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5.4pt; mso-para-margin:0cm; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:10.0pt; font-family:"Calibri",sans-serif; mso-ascii-font-family:Calibri; mso-ascii-theme-font:minor-latin; mso-hansi-font-family:Calibri; mso-hansi-theme-font:minor-latin; mso-bidi-font-family:"Times New Roman"; mso-bidi-theme-font:minor-bidi; mso-ansi-language:EN-US; mso-fareast-language:EN-US;} </style> <![endif]--><!--[if gte mso 9]><xml> <o:shapedefaults v:ext="edit" spidmax="1026"/> </xml><![endif]--><!--[if gte mso 9]><xml> <o:shapelayout v:ext="edit"> <o:idmap v:ext="edit" data="1"/> </o:shapelayout></xml><![endif]--> </head> <body lang="TR" link="#0563c1" vlink="#954f72" style=""> <div class="WordSection1"> <div style="padding: 1pt 4pt;"> <p class="MsoNormal" style="border: medium none ; padding: 0cm; margin-bottom: 0.0001pt; line-height: normal;"><b><span style="font-size: 18pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">UYANDIRILMI^ POTANS0YELLER</span></b><b><span lang="EN-US" style="font-size: 18pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></b></p> <p class="MsoNormal" style="border: medium none ; padding: 0cm; margin-bottom: 0.0001pt; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="border: medium none ; padding: 0cm; margin-bottom: 0.0001pt; line-height: normal;"><span class="SpellE"><span lang="EN-US" style="font-size: 14pt;">Yazanlar</span></span><span lang="EN-US" style="font-size: 14pt;">:</span><span lang="EN-US"> </span><b style=""><span lang="EN-US" style="font-size: 14pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">A. <span class="SpellE">Emre</span> GE, <span class="SpellE">Zeliha</span> MATUR<o:p></o:p></span></b></p> <p class="MsoNormal" style="border: medium none ; padding: 0cm; margin-bottom: 0.0001pt; line-height: normal;"><span lang="EN-US" style="font-size: 12pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">Son Gncelle_tirme Tarihi: </span><b style=""><span lang="EN-US" style="font-size: 14pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">26.03.2019</span></b><span style="font-size: 13.5pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"><o:p></o:p></span></p> </div> <p class="MsoNormal" style="margin-bottom: 0.0001pt; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">Uyand1r1lm1_ potansiyel (UP, evoked potential=EP), <i>bir d1_ uyarana kar_1 merkez sinir sisteminin (MSS) elektriksel aktivitesinde ortaya 1kan dei_im </i>olarak tan1mlanabilir. D1_ar1dan verilen uyaranlarla zamansal ili_ki iinde olan bu aktivite dei_imlerinin kaydedilmesi MSS duyu yollar1ndaki iletim hakk1nda bilgi salar. Ancak, sz konusu biyoelektrik potansiyeller ok kk voltaj deerlerine sahiptirler ve elektroensefalografi (EEG) dalgalar1 _eklinde kaydedilen srekli beyin aktivitesinin ya da kendilerinden ok daha kuvvetli biyolojik ve evresel (elektromanyetik) parazitlerin aras1nda kaybolurlar. Bu nedenle UP incelemesinde uygulanan uyaran1 izleyen belirli bir zaman periyoduna ait sinirsel sinyaller kafa ve omurga zerine konan (EEG kayd1nda kullan1lanlara benzer) elektrodlar ve amplifikatr sistemiyle kaydedilir ve bu _ekilde yap1lan ok say1da kay1tlaman1n elektronik olarak ortalamalar1 al1n1r (averajlan1r). Bylece d1_ar1dan uygulanan sinyale gre zamansal a1dan rasgele nitelik ta_1yan EEG dalgalar1 silinirken, uyaranla zamansal ili_ki iinde olan uyand1r1lm1_ potansiyeller kay1t trasesi zerinde belirginle_ir. Birbirini izleyen en az iki averajlama yap1larak elde edilen potansiyellerin uyarana yan1t olarak kaydedilmi_ gerek biyoelektriksel potansiyeller olduundan ve herhangi bir artefakt kayna1ndan domad11ndan emin olunmaya al1_1l1r <b>(^ekil 1)</b>. Elde edilen potansiyellerin uyarana olan zamansal uzakl11 (latans, gecikme), sinir sisteminin farkl1 yap1lar1ndan kaynaklanan potansiyeller aras1ndaki latans farklar1 ve sz konusu potansiyellerin genlik deerleri llebilir. Bu deerlerin normal birey gruplar1ndan elde edilenlere oranla belirgin farkl1l1k gstermesi ya da ayn1 hastan1n sa ve sol taraflar1 aras1nda anlaml1 derecede farkl1 olu_u MSS de sz konusu uyaran1 ta_1yan yollarda iletimin aksad11n1 gsterebilir.</span><br> </p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 72pt; line-height: normal;"><b><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: rgb(84,141,212);"><br> <br> </span></b></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 72pt; line-height: normal;"><b><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: rgb(84,141,212);"></span></b><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 72pt; line-height: normal;"><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><o:p></o:p></span></u></b></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 72pt; line-height: normal;"><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><o:p><span style="text-decoration: none;"></span></o:p></span></u></b></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><b style=""><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><v:shapetype id="_x0000_t75" coordsize="21600,21600" o:spt="75" o:preferrelative="t" path="m@4@5l@4@11@9@11@9@5xe" filled="f" stroked="f"> <v:stroke joinstyle="miter"> <v:formulas> <v:f eqn="if lineDrawn pixelLineWidth 0"> <v:f eqn="sum @0 1 0"> <v:f eqn="sum 0 0 @1"> <v:f eqn="prod @2 1 2"> <v:f eqn="prod @3 21600 pixelWidth"> <v:f eqn="prod @3 21600 pixelHeight"> <v:f eqn="sum @0 0 1"> <v:f eqn="prod @6 1 2"> <v:f eqn="prod @7 21600 pixelWidth"> <v:f eqn="sum @8 21600 0"> <v:f eqn="prod @7 21600 pixelHeight"> <v:f eqn="sum @10 21600 0"> </v:f> <v:path o:extrusionok="f" gradientshapeok="t" o:connecttype="rect"> <o:lock v:ext="edit" aspectratio="t"> </o:lock><v:shape id="Resim_x0020_34" o:spid="_x0000_i1049" type="#_x0000_t75" style="width: 437.4pt; height: 165pt; visibility: visible;"> <v:imagedata src="ep_dosyalar/image001.jpg" o:title=""> </v:imagedata></v:shape></v:path></v:f></v:f></v:f></v:f></v:f></v:f></v:f></v:f></v:f></v:f></v:f></v:formulas></v:stroke></v:shapetype></span></b><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><img src="up01.jpg" alt="up1" width="823" height="310"> <br> ^ekil 1.</span></u></b><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"> Median somatosensoriyel uyand1r1lm1_ potansiyel (SEP) incelemesinde kal1n traselerde <b>A</b> dan <b>C</b> ye doru giderek artan say1da averajlama yap1ld11nda, uyarana yan1t olarak kaydedilen potansiyellerin belirginle_tii grlmektedir. Zemindeki st ste getirilmi_ iki_er ince trase, yeterli say1da averajlama yap1ld11nda, uyand1r1lm1_ potansiyel yan1tlar1n1n tekrarlanabilir _ekilde kaydedildiini gstermektedir. Kaydedilen potansiyellerin hangileri olduu ileride <b>^ekil 11</b> de a1klanm1_t1r.</span><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 72pt; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">Manyetik rezonans (MR) grntleme gibi geli_mi_ nrolojik grntleme yntemlerinin ortaya 1k1_1 ile UP lerin klinikte kullan1ld11 alanlar k1s1tlanm1_t1r. Ancak, grntleme yntemleri sinir sistemini tutan lezyonlar hakk1nda daha ok anatomik bilgiler salarken, UP ler yard1m1 ile sinir sistemi iindeki iletimin fizyolojik zellikleri hakk1nda veri elde edilebilir. UP ler bu zellikleri ile grntleme yntemlerinin MSS yi tutan lezyonlar hakk1nda sunduklar1na ek bilgiler salayabilir ya da mevcut yntemlerle grntlenemeyen lezyonlar1n yol at11 MSS hasarlar1 hakk1nda bilgi verebilir. Bununla birlikte, UP yntemlerinin ortaya koyduu anormalliklerin bir hastal1k iin zgn olmaktan ok, belirli bir MSS traktusunun geni_e bir blmndeki iletim kusurunu yans1tt11n1, birok hastal1k durumu iin UP lerin d_k duyarl1kl1 ve lezyonlar1 iyi lokalize etmekte yetersiz olabildiklerini hat1rlamak gerekir.</span><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">Teorik olarak herhangi bir duyu modalitesinin olu_turduu UP ler kay1tlanabilir. Ancak bunlar1n klinik pratikte en ok kullan1lanlar1 grsel uyand1r1lm1_ potansiyeller (visual evoked potentials=VEP), k1sa latansl1 somatosensoriyel uyand1r1lm1_ potansiyeller (somatosensory evoked potentials=SEP) ve k1sa latansl1 beyinsap1 i_itsel uyand1r1lm1_ potansiyelleridir (brainstem auditory evoked potentials=BAEP). A_a1da bu uyand1r1lm1_ potansiyel modalitelerinden ve MSS nin inen motor yollar1n1 inceleyen motor uyand1r1lm1_ potansiyellerden (MEP) sz edilecektir. Ge latansl1 uyand1r1lm1_ potansiyeller daha yksek kortikal srelerin deerlendirilmesinde daha ok ara_t1rma amac1yla kullan1lan elektrofizyolojik yntemlerdir. Bu blmde anlat1lmayacak olan hareket ve olayla ili_kili potansiyeller bu amala en ok al1_1lan yntemlerdir.</span><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">UP incelemelerinin nroloji pratiinde belki de en ok kullan1ld11 alan, multipl skleroz (MS) varl11 d_nlen bir hastan1n klinik planda belirti ve bulgu vermeyen lezyonlar1n1n olu_turduu elektrofizyolojik iletim kusurlar1n1n ortaya konmas1d1r (Bak1n1z: </span><u><span style="font-size: 13.5pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><a href="http://www.itfnoroloji.org/miyelin/miyelin.htm"><span style="color: purple;">Merkezi Sinir Sisteminin Miyelin Hastal1klar1</span></a></span></u><span style="font-size: 13.5pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">). Ayr1ca intraoperatif giri_imlerden doan nrolojik bozukluklar1 en aza indirmek amac1yla, gnmzde giderek yayg1nla_an intraoperatif nromonitrizasyonda ok s1k kullan1l1rlar. UP lerin klinik tan1ya salayabildii dier katk1lar a_a1da ilgili blmlerde zetlenecektir.