How Does The BIS Monitor Work?

When we are asked by the anaesthetic registrar or resident or anaesthetic assistant or nurse about how
that “Brainwave box” works- many of us are stumped for an answer or may give relatively vague
replies. But now there is no need for dismay when you are next asked about the BIS monitor. Smile
confidently and trot out this simple yet precise explanation:

“It’s really quite simple. The BIS monitor is a depth of anaesthesia monitor. For the first time it allows the anaesthetist to actually monitor how
“asleep” our patient is. It has a wide range of applications that are of potential benefit to the anaesthetist by allowing him or her to titrate the
optimum anaesthetic for the individual patient. BIS refers to the Bispectral Index. The BIS monitor is a compact processing module designed to
assimilate, process and display the BIS index which is a complex, proprietary electroencephalographic (EEG) parameter. To put it even more
simply, it collects raw EEG data, processes it and after subjecting the processed data to a computational algorithm it generates a single
dimensionless number between 0 and 100. A reading of 100 corresponds to the wide awake alert state and a reading of 0 corresponds with an
isoelectric, i.e. flat EEG. Readings between 40 and 60 correlate with a depressed level of consciousness similar to that of general anaesthesia.
Although the scale is linear, the clinical correlates are not; for example the risk of awareness is exponentially reduced with falling BIS values.
How then does the module perform this feat? First we have to remind ourselves of some details regarding the EEG. The electrical activity of
neurons is composed of action potentials and postsynaptic potentials (PSP). Synaptic activity creates focal patches of altered membrane potential
and ionic currents flow between these disturbances. PSPs generate slowly changing currents within the dendrites of neighbouring pyramidal cells
in the brain cortex. The extracellular component of this current generates voltages that are detectable on the scalp as the EEG. The EEG is a
random, alternating voltage composed of many sine waves superimposed on each other. Under some conditions the EEG may contain stereotypic
waveforms, for example spikes are created by massive but transient synchrony. Anaesthesia is associated with increasing cortical synchrony.
Typical EEG changes seen during general anaesthesia include an increase in the average amplitude of waveforms and a decrease in their average
frequency. Unfortunately the relationship between the dosage of anaesthetic and changes in EEG power and frequency is exceedingly complex and
it has required significant time and effort to develop an EEG derived parameter that accurately reflects anaesthetic depth.
To get information of clinical interest from the EEG it must be processed. But prior to this, artefact must first be removed from the signal.
Common artefacts include the electrocardiogram (ECG), the power line voltage and the electromyogram (EMG). The first two “common mode”
signals are eliminated by using a differential amplifier that has connections to a reference (R) electrode as well as positive (+) and negative (-)
electrodes. The amplifier simply subtracts the difference between R/+ and R/-. The EMG can be removed using a low pass filter to remove high
frequencies because these are different to the EEG frequency range. Once the artefact has been removed the signal can be processed. The EEG is
an analog signal and it is easier to process a digital signal. The conversion of an analog to a digital signal is termed sampling. Sampling occurs at
regular intervals, the reciprocal of the sampling interval is known as the sampling rate, the sampling rate units are in Hertz (Hz). A set of samples
in a finite period of time is termed an epoch. Sampling results in a loss of fidelity in the digital signal. To minimize this digital EEG systems have
a high sampling rate in the order of 250 Hz. Digital signals differ from analog ones in that their values are quantitated to a fixed resolution. The
resolution required for EEG monitoring systems is 12-16 bits.
Having filtered and digitized the EEG the BIS monitor now processes the data to calculate several parameters. There are three types of
processed parameters: time domain, frequency domain and the higher order bispectral parameters. Time domain analysis refers to examining how
the EEG voltage changes over time. One of these methods is burst suppression quantitation. For an epoch we can construct an EEG amplitude
histogram over time. The burst suppression ratio (BSR) measures the fraction of the epoch length where the EEG voltage doesn’t exceed +/- 5mV.
When discussing frequency domain methods of EEG analysis we recall that a sine wave is a function of time and is described by three
parameters- amplitude, frequency and phase angle. Phase angle is a way to describe the starting point of the waveform- spokes on a wheel
