Intensive Care Medicine

, Volume 31, Issue 6, pp 765–775

Are somatosensory evoked potentials the best predictor of outcome after severe brain injury? A systematic review

Systematic Review



Many tests have been used to predict outcome following severe brain injury. We compared predictive powers of clinical examination (pupillary responses, motor responses and Glasgow Coma Scale, GCS), electroencephalography (EEG) and computed tomography (CT) to that of somatosensory evoked potentials (SEPs) in a systematic review.

Materials and methods

Medline (1976–2002) and Embase (1980–2002) were searched, manual review of article reference lists was conducted, and authors were contacted. We selected 25 studies addressing the prediction of outcome after severe brain injury using SEPs and either GCS, EEG, CT, pupillary or motor responses. Outcomes were determined for patients with normal or bilaterally absent SEPs and graded measures of GCS, EEG, CT, pupillary responses or motor responses. For favourable outcome prediction SEPs were superior in sensitivity, specificity and positive and negative predictive values, except for pupillary responses which had superior sensitivity and GCS which had higher specificity. SEPs had superior summary receiver operating characteristic curves, with the exception of motor responses, and superior ratio of odds ratios. For unfavourable outcome prediction SEPs were superior to the other tests in sensitivity, specificity and positive and negative predictive values, except for motor and pupillary responses, GCS and CTs which had superior sensitivity. All SEP summary receiver operating characteristic curves and pooled ratio of odds ratios were superior.


Although imperfect, SEPs appear to be the best single overall predictor of outcome. There is sufficient evidence for clinicians to use SEPs in the prediction of outcome after brain injury.


Somatosensory evoked potentials Glasgow coma scale Electroencephalography Computed tomography Brain injury Head injury 