</span><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify; line-height: normal;"><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">UP incelemelerinde uyarana kar_1 olu_an sinir sistemi sinyalleri <i>yak1n alan</i> ve <i>uzak alan potansiyelleri </i>_eklinde kaydedilir. Yak1n alan potansiyelleri, kay1t elektrodu sinyal jeneratrne yak1n olarak yerle_tirildiinde elde edilirler. Duraan (stationary) ya da sinir dokusu zerinde hareket eden potansiyeller yak1n alan potansiyeli olarak kay1tlanabilir. Bunlardan ikincisine, sinir iletim incelemeleri yap1l1rken uyar1lmakta olan bir periferik sinire yak1n _ekilde deri zerine yerle_tirilen bir elektrod iftinin yakla_an, alt1ndan gemekte olan ve uzakla_an aksiyon potansiyelini birbirini izleyen polarite dei_imleri _eklinde kaydedi_i rnek gsterilebilir. Uzak alan potansiyelleri kay1t ve referans elektrodlar1n1n ikisinin birden elektriksel potansiyel kayna1ndan uzak olarak yerle_tirilmesi halinde kaydedilir. Uzak alan potansiyelleri daima duraan niteliktedir ve uzak sinaptik potansiyellerden ya da hacim iletkeninin konfigrasyon dei_tirdii bir alandan gemekte olan aksiyon potansiyellerinden kaynaklan1rlar. Bu _ekilde sinir sisteminin farkl1 dzeylerinden kaynaklanan potansiyeller tek bir elektrod ifti ile elde edilen ayn1 kay1t montaj1nda birbirinden ayr1 defleksiyonlar olarak gzlenebilir (^ekil 11A). Farkl1 kay1tlama montajlar1nda bu potansiyellerin konfigrasyon ve polariteleri dei_im gsterebilmekle birlikte latanslar1 dei_mez. <i>UP incelemelerinde kaydedilen dalgalar genellikle, elde edilen potansiyelin defleksiyon ynn gsteren bir harfin (pozitif=P ve negatif=N) yan1na, o dalgan1n ortaya 1k1_ s1ras1n1 veya normal ki_ilerdeki ortalama latans1n1 gsteren bir say1n1n eklenmesi ile isimlendirilir (N1, P1, N2 veya N75, P100 gibi).</i></span><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; line-height: normal;"><b><span style="font-size: 13.5pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">GRSEL UYANDIRILMI^ POTANS0YELLER (Visual Evoked Potentials=VEP)</span></b><span lang="EN-US" style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; line-height: normal;"><span lang="EN-US" style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">Bu inceleme retinadan oksipital kortekse kadar grme yollar1n1n fonksiyonunu yans1tmakla birlikte, zellikle n (prekiazmatik) grme yollar1ndaki iletim bozukluunu gstermede duyarl1d1r. Grsel uyaran kayna1 olarak aral1kl1 parlayan 1_1k (fla_) ya da patern uyar1c1lar kullan1l1r.  Patern reversal uyar1m1n tekrarlanabilirlii ve lezyonlar1 gstermedeki duyarl1l11 en yksektir. Bu yntemde patern uyar1c1, bir video monitr taraf1ndan hastaya gsterilen siyah beyaz renkte bir dama tahtas1 _eklinde olup saniyede 1-2 kez bu _eklin siyah kareleri beyaza, beyazlar1 siyaha dner (patern reversal) ve bu dei_imlerle ayn1 anda hastan1n ba_1na yerle_tirilen elektrodlardan kaydedilip averajlanmaya gnderilen traselerin ba_lang1c1 tetiklenir. Hasta, varsa refraksiyon kusurlar1 dzeltilmi_ olarak, lo_ ortamda, monitrn kar_1s1na 1 m kadar uzaa oturtulur, s1ra ile bir gz rtlp dier gz ile monitrn ortas1ndaki bir fiksasyon noktas1na bakmas1 istenir. Kay1tlamalar genellikle oksipital orta hat (Oz) ve paramedian (O1 ve O2) blgeden yzeyel elektrodlarla yap1l1r. Retrokiazmatik iletim kusurlar1n1n gsterilebilmesi iin bazen daha lateral yerle_imli (T5 ve T6) kay1t elektrodlar1 gerekebilir (<b style="">^ekil 2</b>). Genellikle 100-300 kayd1n averajlanmas1 ve bu i_lemin en az 2 kez tekrar edilmesi gerekir. Elde edilen kortikal yan1t s1kl1kla bir ilk negatif pik (N75), onu izleyen byk bir pozitif dalga (P100) ve daha sonra negatif bir pikten (N145) olu_ur. VEP latans1 P100 dalgas1n1n tepe latans1 olarak okunur ve bu deer 60 ya_1n alt1ndaki normallerde 115ms nin alt1ndad1r. Ancak her laboratuvar1n, kulland11 monitrn tipi ve byklne, karelerinin byklne gre kendi normal deerlerini belirlemesi gerekir. Anormal VEP, kortikal yan1t1n tamamen kayb1, P100 latans1n1n anormal derecede uzun olmas1 veya gzler aras1ndaki latans fark1n1n normal deerlerin zerine 1kmas1 _eklinde belirir.</span><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">VEP ler n grme yolar1ndaki lezyonlar1 gstermekte son derece duyarl1d1r. Akut optik nritte bozuk bulunabildikleri gibi (<b>^ekil 3</b>), daha nce geirilmi_ ancak hasta taraf1ndan fark edilmemi_ bir optik nriti ortaya koymakta da ba_ar1l1 olurlar. Bu nedenle VEP lerin optik sinir lezyonlar1n1 gstermekte MR grntleme yntemine oranla daha duyarl1 ve daha ucuz olduunu, normal bir VEP incelemesinin hastada bir optik sinir-kiazma lezyonu olas1l11n1 hemen hemen ekarte ettirebildiini syleyebiliriz. Pratik nroloji uygulamas1nda VEP lere en ok MS tan1s1nda, zellikle optik sinir tutulmas1na ait klinik belirti ve bulgular1 olmayan hastalarda byle bir lezyonun var olup olmad11n1 gstermek amac1yla ba_vurulur. Ancak VEP bozukluklar1n1n optik nrite zgn olmad11n1 hat1rlamak gerekir. VEP anormalliine yol aan nedenler aras1nda optik sinire bas1 yapan tmrler (<b>^ekil 4</b>), iskemik optik nropati (<b style="">^ekil 5</b>), glokom, Friedreich ataksisi ve dier herediter ataksiler, Charcot-Marie-Tooth hastal11, nrosifiliz, Leber in herediter optik atrofisi, lkodistrofiler, pernisiyz anemi, endokrin orbitopatiler, diyabet, alkolizm, fenilketonri ve post-konkzyon sendromlar1 say1labilir. Retrokiazmatik lezyonlar1n VEP ile tan1nmas1 olduka gtr. Bu lezyonlara ili_kin VEP anomalisi zelliklerinin iyi bilinmesi ve yar1m alan patern uyar1mlar1n kullan1lmas1 bazen yard1mc1 olmakla birlikte, sz konusu lezyonlar1n VEP le lokalize edilmesi grntleme yntemleri ile salanan bilgilere nemli bir katk1 salamaz.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify; line-height: normal;"><span style="font-size: 10pt; font-family: &quot;Times New Roman&quot;,serif;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify; line-height: normal;"><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif;"> Patern reversal uyar1m, gz monitr zerindeki odak noktas1na sabitleyerek bakmay1 gerektirdii iin bebekler, kk ocuklar veya bu uygulamay1 yerine getiremeyecek eri_kinlerde (nistagmus, ok d_k grme keskinlii, kooperasyon kayb1 gibi) fla_ uyar1m veya  patern onset uyar1m yapmak uygundur. Fla_ uyar1m stroboskop veya  Ganzfeld gzlkleri ile yap1l1r. Fla_ VEP in dei_kenlii  patern onset VEP e gre ok daha fazlad1r. Grme alan1n1n 60 farkl1 blgesinden uyar1mla kay1t yap1lan yeni bir teknik olan multifokal VEP in optik nrit ve MS te, zellikle kk, periferik lezyonlar1 tan1mada klasik tam alan uyar1m1na gre daha duyarl1 olduu bildirilmektedir.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; line-height: normal;"><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify; line-height: normal;"><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">Kiazmatik veya retrokiazmatik lezyonlar, paramedian ve daha lateral yerle_imli elektrodlar1 da ekleyerek ok kanaldan kay1t yap1ld11nda, bazen tan1nabilir. Kiazmatik lezyonlara bal1 bitemporal hemianopside, her iki gzde, uyar1m yap1lan gzle ayn1 taraftaki paramedian-lateral balant1larda kortikal potansiyeller daha ge latansla kaydedilir (aprazla_m1_ asimetri, </span><b style=""><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif;">^ekil 6</span></b><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">). Retrokiazmatik lezyonlara bal1 homonim hemianopsilerde ise her iki gzde de homonim hemianopsinin taraf1yla ayn1 yndeki paramedian-lateral balant1larda (aprazla_mam1_ asimetri) kortikal potansiyellerin latanslar1 getir (<b style="">^ekil 7</b>).<o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><b><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"><o:p></o:p></span></b></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><span style=""><v:shape id="Resim_x0020_402" o:spid="_x0000_i1048" type="#_x0000_t75" style="width: 424.2pt; height: 311.4pt; visibility: visible;"> <v:imagedata src="ep_dosyalar/image002.jpg" o:title=""> </v:imagedata></v:shape></span><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><o:p></o:p></span></u></b></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><span style="color: purple;"><img src="up02.jpg" alt="up2" width="767" height="544"> </span><a href="http://www.itfnoroloji.org/uyandirilmis/ep2.JPG"><span style="color: purple;"> <br> </span></a><span style="color: purple;"> ^ekil 2.</span></span></u></b><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"> Grme yollar1n1n basit _emas1 (<b>A</b>), patern VEP incelemesi esnas1nda ekilen bir grnt (<b>B</b>) ve bu incelemede elde edilen traseler (<b>C</b>). Her biri 100 uyar1m1n averajlanmas1 ile kaydedilen iki trase st ste getirilmi_tir. Orta hattaki Oz-Cz balant1s1nda kortikal P100 dalgalar1 en yksek amplitdldr.<o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"><o:p><br> <br> </o:p><img src="up03.jpg" alt="3" width="383" height="342"> <o:p><br> </o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><o:p><span style="text-decoration: none;"></span></o:p></span></u></b></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><o:p><span style="text-decoration: none;"></span></o:p></span></u></b></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><b style=""><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><v:shape id="Resim_x0020_35" o:spid="_x0000_i1047" type="#_x0000_t75" style="width: 400.8pt; height: 357.6pt; visibility: visible;"> <v:imagedata src="ep_dosyalar/image003.jpg" o:title=""> </v:imagedata></v:shape></span></b><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><o:p></o:p></span></u></b></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><span style="color: purple;">^ekil 3.</span></span></u></b><b><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"> </span></b><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">Sol optik nrit nedeniyle incelenmekte olan 32 ya_1ndaki kad1n hastada patern VEP incelemesi. Salam (sa) gz uyar1m1 ile elde edilen yan1tlar kesik izgiyle, sol gz uyar1m1 ile kaydedilenler dz izgi ile verilmi_tir. Kortikal yan1tlar, solda belirgin derecede uzun latansl1 (oklar) ve d_k amplitdldr.