analogy. By Fourier analysis any complicated time varying waveform such as the EEG can be decomposed into the sum of simple sine waves.
Fourier transformation refers to the conversion of a time domain waveform into its sine wave frequency components. This transformation
generates a frequency spectrum- a histogram of wave amplitudes or phase angles as a function of frequency. However, this approach to Fourier
transformation is computationally laborious so the Fast Fourier Transform (FFT) algorithm was developed. This generates data in the form of a
power vs. frequency histogram. Data from sequential epochs are plotted in a stack form so that changes in frequency distribution over time are
readily apparent. The compressed spectral array (CSA) presents the data as a pseudo 3D perspective plot. However, by arbitrarily dividing the
continuous waveform into epochs artefact may be introduced due to artefactual frequencies created by the abrupt transitions at the ends of the
epoch. Window functions such as the Blackman function can minimize this artefact. Another consideration with FFT generated data is that for
ease of comparison of epochs using correlation it is necessary to convert the near normal distributed data to a normal distribution by taking the
logarithm of the data.
The third type of processed parameter is the bispectrum, a third order statistical analysis of EEG data. This measures the correlation of phase
between different frequency components. For each triplet of frequency components generated by FFT (f1, f2, f1+f2) the bispectrum is calculated as a
complex product and a bicoherence value is derived (number between 0-1). A high bicoherence value correlates with phase coupling which reflects
synchrony. Increased synchrony is seen in states such as anaesthesia. Bispectral values are calculated for epochs and averaged over time.
We have glossed over the types of parameters that can be generated through analysis of EEG data. Where then does the Bispectral Index come
from? Its formulation can be conceptualized as a stepwise process: firstly there was collection of artefact clear EEGs from multiple subjects
undergoing anaesthetics under varying regimes. Sub-parameters were calculated from the data and ranked statistically. A multivariate statistical
model was used to create the final composite parameter which best correlated with behaviour. The Bispectral Index was subjected to prospective
testing and has been validated and improved further by a wealth of clinical use and study.
Finally, we can describe in detail which parameters are used and how they are integrated to generate the final BIS value. The single use BIS
electrode (Quatro sensor) records the EEG over the frontal-temporal cortex of the patient. The EEG sample is digitized, filtered to exclude high
and low frequency artefacts (ECG, EMG, eye blinks, diathermy, forced air warmer) and is divided into 2s epochs. Two separate algorithms are
used to generate the time domain parameter which in the case of BIS is the degree of burst suppression. One of these is the BSR as described
above, it is reported as the fraction of the epoch during which the criteria are met. The other is QUAZI which detects burst suppression in the
presence of wandering baseline voltage, for example slow wave activity. Further parameters are calculated after the data is subjected to a
Blackman Window function. Next Fast Fourier Transformation of the data is done and the bispectrum of the epochs are calculated and averaged.
The frequency domain parameter is the Beta Ratio: this is the log ratio of power in 2 empirically derived frequency bands = log (P 30-47Hz/ P11-20Hz).
The bispectral parameter, SynchFastSlow, is also computed as a log ratio: log (B0.5-47Hz/B40-47Hz).
The combination algorithm that determines the final BIS value combines these parameters using a nonlinear function. The algorithm weights
various parameters more heavily depending on the EEG characteristics, eg. Beta Ratio during light sedation; SynchFastSlow when EEG shows
activation and surgical anaesthesia; BSR/QUAZI during deep anaesthesia. The final BIS value represents an averaged value for the previous 30s.
An advantage of the algorithm is that it can be further improved with the incorporation of other parameters. Indeed the module has been subjected
to several revisions since its initial release. Current modules display several forms of information in addition to the BIS value: SQI or signal quality
index is self-explanatory, EMG indicates how much high frequency activity is present and the Suppression Ratio (SR) indicates the period of time
over the last 63s in which the EEG has been in a suppressed state. Well, I hope that’s cleared up any queries you might have.”

References:
Rampil, I. A Primer for EEG Processing in Anaesthesia. Anesthesiology 89(4) Oct 1998, 980-1002.
Kelley, S. Monitoring Level of Consciousness During Anesthesia and Sedation. A Clinician’s Guide to the Bispectral Index.