  1. 1.
    Zandbergen EGJ, de Haan RJ, Stoutenbeek CP, Koelman JHTM, Hijdra A (1998) Systematic review of early prediction of poor outcome in anoxic-ischaemic coma. Lancet 352:1808–1812Google Scholar
  2. 2.
    Carter BG, Butt W (2001) A review of the use of somatosensory evoked potentials (SEPs) in the prediction of outcome after severe brain injury. Crit Care Med 29:178–186Google Scholar
  3. 3.
    Irwig L, Macaskill P, Glasziou P, Fahey M (1995) Meta-analytic methods for diagnostic test accuracy. J Clin Epidemiol 45:119–130Google Scholar
  4. 4.
    Moses LE, Shapiro D, Littenberg B (1993) Combining independent studies of a diagnostic test into a summary ROC curve: data analytic approach and some additional considerations. Stat Med 12:1293–1316Google Scholar
  5. 5.
    DerSimonian R, Laird NM (1986) Meta-analysis in clinical trials. Control Clin Trial 7:177–188Google Scholar
  6. 6.
    Anderson DC, Bundlie S, Rockswold GL (1984) Multimodality evoked potentials in closed head trauma. Arch Neurol 41:369–374Google Scholar
  7. 7.
    Bassetti C, Bomio F, Mathis J, Hess CW (1996) Early prognosis in coma after cardiac arrest: a prospective clinical, electrophysiological, and biochemical study of 60 patients. J Neurol Neurosurg Psychiatry 61:610–615Google Scholar
  8. 8.
    Beca J, Cox PN, Taylor MJ, Bohn D, Butt W, Logan WJ, Rutka JT, Barker G (1995) Somatosensory evoked potentials for prediction of outcome in acute severe brain injury. J Pediatr 126:44–49Google Scholar
  9. 9.
    Cant BR, Hume AL, Judson JA, Shaw NA (1986) The assessment of severe head injury by short-latency somatosensory and brain-stem auditory evoked potentials. Electroencephalogr Clin Neurophysiol 65:188–195Google Scholar
  10. 10.
    Chen R, Bolton CF, Young GB (1996) Prediction of outcome in patients with anoxic coma: a clinical and electrophysiologic study. Crit Care Med 24:672–678Google Scholar
  11. 11.
    DeGiorgio CM, Rabinowicz AL, Gott PS (1993) Predictive value of P300 event-related potentials compared with EEG and somatosensory evoked potentials in non-traumatic coma. Acta Neurol Scand 87:423–427Google Scholar
  12. 12.
    Facco E, Baratto F, Munari M, Dona B, Liviero MC, Behr AU, Giron GP (1991) Sensorimotor central conduction time in comatose patients. Electroencephalogr Clin Neurophysiol 80:469–476Google Scholar
  13. 13.
    Facco E, Munari M, Dona B, Baratto F, Fiore D, Behr AU, Giron G (1991) Spatial mapping of SEP in comatose patients: improved outcome prediction by combined parietal N20 and frontal N30 analysis. Brain Topogr 3:447–455Google Scholar
  14. 14.
    Gutling E, Gonser A, Imhof H-G, Landis T (1995) EEG reactivity in the prognosis of severe head injury. Neurology 45:915–918Google Scholar
  15. 15.
    Judson JA, Cant BR, Shaw NA (1990) Early prediction of outcome from cerebral trauma by somatosensory evoked potentials. Crit Care Med 18:363–368Google Scholar
  16. 16.
    Hollerbach S, Kullmann F, Bartsch H, Lögl C, Geissler A, Zeuner M, Leser HG, Schölmerich J (1995) Prediction of outcome in resuscitated patients by clinical course and early somatosensory-evoked potentials. A comparison with the Glasgow coma scale (GCS) and cranial-computed tomography (CCT). Clin Intensive Care 6:219–227Google Scholar
  17. 17.
    Hutchinson DO, Frith RW, Shaw NA, Judson JA, Cant BR (1991) A comparison between electroencephalography and somatosensory evoked potentials for outcome prediction following severe head injury. Electroenceph Clin Neurophysiol 78:228–233Google Scholar
  18. 18.
    Madl C, Grimm G, Kramer L, Yeganehfar W, Sterz F, Schneider B, Kranz A, Schneeweiss B, Lenz K (1993) Early prediction of individual outcome after cardiopulmonary resuscitation. Lancet 341:855–858Google Scholar
  19. 19.
    Nakabayashi M, Kurokawa A, Yamamoto Y (2001) Immediate prediction of recovery of consciousness after cardiac arrest. Intensive Care Med 27:1210–1214Google Scholar
  20. 20.
    Pohlmann-Eden B, Dingethal K, Bender H-J, Koelfen W (1997) How reliable is the predictive value of SEP (somatosensory evoked potentials) patterns in severe brain damage with special regard to the bilateral loss of cortical responses. Intensive Care Med 23:301–308Google Scholar
  21. 21.