</span><br> </p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p><br> <br> </o:p><img src="up04.jpg" alt="4" width="586" height="365"> <o:p><br> </o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><o:p><span style="text-decoration: none;"></span></o:p></span></u></b></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><b style=""><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><v:shape id="Resim_x0020_36" o:spid="_x0000_i1046" type="#_x0000_t75" style="width: 435.6pt; height: 271.2pt; visibility: visible;"> <v:imagedata src="ep_dosyalar/image004.jpg" o:title=""> </v:imagedata></v:shape></span></b><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><o:p></o:p></span></u></b></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><span style="color: purple;">^ekil 4</span><span style="color: purple;">.</span></span></u></b><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"> Alt1 y1l nce sol sfenoid kanat meningiomu nedeniyle ameliyat edilen (parsiyel rezeksiyon) 64 ya_1nda kad1n hasta. Sol gznde vizyon azalmas1n1n belirginle_mesi ve solda papildem nedeniyle incelenmi_tir. ^ekil <b>B</b> de kontrastl1 T1 transversal MR kesitinde tmr kal1nt1s1 (ok), ^ekil <b>A</b> da ise oksipital orta hat (Oz), sol (O1) ve sa (O2) paramedian yerle_imli elektrodlardan verteks (Cz) referans1 ile kaydedilen patern VEP yan1tlar1 grlmektedir. Salam (sa) gz uyar1m1 ile kaydedilen yan1tlar kesikli, sol gz uyar1m1 ile kaydedilenler dz izgi ile verilmi_tir. Sol taraf uyar1m1 ile elde edilen yan1tlar1n latanslar1 belirgin uzundur.<br> </span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"><o:p><br> <br> </o:p><img src="up05.jpg" alt="5" width="742" height="354"> <o:p><br> </o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><o:p><span style="text-decoration: none;"></span></o:p></span></u></b></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><o:p><span style="text-decoration: none;"></span></o:p></span></u></b></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><b style=""><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><v:shape id="Resim_x0020_38" o:spid="_x0000_i1045" type="#_x0000_t75" style="width: 445.2pt; height: 212.4pt; visibility: visible;"> <v:imagedata src="ep_dosyalar/image005.jpg" o:title=""> </v:imagedata></v:shape></span></b><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><span style="color: purple;">^ekil 5.</span></span></u></b><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"> </span><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">Koroner arter by-pass ameliyat1n1n 3. gnnde ani geli_en sol gzde grme kayb1 olan 52 ya_1ndaki erkek hastan1n patern-VEP incelemesi. Kortikal potansiyeller, sa gz uyar1m1yla normal olarak kaydedilirken, solda elde edilememi_tir.</span><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><b><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"><o:p><br> </o:p><img src="up06.jpg" alt="6" width="623" height="515"> <o:p><br> </o:p></span></b></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><o:p><span style="text-decoration: none;"></span></o:p></span></u></b></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><o:p><span style="text-decoration: none;"></span></o:p></span></u></b></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><b style=""><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><v:shape id="Resim_x0020_39" o:spid="_x0000_i1044" type="#_x0000_t75" style="width: 431.4pt; height: 356.4pt; visibility: visible;"> <v:imagedata src="ep_dosyalar/image006.jpg" o:title=""> </v:imagedata></v:shape></span></b><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><o:p></o:p></span></u></b></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><span style="color: purple;">^ekil 6.</span></span></u></b><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"> </span><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif;">Alt1 y1l nce trafik kazas1 sonucu sa orbita tavan1nda fraktr ve kiazma optikuma bas1 nedeniyle opere olan 20 ya_1ndaki erkek hastan1n koronal (<b>A</b>) ve aksiyal (<b>B, C</b>) planda T2 MR kesitleri ve patern VEP incelemesi (<b>D, E</b>). Sa gz uyar1m1yla sa (O2-Cz), sol gz uyar1m1yla sol (O1-Cz) oksipital balant1lar1ndan kaydedilen P100 latans1n1n uzun olduu grlmektedir (aprazla_m1_ asimetri, kiazmatik lezyon).</span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif;"><br> <br style=""> <!--[if !supportLineBreakNewLine]--><br style=""> <img src="up07.jpg" alt="7" width="595" height="580"> <!--[endif]--><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><o:p><span style="text-decoration: none;"></span></o:p></span></u></b></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><b style=""><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><v:shape id="Resim_x0020_40" o:spid="_x0000_i1043" type="#_x0000_t75" style="width: 414.6pt; height: 403.8pt; visibility: visible;"> <v:imagedata src="ep_dosyalar/image007.jpg" o:title=""> </v:imagedata></v:shape></span></b><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><o:p></o:p></span></u></b></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><span style="color: purple;">^ekil 7.</span></span></u></b><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"> </span><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif;">Dengesizlik ve ellerde titreme yak1nmas1 olan 22 ya_1ndaki multipl skleroz tan1l1 kad1n hastan1n patern VEP incelemesi (<b>A, B</b>) ve aksiyal planda FLAIR (<b>C</b>) ve T2 (<b>D</b>) MR kesitleri. Sol oksipital blgede, lateral ventrikl arka boynuzuna kom_u, subkortikal hiperintens lezyon grlmektedir. Patern VEP incelemesinde, hem sa hem sol gz uyar1m1yla orta hat ve sol oksipital balant1larda (Oz-Cz ve O1-Cz), P100 latanslar1 normalken, sa oksipital balant1larda (O2-Cz) P100 latanslar1 uzundur (aprazla_mam1_ asimetri, retrokiazmatik lezyon).<o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; line-height: normal;"><b><span style="font-size: 13.5pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">BEY0NSAPI 0^0TSEL UYANDIRILMI^ POTANS0YELLER0 (Brainstem Auditory Evoked Potentials=BAEP)</span></b><span lang="EN-US" style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"></span><span lang="EN-US" style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">BAEP i_itme sinirinin ve beyinsap1ndaki i_itme yollar1n1n fonksiyonunu yans1t1r. Uyaran, s1ra ile kulaklardan her birine bir kulakl1k (ya da gereinde d1_ kulak yoluna yerle_tirilen bir prob) arac1l11yla uygulanan, i_itme e_iinin 60-70 dB zerindeki bir _iddette ve akustik zellikleri belirlenmi_ yakla_1k 10 Hz frekansta bir  klik sesidir. En s1k kullan1lan  rarefaksiyon klii kulak zar1n1n d1_a doru hareketine neden olur. Bu s1rada kar_1 tarafa, dier kulaa verilen uyaran1n kemik yoluyla iletilen etkisini maskelemek amac1yla bir  beyaz grlt verilir. BAEP i olu_turan potansiyeller, i_itsel uyaran1 izleyerek beyinsap1 i_itsel yollar1n1n ard1_1k aktivasyonu ile ortaya 1kan bir dalgalar serisidir. Kay1tlama sa ve sol kulak memesi (veya mastoid 1k1nt1 zerindeki deri) ile verteks zerine yerle_tirilen elektrodlar arac1l11 ile yap1l1r. Bylece sa kulak-verteks ve sol kulak-verteks balant1lar1 kay1t cihaz1n1n birer kanal1 ile ili_kilendirilerek iki kanall1 kay1tlama yap1l1r. Elde edilen dalgalar yakla_1k 0,1-0,5 </span><span style="font-size: 13.5pt; font-family: Symbol; color: black;">m</span><span style="font-size: 13.5pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">V amplitdde, yani EEG aktivitesinin 1/100 kadar olan potansiyellerdir. Bu nedenle her seferinde 1500-2000 in zerinde kayd1n averajlanmas1 ve tm UP lerde olduu gibi averajlaman1n en az iki kez yinelenmesi gerekir. Klinik lokalizasyonda en fazla kullan1lan ilk be_ BAEP dalgas1n1n kaynakland11 d_nlen anatomik blgeler _yledir (<b style="">^ekil 8</b>):</span><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">I. dalga: VIII sinir aksiyon potansiyeli</span><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">II. dalga: Koklear nukleus (ve VIII. sinir)</span><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">III. dalga: 0psilateral superior oliver nukleus</span><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">IV. dalga: Lateral lemniskus nukleus veya aksonlar1</span><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">V. dalga: 0nferior kollikulus.</span><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">Beyinsap1 i_itsel yollar1n1 etkileyen bir patolojik srecin varl11nda lezyonun etkiledii dzeyden sonraki potansiyellerin latans1n1n uzamas1 veya bu potansiyellerin kaybolmas1 beklenir (<b>^ekil 9 ve 10</b>). Byle bir anormallii en ok yans1tan parametre dalgalar (pikler) aras1 latanslard1r. I-III interpik latans1n1n uzamas1 VIII. sinir ve alt ponsa ili_kin patolojik durumlar1 gsterirken (akustik nrinom gibi), III-V interpik latans1ndaki uzama daha ok orta pons ve alt mezensefalonun uyar1lan kulakla ayn1 tarafta olan lezyonuna i_aret eder. I-V interpik latans1, beyinsap1 i_itme yollar1ndaki iletimin total sresini yans1t1r ve bu yollar1n herhangi bir dzeyindeki lezyondan etkilenerek uzayabilir.</span><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><b style=""><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><v:shape id="Resim_x0020_41" o:spid="_x0000_i1042" type="#_x0000_t75" style="width: 470.4pt; height: 422.4pt; visibility: visible;"> <v:imagedata src="ep_dosyalar/image008.jpg" o:title=""> </v:imagedata></v:shape></span></b><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><o:p></o:p></span></u></b></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><span style="color: purple;"><img src="up08.jpg" alt="" width="849" height="763"> <br> </span><span style="color: purple;">^ekil 8.</span></span></u></b><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"> 0_itme yollar1n1n basit _emas1 (<b style="">A</b>), BAEP incelemesi yap1l1rken ekilen bir grnt (<b style="">B</b>) ve kaydedilen k1sa latansl1 potansiyeller (<b style="">C</b>). Sol kulak uyar1m1 ile sol (L/L) ve sa (L/R), sa kulak uyar1m1 ile sol (R/L) ve sa (R/R) verteks-mastoid balant1lar1ndan kaydedilen traseler alt alta gsterilmi_, en az 1500 averajlama ile kaydedilen iki_er trase st ste yazd1r1lm1_t1r. Her trasede ilk be_ BAEP dalgas1 i_aretlenmi_tir. KN=Koklear nukleus, SO=Superior oliver nukleus, LN=</span><span style="font-size: 10pt;"> </span><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">Lateral lemniskus nukleus veya aksonlar1, IF=0nferior kollikulus, TAL=Talamusun medial geniklat cismi, KORT=0_itme korteksi.