
is so small it is necessary to average the responses to multiple stimuli (clicks) to unmask them from the other unrelated
electrical activity that is also present on the scalp (EEG, muscle activity, etc).
The response is collected with a special computer through extremely small electrodes placed under the skin of the scalp: one in
front of each ear, one at the top of the head, and one between the shoulders. It is rare for a dog to show any evidence of pain
from the placement of the electrodes - if anything the dog objects to the gentle restraint and the irritation of wires hanging in
front of its face. The stimulus click produced by the computer is directed into the ear with a foam insert earphone. Each ear is
tested individually, and the test usually is complete in 10-15 minutes. Sedation or anesthesia are usually not necessary unless
the dog becomes extremely agitated, which can usually be avoided with patient and gentle handling. A printout of the test
results, showing the actual recorded waveform, is provided at the end of the procedure. Test results are confidential.

BERA
Synonyms: Brain stem evoked response audiometry, Auditory brain stem response, ABR audiometry, BAER (Brainstem
auditory evoked response audiometry).
Definition: Bera is an objective way of eliciting brain stem potentials in response to audiological click stimuli. These waves are
recorded by electrodes placed over the scalp. This investigation was first described by Jewett and Williston in 1971.
Even though BERA provides information regarding auditory function and sensitivity, it is not a substitute for other methods of
audiological evaluation. It should be always viewed in conjunction with other audiological investigations.
Procedure: The stimulus either in the form of click or tone pip is transmitted to the ear via a transducer placed in the insert ear
phone or head phone. The wave froms of impulses generated at the level of brain stem are recorded by the placement of
electrodes over the scalp.
Electrode placement: Since the electrodes should be placed over the head, the hair must be oil free. The patient should be
instructed to have shampoo bath before coming for investigation. The standard electrode configuration for BERA involves
placing a non inverting electrode over the vertex of the head, and inverting electrodes placed over the ear lobe or mastoid
prominence. One more earthing electrode is placed over the forehead. This earthing electrode is important for proper
functioning of preamplifier.

Figure showing placement of BERA electrodes

Since the potentials recorded are in far field, well displaced from the site of impulse generation, the wave forms recorded are
very weak and they need to be amplified. This amplification is achieved by improving the signal : noise ratio.
How to improve signal to noise ratio: Three parallel approaches are designed to achieve this goal.
Filtering: This is employed to reduce the recording bandwidth so that only the important components of the siganal generated
are recorded.
Repeated stimulation: This is done with synchronous time domain averaging to increase the amplitude of the components of
the signal. In real time situations these two can be achieved by connecting the recording electrodes to a preamplifier, with
appropriate filter settings.
Polarity alteration: By altering the polarity of impuses recorded, the artifacts are cancelled making the brain stem waves stand
out.
In auditory brain stem evoked response audiometry, the impulses are generated by the brain stem. These impulses when
recorded contains a series of peaks and troughs. The positive peaks (vortex positive) are referred to by the Roman numerals I VII.
These peaks are considered to originate from the following anatomical sites:
1. Cochlear nerves - waves I and II
2. Cochlear nucleus - wave III
3. Superior olivary complex - wave IV
4. Nulclei of lateral lemniscus - wave V
5. Inferior colliculus - waves VI and VII
These peaks occur in most readable form in response to click stimuli over a period of 1 - 10 milliseconds after the stimulus in
normal hearing adults.
BERA is resistant to the effects of sleep, sedation, sleep and anesthesia. Its threshold has been found to be within 10dB as
elicited by conventional audiometry.

There are two different types of auditory evoked potential tests. These tests are being used as an adjunct to routine diagnostic
testing. The two types of auditory evoked potential tests are: 1. Auditory brain stem response and 2. Auditory cortical response.
Auditory cortical response: Records the impulses generated by brain in response to tone stimuli. It is recorded using cortical
response audiometry (CERA). CERA is very useful for threshold estimation of hearing, where as BERA is highly useful for
objective threshold estimation of hearing as well as differential diagnostic purposes. These reponses are more generalised and
originate form the brain cortex occurring between 50 - 300 milliseconds after the onset of stimulation. Since these responses
are generally elicited with a tone burst lasting approximately for about 200 milliseconds, its responses are highly frequency
specific. This is in contrast to BERA because brain stem responses are evoked by click stimuli and are not frequency specific.
Interpretation of CERA is easy and straightforward. Threshold is defined as the minimum stimulus level that gives a consistent
and identifiable response. The patient must be lying still during the recording process. This test is hence unsuitable for young
children who may not co-operate
Differences between BERA and CERA
BERA

CERA

Recording is made from brain stem Recording

potentials
potentials
Click stimulus is used
Responses
specific

are

not

is

made

from

cortical

Tone stimulus is used

frequnency

Responses are frequency specific

Can be performed in awake and The patient must lie still through out the
restless patients
process
Responses begin after 1 - 10 Response begins after 50
milliseconds after stimuli
milliseconds after stimulation
Suitable for even young children

300

Unsuitable for children

Uses of BERA:
1. It is an effective screening tool for evaluating cases of deafness due to retrocochlear pathology i.e. (Acoustic schwannoma).
An abnormal BERA is an indication for MRI scan.
2. Used in screening newborns for deafness
3. Used for intraoperative monitoring of central and peripheral nervous system
4. Monitoting patients in intensive care units
5. Diagnosing suspected demyelinated disorders
BERA findings suggestive of retrocochlear pathology:
1. Latency differences between interaural wave 5 (prolonged in cases of retrocochlear pathology)
2. Waves I - V interaural latency differences - prolonged
3. Absolute latency of wave V - prolonged
4. Absence of brain stem response in the affected ear
BERA has 90% sensitivity and 80% specificity in identifying cases of acoustic schwannoma. The sensitivity increases in
proportion to the size of the tumor.
Criteria for screening newborn babies using BERA:
1. Parental concern about hearing levels in their child
2. Family history of hearing loss
3. Pre and post natal infections
4. Low birth weight babies
5. Hyperbilirubinemia
6. Cranio facial deformities
7. Head injury
8. Persistent otitis media
9. Exposure to ototoxic drugs