    Rothstein TL, Thomas EM, Sumi SM (1991) Predicting outcome in hypoxic-ischaemic coma. A prospective clinical and electrophysiological study. Electroenceph Clin Neurophysiol 79:101–107Google Scholar
  22. 22.
    Rumpl E, Prugger M, Gerstenbrand F, Hackl JM, Pallua A (1983) Central somatosensory conduction time and short latency somatosensory evoked potentials in post-traumatic coma. Electroencephalogr Clin Neurophysiol 56:583–596Google Scholar
  23. 23.
    Sandroni C, Barelli A, Piazza O, Proietti R, Mastria D, Boninsegna R (1995) What is the best test to predict outcome after prolonged cardiac arrest? Eur J Emerg Med 2:33–37Google Scholar
  24. 24.
    Taylor MJ, Farrell EJ (1989) Comparison of the prognostic utility of VEPs and SEPs in comatose children. Pediatr Neurol 5:145–150Google Scholar
  25. 25.
    Whittle IR, Johnston IH, Besser M (1987) Short latency somatosensory-evoked potentials in children. III. Findings following head injury. Surg Neurol 27:29–36Google Scholar
  26. 26.
    Ying Z, Schmid UD, Schmid J, Hess CW (1992) Motor and somatosensory evoked potentials in coma: analysis and relation to clinical status and outcome. J Neurol Neurosurg Psychiatry 55:470–474Google Scholar
  27. 27.
    Cheliout-Heraut F, Durand MC, Clair B, Gajdos P, Raphaël JC (1992) Prognosis value of evoked potentials in the postanoxic comas in adult. Neurophysiol Clin 22:269–280Google Scholar
  28. 28.
    Maurer E, Milewski P (1998) Usefulness and diagnostic value of evoked potentials in surgical ICU patients with neurological deficits. Anasthesiol Intensivmed Notfallmed Schmerzther 33:430–440Google Scholar
  29. 29.
    Parain D, Devaux AM, Proust B (1989) The contribution of EEG and evoked potentials in the post-anoxic prognosis of coma in children. Neurophysiol Clin 19:489–494Google Scholar
  30. 30.
    Riffel B, Stöhr M, Graser W, Trost E, Baumgärtner H (1989) Early outcome prediction in patients with severe head injury by Glasgow Coma Score and evoked potentials. Anaesthesist 38:51–58Google Scholar
  31. 31.
    Anonymous (1994) Guideline 9. Guidelines on evoked potentials. J Clin Neurophysiol 11:40–73Google Scholar
  32. 32.
    Mauguiere F, Allison T, Babiloni C, Buehner H, Eisen AA, Goodin DS, Jones SJ, Kakigi R, Matsuoka S, Nuwer M, Rossini PM, Shihasaki H (1999) Somatosensory evoked potentials. Electroencephalogr Clin Neurophysiol Suppl 52:79–90Google Scholar
  33. 33.
    Shapiro DE (1999) The interpretation of diagnostic tests. Stat Methods Med Res 8:113–134Google Scholar
  34. 34.
    Begg CB, McNeil BJ (1988) Assessment of radiologic tests: control of bias and other design considerations. Radiology 167:565–569Google Scholar
  35. 35.
    Zweig MH, Campbell G (1993) Receiver-operating characteristic (ROC) plots: a fundamental evaluation tool in medical research. Clin Chem 39:561–577Google Scholar
  36. 36.
    Irwig L, Tosteson ANA, Gatsonis C, Law J, Colditz G, Chalmers TC, Mosteller F (1994) Guidelines for meta-analyses evaluating diagnostic tests. Ann Intern Med 120:667–676Google Scholar
  37. 37.
    De Meirleir LJ, Taylor MJ (1987) Prognostic utility of SEPs in comatose children. Pediatr Neurol 3:78–82Google Scholar
  38. 38.
    Lindsay KW, Carlin J, Kennedy I, Fry J, McInnes A, Teasdale GM (1981) Evoked potentials in severe head injury—analysis and relation to outcome. J Neurol Neurosurg Psychiatry 44:796–802Google Scholar
  39. 39.
    Lindsay K, Pasaglou A, Hirst D, Allardyce G, Kennedy I, Teasdale G (1990) Somatosensory and auditory brain stem conduction after head injury: a comparison with clinical features in prediction of outcome. Neurosurgery 26:278–285Google Scholar
  40. 40.
    Greenberg RP, Becker DP, Miller JD, Mayer DJ (1977) Evaluation of brain function in severe head trauma with multimodality evoked potentials. II. Localization of brain dysfunction and correlation with post-traumatic neurological condition. J Neurosurg 47:163–177Google Scholar
  41. 41.
    Rappaport M, Hopkins HK, Hall K, Belleza T (1981) Evoked potentials and head injury. 2. Clinical applications. Clin Electroencephalogr 12:167–176Google Scholar
  42. 42.
    Cusumano S, Paolin A, Di Paolo F, Boccaletto F, Simini G, Palermo F, Carteri A (1992) Assessing brain function in post-traumatic coma by means of bit-mapped SEPs, BAEPs, CT, SPET and clinical scores. Prognostic implications. Electroencephalogr Clin Neurophysiol 84:499–514Google Scholar