<br> <br> </span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"></span><span style="font-size: 10pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><o:p><span style="text-decoration: none;"></span></o:p></span></u></b></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><b style=""><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><v:shape id="Resim_x0020_42" o:spid="_x0000_i1041" type="#_x0000_t75" style="width: 437.4pt; height: 212.4pt; visibility: visible;"> <v:imagedata src="ep_dosyalar/image009.jpg" o:title=""> </v:imagedata></v:shape></span></b><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><o:p></o:p></span></u></b></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><a href="http://www.itfnoroloji.org/uyandirilmis/ep5.JPG"><span style="color: purple;"><br> </span></a><span style="color: purple;"><img src="up09.jpg" alt="" width="729" height="354"> <br> </span><span style="color: purple;">^ekil 9.</span></span></u></b><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"> Multipl sklerozu olan 37 ya_1ndaki kad1n hastan1n BAEP incelemesi. Sa kulak uyar1m1yla sada I den V e kadar dalgalar normal latansla kaydedilirken, sol kulak uyar1m1yla solda II. dalgadan sonraki dalgalar elde edilememi_tir.<br> <br> </span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"></span><span style="font-size: 10pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><o:p><span style="text-decoration: none;"></span></o:p></span></u></b></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><b style=""><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><v:shape id="Resim_x0020_43" o:spid="_x0000_i1040" type="#_x0000_t75" style="width: 426.6pt; height: 208.8pt; visibility: visible;"> <v:imagedata src="ep_dosyalar/image010.jpg" o:title=""> </v:imagedata></v:shape></span></b><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><o:p></o:p></span></u></b></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><a href="http://www.itfnoroloji.org/uyandirilmis/ep6.JPG"><span style="color: purple;"><br> </span></a><span style="color: purple;"><img src="up10.jpg" alt="" width="711" height="348"> <br> </span><span style="color: purple;">^ekil 10.</span></span></u></b><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"> Geirilmi_ sol pontin k_e tmr nedeniyle solda kulakta i_itme kayb1, periferik fasial paralizisi olan 65 ya_1ndaki kad1n hastan1n BAEP incelemesi. Sa kulak uyar1m1yla sada I den V e kadar, solda II den V e kadar dalgalar normal olarak kaydedilirken, sol kulak uyar1m1yla yan1t elde edilememi_tir (sol 8. kranyal sinir tutulumu).</span><br> </p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><span style="font-size: 10pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p><br> </o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">BAEP in nrolojide en ok kullan1ld11 alanlardan biri MS varl11 d_nlen hastalarda klinik olarak belirti vermeyen ya da _pheli belirti ve bulgular1 olan beyinsap1 lezyonlar1n1n ortaya konmas1d1r. BAEP, MS lezyonlar1n1n belirlenmesinde VEP ve SEP e oranla daha az duyarl1 olmakla birlikte, bir iletim aksamas1n1 ortaya koymas1 halinde tan1ya nemli bir katk1 salar. Beyinsap1n1 etkileyen santral pontin miyelinoliz, metakromatik lkodistrofi ve adrenolkodistrofi gibi dier demiyelinizan srelerde de BAEP anormallikleri grlr. BAEP in tan1s1nda kullan1labildii dier bir hastal1k grubu arka ukur tmrleridir. Akustik nrinomlarda BAEP anormallii erken ortaya 1kar ve tan1ya olduka yard1mc1 olur. Her ne kadar ada_ MR cihazlar1n1n duyarl11na ve salad1klar1 anatomik bilginin yksek deerine ula_amasa da ucuz bir inceleme olu_u, kardiyak  pacemaker gibi implantlar1 ta_1yan hastalarda kullan1labilmesi gibi nedenler bu alanda BAEP e bir kullan1m yeri kazand1rabilir. Arka kafa ukurunun dier yer kaplay1c1 lezyonlar1, ancak beyinsap1n1n iinden kaynakland1klar1 ya da belirgin beyinsap1 bas1s1 olu_turduklar1 zaman BAEP anormalliine neden olurlar. Bu nedenle sz konusu lezyonlar1n tan1s1nda BAEP nemli bir rol oynamaz. Arka ukur tmrlerinin cerrahisinde BAEP in intraoperatif kullan1m1 VIII. sinirin cerrahi travmadan korunmas1na yard1mc1 olabilir.</span><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify; line-height: normal;"><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">BAEP genellikle anestetik ve sedatif maddelerden, komaya neden olan metabolik bozukluklardan ve beyinsap1 i_itsel yollar1n1 etkilemeyen fakat komaya yol aan yap1sal lezyonlardan etkilenmez. Bu nedenle komal1 hastalarda prognozu belirleme ya da beyin lm tan1s1 amac1yla kullan1labilir. Beyin lm iin tipik olan BAEP bozukluu, I. dalga elde edilebilirken dier dalgalar1n kaydedilemiyor olmas1d1r. Tm dalgalar1n kaybolmas1 hali ba_ka nedenlere de bal1 olabileceinden (koklear lezyon, eski bir sa1rl1k nedeni gibi) bu durumda BAEP in beyin lm tan1s1na yard1mc1 olma deeri azal1r.</span><span style="font-size: 10pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; line-height: normal;"><b><span style="font-size: 13.5pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">SOMATOSENSOR0YEL UYANDIRILMI^ POTANS0YELLER (Somatosensory Evoked Potentials=SEP)</span></b><span lang="EN-US" style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify; line-height: normal;"><span lang="EN-US" style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">SEP incelemesi aferent periferik sinir liflerinin uyar1lmas1n1n ard1ndan periferik ve MSS kaynakl1 bir dizi potansiyelin kaydedilmesinden ibarettir. Bu incelemede kaydedilen potansiyellerden sorumlu olan yap1lar, periferik sinir sisteminde kal1n miyelinli lifler, MSS de ise arka kordon-medial lemniskus sistemidir. Periferik sinirleri uyarabilecek herhangi bir stimulus tr verilebilirse de, uygulama kolayl11 ve </span><span style="font-size: 13.5pt; font-family: &quot;Tahoma&quot;,sans-serif;">llebilir<span style="color: black;"> zelikleri nedeniyle EMG incelemesinde kullan1lan trden elektriksel uyaranlar tercih edilir. Kaydedilmesi ve yorumlanmas1 daha kolay olduundan karma sinirlerin uyar1lmas1 ile gerekle_tirilen SEP incelemeleri standart hale gelmi_tir. Bunlar1n en ok uygulananlar1 median ve ulnar sinirlerin bilekten, tibial sinirin ayak bilei, peroneal sinirin diz dzeyinden uyar1lmas1 ile yap1lan SEP incelemeleridir. Bu karma sinirlerin uyar1m1nda hafif bir parmak hareketi olu_turmaya yetecek kadar uyaran _iddeti yeterli olur ve hasta taraf1ndan olduka iyi tolere edilir. Kay1t elektrodlar1 periferik nral yap1lar1n (median ve ulnar SEP iin Erb noktas1, tibial SEP iin dizard1), omurgan1n (median ve ulnar SEP te servikal, tibial SEP te lomber dzeyde orta hatta), ve kafatas1n1n zerine (kar_1 parietal blge veya verteks) yerle_tirilerek kay1t cihaz1n1n farkl1 kanallar1na balan1r. Referans elektrodlar1 ise kafatas1 zerinde ve/veya d1_1ndaki noktalara yap1_t1r1l1r.</span></span><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"></span><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; line-height: normal;"><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">SEP incelemelerinde kaydedilen ba_l1ca potansiyellerin kaynaklar1 _yle zetlenebilir (<b>^ekil 11</b>):</span><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; line-height: normal;"><i><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">Median ve ulnar SEP:</span></i><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"> <b>N9</b>: Brakial pleksus, <b>N11</b>: Spinal kklerin medulla spinalise giri_ blgesi, <b>N13</b>: Arka boynuz postsinaptik potansiyeli, <b>N14/P14</b>: Medial lemniskus, <b>N20/P25</b>: Primer somatosensoriyel korteks.</span><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; line-height: normal;"><i><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">Tibial SEP:</span></i><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"> <b>N18</b>: Sinir kkleri, kauda ekuina, <b>N22</b>: Arka boynuzda postsinaptik potansiyeller, <b>P37</b>: Primer sensoriyel korteks.</span><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 18pt; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 18pt; line-height: normal;"><b style=""><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><v:shape id="Resim_x0020_44" o:spid="_x0000_i1039" type="#_x0000_t75" style="width: 455.4pt; height: 220.2pt; visibility: visible;"> <v:imagedata src="ep_dosyalar/image011.jpg" o:title=""> </v:imagedata></v:shape></span></b><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><o:p></o:p></span></u></b></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 18pt; line-height: normal;"><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><span style="color: purple;"><img src="up11.jpg" alt="" width="724" height="350"> <br> </span><span style="color: purple;">^ekil 11.</span></span></u></b><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"> Normal median (<b>A</b>) ve tibial (<b>B</b>) SEP.</span><span lang="EN-US" style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 54pt; text-indent: -18pt; line-height: normal;"><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">A.</span><span style="font-size: 7pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"> </span><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">N. medianusun bilekten submaksimal uyar1lmas1 ile</span><span lang="EN-US" style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><i><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">1. trasede</span></i><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"> Erb-Fz balant1s1ndan kaydedilen periferik yan1t (Erb potansiyeli, N9),</span><span lang="EN-US" style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><i><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">2. ve 3. trasde</span></i><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"> servikal 7. ve 2. vertebra spinoz 1k1nt1lar1 hizas1na konan elektrodlarla (Cv7-Fz ve Cv2-Fz) kaydedilen servikal potansiyeller (N11 ve N13),</span><span lang="EN-US" style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><i><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">4. trasede</span></i><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"> uyar1m1n kar_1 taraf1ndaki parietal balant1dan (Cc-Fz) kaydedilen kortikal potansiyel (N20) i_aretlenmi_tir.</span><span lang="EN-US" style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 54pt; text-indent: -18pt; line-height: normal;"><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">B.</span><span style="font-size: 7pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"> </span><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">N. tibialisin i malleol dzeyinden submaksimal uyar1lmas1 ile</span><span lang="EN-US" style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><i><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">1. trasede</span></i><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"> dizard1na konan elektrod ifti ile kaydedilen periferik yan1t (DA),</span><span lang="DE" style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><i><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">2. trasede</span></i><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"> st lomber blgede orta hatta konan elektrod ifti ile kaydedilen lomber potansiyel (LUMB),</span><span lang="DE" style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><i><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">3. trasede</span></i><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"> verteks ve uyar1m1n kar_1 taraf1ndaki parietal blgeye konan elektrod iftinden (Cz-Cc) kaydedilen kortikal potansiyeller (P37-N45) i_aretlenmi_tir.</span><br> </p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><span lang="DE" style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><span lang="DE" style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p><br> </o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">SEP incelemesinde bir anomaliyi en net gsteren bulgu, lezyon dzeyinden ve bunun rostralinden kaynaklanan potansiyellerin kaybolmas1 veya latanslar1n1n uzamas1d1r. SEP dalgalar1n1n latanslar1 vcut boyu, ekstremite s1cakl11, sinir iletim h1zlar1 ve hasta ya_1 gibi faktrlerden etkilendiinden, incelemede anormal sonular elde edildiine karar vermeden nce bulgular1n bu faktrlere gre dzeltilmesi gerekir. Sa ve sol taraf uyar1m1 ile elde edilen dalgalar aras1nda anlaml1 latans fark1 bulunmas1 tek tarafl1 lezyonlar iin deerli bir SEP bulgusudur.</span><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">SEP incelemesinde periferik ve MSS yi tutan patolojik srelere ili_kin bilgiler elde edilebilir. Periferik sinirlerin proksimal kesimlerini tutan lezyonlarda SEP, elektromiyografi incelemesinin salad11 bilgilere katk1 salayabilir. Bu patolojik durumlara rnek olarak e_itli nedenlere bal1 pleksopatileri ve baz1 radiklopatileri sayabiliriz. MSS lezyonlar1 iinde en ok SEP anormalliine neden olan patolojik sreler omurilii tutanlard1r. Sessiz bir MS lezyonunu ortaya koymada SEP, yakla_1k VEP kadar duyarl1l1a sahiptir (</span><b><span style="font-size: 13.5pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">^ekil 12 ve 13</span></b><span style="font-size: 13.5pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">). MS olgular1nda median ve ulnar SEP incelemeleri seyrek olarak anormal bulgu verirken alt ekstremite uyar1m1 ile yap1lan SEP ler s1kl1kla patolojik bulunur. Bu durum, alt taraflardan ykselen somatosensoriyel yollar1n omurilikte daha uzun bir mesafe kat etmelerinden ve bu nedenle demiyelinizan plaklar taraf1ndan yakalanma olas1l1klar1n1n daha yksek olmas1ndan kaynaklan1r.</span><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"></span><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><b style=""><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><v:shape id="Resim_x0020_45" o:spid="_x0000_i1038" type="#_x0000_t75" style="width: 408.6pt; height: 373.8pt; visibility: visible;"> <v:imagedata src="ep_dosyalar/image012.jpg" o:title=""> </v:imagedata></v:shape></span></b><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><o:p></o:p></span></u></b></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><span style="color: purple;"><img src="up12.jpg" alt="" width="408" height="373"> <br> </span><span style="color: purple;">^ekil 12.</span> </span></u></b><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">Multipl skleroz tan1s1yla izlenen 27 ya_1ndaki kad1n hastan1n tibial SEP incelemesi. N. tibialis, i malleol yan1ndan submaksimal _iddette elektrikle uyar1lm1_t1r. Sol taraf uyar1m1 ile elde edilen traseler kesikli gri, sa taraf uyar1m1 ile elde edilen traseler ise dz siyah izgilerle verilmi_tir. Kortikal p37 dalgalar1n1n latanslar1 normal s1n1rlar iinde olmakla birlikte sa taraf uyar1m1 ile elde edilenlerin latans1 sola gre 4 ms uzun olup bu fark anlaml1d1r. Bu bulgu lomber blgenin stnde, sada, arka kordon iletiminde aksama olduunu d_ndrr.</span><b><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: rgb(0,112,192);"><o:p></o:p></span></b></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p><br> </o:p><img src="up13.jpg" alt="" width="612" height="563"> <o:p><br> </o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><b style=""><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><v:shape id="Resim_x0020_46" o:spid="_x0000_i1037" type="#_x0000_t75" style="width: 411pt; height: 378.6pt; visibility: visible;"> <v:imagedata src="ep_dosyalar/image013.jpg" o:title=""> </v:imagedata></v:shape></span></b><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><o:p></o:p></span></u></b></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><span style="color: purple;">^ekil 13.</span></span></u></b><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"> Multipl skleroz tan1l1 k1rk bir ya_1ndaki erkek hastan1n sagital (<b>A</b>) ve transversal (<b>B</b>) planda T2 MR kesitlerinde servikal omuriliin sol posterior parasantral kesimini tutan, demiyelinizan bir lezyon grlmektedir (oklar). Sa n. medianusun bilekten uyar1lmas1yla normal latans ve amplitdl periferik (1. trase), spinal (2. ve 3. trase) ve kortikal (4. trase) yan1tlar kaydedilmi_tir (<b>C</b>) Sol taraf uyar1m1 ile periferik ve kortikal potansiyeller normal olarak kaydedilirken servikal potansiyeller elde edilememi_tir (<b>D</b>). Bu hastan1n tibial SEP incelemesinde iki yanl1 normal ve simetrik periferik, spinal ve kortikal yan1tlar kaydedilmi_tir.</span><br> </p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p><br> </o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">Servikal spondilotik miyelopati ve dier nedenlere bal1 omurilik bas1lar1 ile sirengomiyeli gibi lezyonlar1n olu_turduu iletim kusurlar1n1n gsterilmesi ve takibinde; travmatik miyelopatilerde arka kordon iletiminin bir derece sregeldiinin ortaya konmas1nda SEP ten yararlan1labilir (<b>^ekil 14, 15, 16, 17)</b>. <o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">MSS nin daha st dzeylerini tutan fokal ve yayg1n srelerde de SEP ten yararlan1labilir. rnein kortikal ve subkortikal kkenli miyoklonilerin ay1rt edilmesinde, ilkinde yksek amplitdl (dev) kortikal potansiyeller grlmesi nedeniyle SEP incelemesi faydal1 olabilir (<b style="">^ekil 18</b>). Kortikal geri averajlama yntemi ile miyoklonilere nclk eden kortikal bo_al1mlar1n gsterilmesi, kortikal miyokloni tan1s1n1 destekler (<b style="">^ekil 19</b>). </span><br> </p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p><br> </o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><b style=""><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><v:shape id="Resim_x0020_47" o:spid="_x0000_i1036" type="#_x0000_t75" style="width: 459.6pt; height: 316.8pt; visibility: visible;"> <v:imagedata src="ep_dosyalar/image014.jpg" o:title=""> </v:imagedata></v:shape></span></b><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><o:p></o:p></span></u></b></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><span style="color: purple;"><img src="up14.jpg" alt="" width="766" height="528"> <br> </span><span style="color: purple;">^ekil 14.</span></span></u></b><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif;"> Altm1_ dokuz ya_1nda, eski trafik kazas1 yks olan, 2 y1ld1r yava_a ilerleyen kollarda uyu_ma ve yrme gl yak1nmalar1 nedeniyle incelenen erkek hastan1n aksiyal </span><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">(<b>A) </b>ve sagital (<b>B</b>)</span><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif;"> planda T2 MR kesitlerinde </span><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">orta-alt servikal omurilikte, belirgin atrofiyle seyreden miyelomalazik lezyonu grlmektedir. Sa (<b>C</b>) ve sol (<b>D</b>) tibial SEP incelemesinde lomber ve kortikal potansiyeller elde edilememi_tir. Sa (<b>E</b>) ve sol (<b>F</b>) median SEP incelemesinde st servikal balant1lardan servikal N13 potansiyelleri elde edilememi_, sada kortikal N20 potansiyelleri hafif derecede uzun latansla kaydedilmi_tir. </span><br> </p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 72pt; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p><br> </o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><b style=""><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><v:shape id="Resim_x0020_48" o:spid="_x0000_i1035" type="#_x0000_t75" style="width: 427.2pt; height: 327.6pt; visibility: visible;"> <v:imagedata src="ep_dosyalar/image015.jpg" o:title=""> </v:imagedata></v:shape></span></b><img src="up15.jpg" alt="" width="667" height="511"> <br> <b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><o:p></o:p></span></u></b></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><span style="color: purple;">^ekil 15.