  43. 43.
    De Weerd AW, Groenveld C (1985) The use of evoked potentials in the management of patients with severe cerebral trauma. Acta Neurol Scand 72:489–494Google Scholar
  44. 44.
    Madl C, Kramer L, Domanovitis H, Woolard RH, Gervais H, Gendo A, Eisenhuber E, Grimm G, Sterz F (2000) Improved outcome prediction in unconscious cardiac arrest survivors with sensory evoked potentials compared with clinical assessment. Crit Care Med 28:721–726Google Scholar
  45. 45.
    Sherman AL, Tirschwell DL, Micklesen PJ, Longstreth WT, Robinson LR (2000) Somatosensory potentials, CSF creatine kinase BB activity, and awakening after cardiac arrest. Neurology 54:889–894Google Scholar
  46. 46.
    Berek K, Lechleitner P, Luef G, Felber S, Saltuari L, Schinnerl A, Traweger C, Dienstl F, Aichner F (1995) Early determination of neurological outcome after prehospital cardiopulmonary resuscitation. Stroke 26:543–549Google Scholar
  47. 47.
    Pfurtscheller G, Schwarz G, Gravenstein N (1985) Clinical relevance of long-latency SEPs and VEPs during coma and emergence from coma. Electroencephalogr Clin Neurophysiol 62:88–98Google Scholar
  48. 48.
    Gutling E, Gonser A, Imhof H-G, Landis T (1994) Prognostic value of frontal and parietal somatosensory evoked potentials in severe head injury: a long-term follow-up study. Electroencephalogr Clin Neurophysiol 92:568–570Google Scholar
  49. 49.
    Gutling E, Gonser A, Regard M, Glinz W, Landis T (1993) Dissociation of frontal and parietal components of somatosensory evoked potentials in severe head injury. Electroencephalogr Clin Neurophysiol 88:369–376Google Scholar
  50. 50.
    Stelzl T, von Bose MJ, Hogl B, Fuchs H-H, Flugel KA (1995) A comparison of the prognostic value of neuron-specific enolase serum levels and somatosensory evoked potentials in 13 reanimated patients. Eur J Emerg Med 2:24–27Google Scholar
  51. 51.
    Schreiner A, Pohlmann-Eden B (1999) Cerebral hypoxia after cardiopulmonary resuscitation. Lancet 353:750–751Google Scholar
  52. 52.
    Narayan RK, Greenberg RP, Miller JD, Enas GG, Choi SC, Kishore PRS, Selhorst JB, Cutz HA, Becker DP (1981) Improved confidence of outcome prediction in severe head injury. A comparative analysis of the clinical examination, multimodality evoked potentials, CT scanning and intracranial pressure. J Neurosurg 54:751–762Google Scholar
  53. 53.
    Greenberg RP, Newlon PG, Becker DP (1982) The somatosensory evoked potential in patients with severe head injury: outcome prediction and monitoring of brain function. Ann NY Acad Sci 388:683–688Google Scholar
  54. 54.
    Sleigh JW, Havill JH, Frith R, Kersei D, Marsh N, Ulyatt D (1999) Somatosensory evoked potentials in severe traumatic brain injury: a blinded study. J Neurosurg 91:577–580Google Scholar
  55. 55.
    Kane NM, Curry SH, Rowlands CA, Manara AR, Lewis T, Moss T, Cummins BH, Butler SR (1996) Event-related potentials-neurophysiological tools for predicting emergence and early outcome from traumatic coma. Intensive Care Med 22:39–46Google Scholar
  56. 56.
    Shewmon DA, DeGiorgio CM (1989) Early prognosis in anoxic coma. Reliability and rationale. Neurol Clin 7:823–843Google Scholar
  57. 57.
    Adams E, Kane N, Boyd S, Kerr S (1996) Somatosensory evoked potentials: predictors of outcome in children with severe brain injury. J Pediatr 128:438–439Google Scholar
  58. 58.
    Attia J, Cook DJ (1998) Prognosis in anoxia and traumatic coma. Crit Care Clin 14:497–511Google Scholar
  59. 59.
    Bohn D (1993) Tools for predicting outcome in the neurologically injured child. Crit Care Med 21 [Suppl]:S332–S333Google Scholar
  60. 60.
    Diringer MN (1992) Early prediction of outcome from coma. Curr Opin Neurol Neurosurg 5:826–830Google Scholar
  61. 61.
    Facco E, Zuccarello M, Pittoni G, Zanardi L, Chiarnadra M, Davia G, Giron GP (1986) Early outcome prediction in severe head injury: comparison between children and adults. Childs Nerv Syst 2:67–71Google Scholar

Copyright information

© Springer-Verlag 2005

Authors and Affiliations

  1. 1.Paediatric Intensive Care UnitRoyal Children’s HospitalParkville, MelbourneAustralia

Personalised recommendations