</span></span></u></b><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif;"> Sol elde uyu_ma yak1nmas1 olan, st servikal blgede omurilikte sirengomiyeli bulunan 30 ya_1ndaki kad1n hastan1n sagital planda T2 (<b>A</b>) ve T1 (<b>B</b>) MR kesitleri ile median (<b>C, D</b>) ve tibial (E, F) SEP incelemeleri. Sol n. medianusun bilek seviyesinde uyar1m1yla servikal ve kortikal potansiyeller elde edilememi_tir.</span><br> </p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p><br> </o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><b style=""><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><v:shape id="Resim_x0020_50" o:spid="_x0000_i1034" type="#_x0000_t75" style="width: 429.6pt; height: 422.4pt; visibility: visible;"> <v:imagedata src="ep_dosyalar/image016.jpg" o:title=""> </v:imagedata></v:shape></span></b><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><o:p></o:p></span></u></b></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><span style="color: purple;"><img src="up16.jpg" alt="" width="541" height="532"> <br> </span><span style="color: purple;">^ekil 16.</span></span></u></b><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"> Alt1 buuk ya_1ndaki spina bifidali k1z ocuunun sagital ve aksiyal plandaT2 MR kesitleri (<b style="">A, B</b>) ve tibial SEP incelemesi (<b style="">C</b>). D10 seviyesi ve distalinde tam diastometamiyeli (<b style="">B</b>), D7 seviyesinde sringohidromiyeli, filar lipom ve gergin kord (<b style="">A</b>) mevcuttur. Tibial SEP incelemesinde kortikal yan1t potansiyelleri solda (dz siyah), saa gre (gri noktal1) 5ms daha uzun latansla kaydedilmi_tir ve merkezi iletim sresi solda saa gre 5,5ms uzundur.<br> </span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"><o:p><br> </o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><b style=""><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><v:shape id="Resim_x0020_51" o:spid="_x0000_i1033" type="#_x0000_t75" style="width: 469.8pt; height: 441.6pt; visibility: visible;"> <v:imagedata src="ep_dosyalar/image017.jpg" o:title=""> </v:imagedata></v:shape></span></b><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><o:p></o:p></span></u></b></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><span style="color: purple;"><img src="up17.jpg" alt="" width="837" height="785"> <br> </span><span style="color: purple;">^ekil 17.</span></span></u></b><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"> Kranyovertebral bile_ke anomalisi olan 36 ya_1ndaki kad1n hastan1n MR kesitleri (<b style="">A, B, C</b>), pre- (<b style="">D, E</b>) ve post-op (<b style="">F, G</b>) median SEP incelemeleri ile pre- (<b style="">H, I</b>) ve post-op (<b style="">J, K</b>) tibial SEP incelemeleri. Pre-op incelemelerde sa ve solda hem median hem de tibial kortikal potansiyellerin kay1p olduu grlmektedir. Post-op erken dnemde d_k amplitdl de olsa tm kortikal potansiyeller elde edilmi_tir. <b style="">*</b>Ameliyat kesisi nedeniyle C2 elektrodu yerle_tirileme<small>mi_tir </small></span><small>(Hasta Prof. Dr. Faruk nal taraf1ndan ameliyat edilmi_tir</small><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"><small>).</small><br> </span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"><br> <o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><b style=""><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><v:shape id="Resim_x0020_52" o:spid="_x0000_i1032" type="#_x0000_t75" style="width: 416.4pt; height: 348pt; visibility: visible;"> <v:imagedata src="ep_dosyalar/image018.jpg" o:title=""> </v:imagedata></v:shape></span></b><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><o:p></o:p></span></u></b></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><span style="color: purple;"><img src="up18.jpg" alt="" width="484" height="405"> <br> </span><span style="color: purple;">^ekil 18.</span></span></u></b><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"> </span><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif;">Yeni ba_lang1l1 progresif miyoklonik epilepsili 61 ya_1ndaki kad1n hastan1n sa median SEP incelemesi. 0lk 3 trase kortikal, sonuncu trase tenar kas kayd1n1 gstermektedir. Kortikal C3-Cz balant1s1nda 70V u bulan dev kortikal potansiyel kaydedilmi_tir. zellikle N35 bile_eninin artt11 grlmektedir. Tenar kay1tlarda, normalde istirahatte olmamas1 gereken orta latansl1, yksek amplitdl kortikal refleks (C refleksi) yan1t1 izlenmektedir.<br> </span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif;"><o:p><br> </o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><b style=""><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><v:shape id="Resim_x0020_53" o:spid="_x0000_i1031" type="#_x0000_t75" style="width: 461.4pt; height: 211.8pt; visibility: visible;"> <v:imagedata src="ep_dosyalar/image019.jpg" o:title=""> </v:imagedata></v:shape></span></b><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><o:p></o:p></span></u></b></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><span style="color: purple;"><img src="up19.jpg" alt="" width="769" height="353"> <br> </span><span style="color: purple;">^ekil 19.</span></span></u></b><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"> </span><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif;">Progresif miyoklonik epilepsili bir hastan1n geri averajlama incelemesi. nkoldan kaydedilen miyoklonik bo_al1mlar (siyah traseler) ile tetiklenerek 100ms lik traseler averajlanm1_t1r. Kortikal balant1lardan yap1lan kay1tlarda (ye_il ve petrol mavisi traseler), miyoklonilerin 22ms ncesinde kortikal de_arjlar izlenmektedir.</span><br> </p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif;"><o:p><br> </o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify; line-height: normal;"><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">SEP, travmatik veya post-anoksik komalarda prognoz belirlenmesinde deerli bir yere sahiptir. Bu durumdaki hastalarda st ekstremite uyar1m1 ile elde edilen kortikal SEP yan1tlar1n1n korunmas1 iyi, bilateral kayb1 ise kt prognozu (kal1c1 vejetatif durum gibi) i_aret eder. 0ntraoperatif SEP kay1tlamalar1 bu incelemenin olduka s1k faydalan1lan ba_ka bir kullan1m alan1n1 olu_turmaktad1r. Skolyoz cerrahisi gibi omurilie kal1c1 hasar olu_turma riskinin bulunduu operasyonlar s1ras1nda, bu konuda eitimli bir ekip devaml1 SEP kayd1 yapar ve iletim kusurunun elektrofizyolojik belirtileri grldnde cerrah1 uyar1r. Bylece kal1c1 hasara neden olacak giri_im sona erdirilebilir. Beyin ameliyatlar1 s1ras1nda primer motor korteksin yerinin belirlenmesinde, dorudan korteks zerinden kay1tlama ile yap1lan SEP lerden yararlan1labilmektedir.</span><span style="font-size: 10pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify; line-height: normal;"><span style="font-size: 10pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify; line-height: normal;"><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">Dermatomal uyar1m veya kutanz sinir uyar1m1 ile yap1lan SEP ler genellikle monoradikler lezyonlar1n ara_t1r1lmas1nda kullan1l1r. Bunlar1n ou kez elektromiyografi incelemesi ile elde edilenlere eklenebilecek bir elektrofizyolojik veri salamad11 d_nlr. Yine de baz1 nadir lezyonlar1n gsterilmesi ve lokalize edilmesinde yararl1 bilgiler salayabilirler (<b>^ekil 20</b>). </span><br> </p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify; line-height: normal;"><span style="font-size: 10pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><b><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"><br> </span></b><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><b style=""><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><v:shape id="Resim_x0020_33" o:spid="_x0000_i1030" type="#_x0000_t75" style="width: 434.4pt; height: 229.2pt; visibility: visible;"> <v:imagedata src="ep_dosyalar/image020.jpg" o:title=""> </v:imagedata></v:shape></span></b><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><o:p></o:p></span></u></b></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><span style="color: purple;"><img src="up20.jpg" alt="" width="784" height="414"> <br> </span><span style="color: purple;">^ekil 20.</span></span></u></b><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"> Sada L3 vertebra korpusu dzeyinde intraspinal kistik lezyonu olan hastan1n MR (<b>A</b>, <b>B</b>, <b style="">C</b>) tibial (D, E) ve dermatomal (F, G) SEP incelemeleri. Tibial SEP incelemelerinde iki yanl1 simetrik ve normal periferik, spinal ve kortikal potansiyeller kay1tlan1rken (<b>D, E</b>), L3 dermatomu zerinden duyu e_iinin 3 kat1 _iddetinde verilen elektriksel uyaranla elde edilen kortikal yan1tlar1n latans1, sa taraf uyar1m1 ile sola oranla belirgin olarak uzun bulunmu_tur (<b>F </b><span style="">ve<b> G</b></span>, vertikal izgi kar_1la_t1rmay1 kolayla_t1rmak amac1yla konmu_tur).</span><br> </p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p><br> </o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; line-height: normal;"><b><span style="font-size: 13.5pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">MOTOR UYANDIRILMI^ POTANS0YELLER (Motor Evoked Potentials=MEP)</span></b><span lang="EN-US" style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; line-height: normal;"><span lang="EN-US" style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">Buraya kadar incelediimiz uyand1r1lm1_ potansiyellerde MSS ye ula_an duyu yollar1na ili_kin veriler elde edilmektedir. MEP incelemelerinde ise MSS den evreye giden (eferent) motor yollar1n incelenmesi amalan1r (<b style="">^ekil 21</b>). Bu amala motor korteks zel elektriksel ya da manyetik uyar1c1larla uyar1l1r. Manyetik uyar1c1lar zellikle ar1s1z olmalar1 nedeni ile daha kullan1l1_l1d1r ve elektrofizyoloji ara_t1rma laboratuvarlar1nda olduka yayg1n _ekilde kullan1l1r hale gelmi_lerdir. Bir manyetik uyar1c1 yksek kapasiteli bir seri kondansatr ve bir bak1r sar1mdan (<i style="">coil</i>) olu_ur. Kondansatrn bo_almas1 ile sar1m evresinde ani ve yksek gte (1-3 T) bir manyetik alan dei_imi olu_ur. Bunun etkisi ile sar1m1n zerine yerle_tirildii blgeye kom_u nral dokular ierisinde iyon ak1mlar1 ortaya 1kar ve bunlar sinir dokusunu uyar1r. Manyetik uyar1m deri ve kemik gibi araya giren dokular taraf1ndan engellenmeden sinir dokusuna ula_1r, sz konusu evre dokular1 uyarmad11 iin de belirgin bir ar1 olu_turmaz. <o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; text-indent: 36pt; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"><span style=""> </span><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">0nen motor yollar1 tutan lezyonlar1n varl11nda kortikal yan1tlar1n latans1 ve M0S uzar veya kortikal yan1tlar kaybolabilir. MEP incelemelerinde korteksin uyar1labilirlik durumu gibi motor yan1tlar1n ortaya 1kmas1 ile ilintili ba_ka parametreler de incelenebilir. 0ncelemede kullan1lacak manyetik sar1mlar uyar1lmak istenen doku ve ara_t1r1lan parametrelere gre seilir. Geni_ apl1 ve yuvarlak sar1mlar gl bir manyetik alan yaratarak geni_ bir alan1 ve olduka derin yap1lar1 uyarabilir, buna kar_1l1k odaksal uyar1m yapamaz. Kk apl1 ve zellikle 8 rakam1 _eklindeki sar1mlar ise daha odaksal uyar1m salayabilir.</span><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><b style=""><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><v:shape id="Resim_x0020_29" o:spid="_x0000_i1029" type="#_x0000_t75" style="width: 378pt; height: 373.8pt; visibility: visible;"> <v:imagedata src="ep_dosyalar/image021.jpg" o:title=""> </v:imagedata></v:shape></span></b><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><o:p></o:p></span></u></b></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><span style="color: purple;"><img src="up21.jpg" alt="" width="525" height="519"> <br> ^ekil 21.</span></span></u></b><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"> Hipotenar kastan yzeyel elektrodlarla kay1tlanarak yap1lan MEP incelemesi. Kay1t traseleri zerindeki harfler, _ekil zerindeki uyar1m yerlerine kar_1l1k gelmektedir.</span><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">a, b ve c: N. ulnarisin bilek, dirsek ve aksilladan elektriksel supramaksimal uyar1m1 ile elde edilen bile_ik kas aksiyon potansiyelleri.</span><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">d: Manyetik sar1m, merkezi posterior servikal orta hatta olacak _ekilde yerle_tirilerek sinir kk uyar1m1 ile elde edilen motor yan1tlar.</span><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">e: Kortikal manyetik uyar1mla elde edilen MEP yan1tlar1 (3 yan1t st ste kaydedilmi_tir). <o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">Trase e ve d deki motor yan1tlar aras1ndaki latans fark1 merkezi iletim sresini verir.</span><br> </p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p><br> </o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">TMU, gnmzde motor i_lev bozukluu ile seyreden birok hastal1kta kortikomotor yollar1n i_levini test etmede kullan1lmaktad1r. Sessiz kalm1_ MS lezyonlar1n1 gstermede SEP ten daha duyarl1 olduunu gsteren al1_malar mevcuttur. 0nme olgular1n1n erken evreden itibaren prognozlar1n1n belirlenmesinde MEP incelemesinin rol konusunda olduka geni_ al1_malar yap1lm1_t1r. Motor nron hastal1klar1nda da genellikle anormal MEP bulgular1 saptan1r. zellikle primer lateral sklerozda kortikal uyar1mla motor yan1tlar1n elde edilememesi ya da ok d_k amplitdl ve ge latansl1 bulunmas1 tan1ya yard1mc1 olabilir (<b style="">^ekil 22</b>). Servikal spondilotik miyelopatide inen motor yollardaki iletimin aksamas1n1 gstermede MEP in, MR ve SEP ten daha duyarl1 olduu bildirilmi_tir <b>(^ekil 23)</b>. stelik MEP, bas1ya bal1 miyelopatiyi amiyotrofik lateral sklerozdan (ALS) ay1rt etmeye de yard1mc1 olur. Periferik sinirlerin rutin sinir iletim incelemeleri ile dorudan ara_t1r1lamayan proksimal segmentlerindeki lezyonlar1n (pleksopati, radiklopati gibi) elektrofizyolojik olarak lokalize edilmesinde de MEP ler kullan1labilir (<b>^ekil 24</b>). Ancak bu alandaki teknik problemler yeterince zlememi_tir. MEP, intraoperatif monitrizasyonda, zellikle omurilik cerrahisinde kullan1l1r. <o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; text-indent: 36pt; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify; line-height: normal;"><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">MEP ler periferik sinir uyar1m1yla elde edilen bile_ik kas aksiyon potansiyellerine gre genellikle daha d_k amplitdl olup, genlik, sre ve alanlar1 bir uyar1mdan dierine dei_ir. Bir kollisyon yntemi olan l uyar1m teknii (triple stimulation technique=TST), TMU ya cevaben olu_an motor nron de_arjlar1n1n senkron halini simle eder. Bu sayede kortikospinal iletim bozukluklar1, standart TMU yntemlerine gre daha hassas olarak saptan1r ve llr.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; line-height: normal;"><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><b style=""><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><v:shape id="Resim_x0020_28" o:spid="_x0000_i1028" type="#_x0000_t75" style="width: 297pt; height: 378.6pt; visibility: visible;"> <v:imagedata src="ep_dosyalar/image022.jpg" o:title=""> </v:imagedata></v:shape></span></b><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><o:p></o:p></span></u></b></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><span style="color: purple;"><img src="up22.jpg" alt="" width="405" height="517"> <br> ^ekil 22.</span></span></u></b><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"> </span><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif;">Primer lateral skleroz tan1s1yla izlenen 60 ya_1ndaki erkek hastan1n sa ve sol abduktor digiti minimi kaslar1ndan kaydedilen MEP incelemesi. Sada, kortikal uyar1mla elde edilen yan1tlar1n ok d_k amplitdl ve ge latansl1, merkezi iletim sresinin uzun olduu grlyor.<o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><b style=""><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><v:shape id="Resim_x0020_23" o:spid="_x0000_i1027" type="#_x0000_t75" style="width: 430.8pt; height: 303pt; visibility: visible;"> <v:imagedata src="ep_dosyalar/image023.jpg" o:title=""> </v:imagedata></v:shape></span></b><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><o:p></o:p></span></u></b></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><span style="color: purple;"><img src="up23.jpg" alt="" width="787" height="554"> <br> ^ekil 23.</span></span></u></b><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"> 0lerleyici yrme glnden yak1nan ve muayenesinde piramidal kuadriparezi bulgular1 saptanan hastada, MR grntleme incelemelerinde (<b>A, B</b>) C4-C5 dzeyinde omurilik ierisinde sinyal art1_1na neden olan lezyonun (servikal spondilotik miyelopati?) hastan1n yak1nmalar1ndan sorumlu olup olmad11 ara_t1r1l1yor. 0ki yanl1 mm. trapezius (<b>C</b> ve <b>D</b>) ve abduktor digiti minimiden (<b>E </b>ve <b>F</b>) kay1tlama ile yap1lan MEP incelemesinde elektriksel periferik sinir uyar1m1n1 izleyerek (C ve D de stteki traseler, E ve F de st traselerdeki ilk 4 potansiyel) manyetik sinir kk uyar1m1 (C ve D de ortadaki traseler, E ve F de st traselerde son potansiyeller) ve kortikal uyar1m (en alttaki traseler) yap1lm1_, </span><span style="font-size: 10pt; font-family: &quot;Times New Roman&quot;,serif; color: black;">! </span><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">merkezi iletim srelerini gsteriyor. Merkezi iletim sreleri C ve D de simetrik ve normal bulunurken, E ve F de sada bask1n (E) olmak zere belirgin derecede uzam1_. Bu durum, iki yanl1 inen motor yollar1 etkileyen orta servikal blge yerle_imli bir lezyonu d_ndryor ve grntleme incelemesinde saptanan hiperintens lezyonun klinik tablodan sorumlu olduunu telkin ediyor.</span><br> </p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><b><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: rgb(0,112,192);"><br> </span></b><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><b style=""><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><v:shape id="Resim_x0020_13" o:spid="_x0000_i1026" type="#_x0000_t75" style="width: 427.2pt; height: 197.4pt; visibility: visible;"> <v:imagedata src="ep_dosyalar/image024.jpg" o:title=""> </v:imagedata></v:shape></span></b><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><o:p></o:p></span></u></b></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><span style="color: purple;"><img src="up24.jpg" alt="" width="1096" height="506"> <br> ^ekil 24.</span></span></u></b><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"> Radyasyon pleksopatisi olgusunda (Bak1n1z:</span><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: rgb(0,0,204);"> </span><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><a href="http://www.itfnoroloji.org/spinalsinir/spinalsinir.html"><span style="color: purple;">Spinal Sinirlerin Hastal1klar1</span></a></span></u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">) <b>A</b> da radyasyona bal1 deri dei_iklii grlmekte (ok). <b>B </b>de sol (stteki traseler) ve sa (alttaki traseler) m. abduktor digiti minimiden kay1tlama yap1l1rken n. ulnarisin bilek, dirsek alt1, dirsek st ve aksilladan elektriksel uyar1m1 ve servikal manyetik sinir kk uyar1m1 ile elde edilen yan1tlar st ste konarak verilmi_. D_ey oklar servikal uyar1mla kaydedilen yan1tlar1n ba_lang1lar1n1 gsteriyor. Elektriksel uyar1mla elde edilen yan1tlar iki taraf aras1nda belirgin farkl1l1k gstermezken, sada sinir kk uyar1m1 ile elde edilen yan1t belirgin derecede daha ge latansl1 ve d_k amplitdl bulunmu_. Bu, radyasyona bal1 pleksus lezyonunun n planda segmental demiyelinizasyonla seyreden doas1na i_aret ediyor. <b>C</b> de hastan1n bir sa st ekstremite kas1n1n ine elektromiyografisinde kaydedilen ve radyasyon nropatileri iin olduka tan1 koydurucu olan miyokimik bo_al1m grlyor (ba_lang1 ve biti_i * ile i_aretlenmi_).</span><br> </p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p><br> </o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">MEP lerin dier bir kullan1m alan1, e_itli fizyolojik ve patolojik srelerin etkisiyle kortikal eksitabilitede ortaya 1kan dei_imlerin ara_t1r1lmas1d1r. Bu amala en ok kortikal uyar1labilirlik e_ii ve kortikal sessiz sre deerlendirilir veya farkl1 yntemlerle ikili kortikal uyar1m al1_malar1 yap1l1r (<b>^ekil 25</b>). Manyetik kortikal uyar1mlar, belirli fonksiyonlar1n korteks zerinde lokalize edilmesinde de kullan1labilir. Bu amala odaksal uyar1m veren sar1mlar kullan1larak, uyar1lmas1, belirli kay1t kaslar1nda en yksek yan1tlar1 olu_turan, belirli duyumlar1 ortaya 1karan, belirli grev ve fonksiyonlar1n icra edilmesini kolayla_t1ran ya da bask1layan blgeler haritalan1r ya da sz konusu blgeler ve fonksiyonlar aras1ndaki ili_kiler yksek bir zamansal duyarl1l1kla ara_t1r1labilir. Bu bulgular1n e_itli fizyolojik ve fizyopatolojik _artlar alt1ndaki dei_imi beynin fonksiyonlar1 ve plastik zellikleri konusundaki anlay1_1m1z1n geli_mesine nemli katk1lar salam1_t1r. <o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">Belirli frekanslarda tekrarlanan (repetitif) transkranyal manyetik uyar1mlar1n (rTMU), MSS de uyar1m1n kesilmesinden sonra da devam eden ve uzun sreli olabilen etkiler yaratt11 gsterilmi_tir. Bundan dolay1, rTMU ve transkranyal elektriksel uyar1m1n, baz1 nrolojik ve psikiyatrik hastal1k durumlar1n1n tedavisi ya da rehabilitasyonunda invazif olmayan umut verici bir tedavi yntemi olabilecei d_nlmektedir. rTMU, antidepresan ilalara direnli majr depresyon tedavisinde ve migren atak tedavisinde (tek uyar1m TMS) Amerika Bile_ik Devletleri nde  Food and Drug Administration onay1 alm1_t1r. Ar1, hareket bozukluklar1, inme rehabilitasyonu, MS, ALS,<span style=""> </span>Alzheimer hastal11, epilepsi, depresyon, anksiyete bozukluklar1, obsesif-komplsif bozukluk, madde ba1ml1l11, _izofreni ve tinnitus gibi birok alanda farkl1 protokollerle tedavi al1_malar1 devam etmekte, daha az zaman alacak ve daha uzun etkili olacak yeni tedavi protokolleri geli_tirilmeye al1_1lmaktad1r. </span><br> </p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: justify; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p><br> </o:p></span></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; line-height: normal;"><b style=""><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><v:shape id="Resim_x0020_5" o:spid="_x0000_i1025" type="#_x0000_t75" style="width: 300pt; height: 445.8pt; visibility: visible;"> <v:imagedata src="ep_dosyalar/image025.jpg" o:title=""> </v:imagedata></v:shape></span></b><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><o:p></o:p></span></u></b></p> <p class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt; text-align: justify; line-height: normal;"><b><u><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: purple;"><span style="color: purple;"><img src="up25.jpg" alt="" width="400" height="594"> <br> ^ekil 25.</span></span></u></b><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"> <b>A</b>) Manyetik uyar1mla olu_turulan sessiz sre. Kay1t kas1 istemli kas1 yaparken uygulanan transkranyal manyetik uyar1m, ift ba_l1 okla i_aretlenen sre iinde istemli motor aktiviteyi bask1lar. Daha sonra motor aktivite yeniden ba_lar. <b>B</b>) Normal denekte manyetik ift uyar1mla kortikal uyar1labilirlik (eksitabilite) al1_mas1. 0lk uyar1m trase ba_lang1c1nda e_ik alt1 _iddette verilir. 0kinci uyar1m (* ile i_aretli) her keresinde ayn1 e_ik st _iddette fakat ilk uyar1m1n ard1ndan gittike uzayan aral1klarla (uyar1mlar aras1 aral1k=interstimulus interval) verilir. Uyar1mlar aras1 aral1klar dei_tike ikinci uyar1m1n olu_turduu motor yan1t1n genlii dei_ir ve bylece ilk uyar1m1n ikincisi zerine olan etkisi ara_t1r1l1r.</span><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; line-height: normal;"><span style="font-size: 13.5pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-bottom: 0.0001pt; line-height: normal;"><b><span style="font-size: 14pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">KAYNAKLAR</span></b><b><span lang="EN-US" style="font-size: 14pt; font-family: &quot;Times New Roman&quot;,serif; color: black;"><o:p></o:p></span></b></p> <p class="MsoListParagraphCxSpFirst" style="text-indent: -18pt; line-height: normal;"><!--[if !supportLists]--><span lang="EN-US" style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"><span style="">1.<span style="font-family: &quot;Times New Roman&quot;; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-stretch: normal; font-size-adjust: none;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">Chawla J. Motor Evoked Potentials.</span><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif;"> </span><span class="MsoHyperlink"><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif;"><a href="https://emedicine.medscape.com/article/1139085-overview">https://emedicine.medscape.com/article/1139085-overview</a></span></span><span lang="EN-US" style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"><o:p></o:p></span></p> <p class="MsoListParagraphCxSpMiddle" style="text-indent: -18pt;"><!--[if !supportLists]--><span style="font-size: 10pt; line-height: 106%; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"><span style="">2.<span style="font-family: &quot;Times New Roman&quot;; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-stretch: normal; font-size-adjust: none;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; line-height: 106%; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">Chawla J, Burneo JG. Clinical Applications of Somatosensory Evoked Potentials. </span><span class="MsoHyperlink"><span style="font-size: 10pt; line-height: 106%; font-family: &quot;Tahoma&quot;,sans-serif;"><a href="https://emedicine.medscape.com/article/1139393-overview">https://emedicine.medscape.com/article/1139393-overview</a></span></span><span style="font-size: 10pt; line-height: 106%; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"><o:p></o:p></span></p> <p class="MsoListParagraphCxSpMiddle" style="text-indent: -18pt;"><!--[if !supportLists]--><span lang="EN-US" style="font-size: 10pt; line-height: 106%; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"><span style="">3.<span style="font-family: &quot;Times New Roman&quot;; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-stretch: normal; font-size-adjust: none;"> </span></span></span><!--[endif]--><span style="font-size: 10pt; line-height: 106%; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">Chiappa KH. Evoked Potentials in Clinical Medicine. 3<sup>rd</sup> Ed. New York: <span class="SpellE">Raven</span> <span class="SpellE">Press</span>, 1997.</span><span lang="EN-US" style="font-size: 10pt; line-height: 106%; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"><o:p></o:p></span></p> <p class="MsoListParagraphCxSpMiddle" style="text-indent: -18pt; line-height: normal;"><!--[if !supportLists]--><span lang="EN-US" style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"><span style="">4.<span style="font-family: &quot;Times New Roman&quot;; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-stretch: normal; font-size-adjust: none;"> </span></span></span><!--[endif]--><span class="SpellE"><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">Chokroverty</span></span><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"> S. <span class="SpellE">Magnetic</span> <span class="SpellE">Stimulation</span> in <span class="SpellE">Clinical</span> <span class="SpellE">Neurophysiology</span>. Boston: <span class="SpellE">Butterworths</span>, 1990.</span><span lang="EN-US" style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"><o:p></o:p></span></p> <p class="MsoListParagraphCxSpMiddle" style="text-indent: -18pt; line-height: normal;"><!--[if !supportLists]--><span lang="EN-US" style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"><span style="">5.<span style="font-family: &quot;Times New Roman&quot;; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-stretch: normal; font-size-adjust: none;"> </span></span></span><!--[endif]--><span class="SpellE"><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;">Evans</span></span><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"> AB, <span class="SpellE">Boggs</span> JG. <span class="SpellE">Clinical</span> <span class="SpellE">Utility</span> of <span class="SpellE">Evoked</span> <span class="SpellE">Potentials</span>. </span><span class="MsoHyperlink"><span style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif;"><a href="https://emedicine.medscape.com/article/1137451-overview">https://emedicine.medscape.com/article/1137451-overview</a></span></span><span lang="EN-US" style="font-size: 10pt; font-family: &quot;Tahoma&quot;,sans-serif; color: black;"><o:p></o:p></span></p> <p class="MsoListParagraphCxSpMiddle" style="text-indent: -18pt;"><!--[if !supportLists]--><span style="font-size: 10pt; line-height: 106%; font-family: &quot;Tahoma&quot;,sans-serif;"><span style="">6.<span style="font-family: &quot;Times New Roman&quot;; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-stretch: normal; font-size-adjust: none;"> </span></span></span><!--[endif]--><span class="SpellE"><span style="font-size: 10pt; line-height: 106%; font-family: &quot;Tahoma&quot;,sans-serif;">Groppa</span></span><span style="font-size: 10pt; line-height: 106%; font-family: &quot;Tahoma&quot;,sans-serif;"> S, <span class="SpellE">Oliviero</span> A, <span class="SpellE">Eisen</span> A, <span class="SpellE">Quartarone</span> A, <span class="SpellE">Cohen</span> LG, <span class="SpellE">Mall</span> V, <span class="SpellE">Kaelin-Lang</span> A, <span class="SpellE">Mima</span> T, <span class="SpellE">Rossi</span> S, <span class="SpellE">Thickbroom</span> GW, <span class="SpellE">Rossini</span> PM, <span class="SpellE">Ziemann</span> U, <span class="SpellE">Valls-Sol</span> J, <span class="SpellE">Siebner</span> HR. 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