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Siller S, Briegel J, Kunz M, Liebig T, Forbrig R, Tonn JC, Schichor C, Thorsteinsdottir J. Improved rates of postoperative ischemia, completeness of aneurysm occlusion and neurological deficits in elective clipping of anterior circulation aneurysms over the past 20 years - association with technical improvements. Acta Neurochir (Wien) 2024; 166:253. [PMID: 38847921 PMCID: PMC11161420 DOI: 10.1007/s00701-024-06150-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 05/29/2024] [Indexed: 06/10/2024]
Abstract
BACKGROUND/PURPOSE Several periprocedural adjuncts for elective surgical aneurysm treatment have been introduced over the last 20 years to increase safety and efficacy. Besides the introduction of IONM in the late-1990s, ICG-videoangiography (ICG-VAG) since the mid-2000s and intraoperative CT-angiography/-perfusion (iCT-A/-P) since the mid-2010s are available. We aimed to clarify whether the introduction of ICG-VAG and iCT-A/-P resulted in our department in a stepwise improvement in the rate of radiologically detected postoperative ischemia, complete aneurysm occlusion and postoperative new deficits. METHODS Patients undergoing microsurgical clip occlusion for unruptured anterior circulation aneurysms between 2000 and 2019 were included, with ICG-VAG since 2009 and iCT-A/-P (for selected cases) since 2016. Baseline characteristics and treatment-related morbidity/outcome focusing on differences between the three distinct cohorts (cohort-I: pre-ICG-VAG-era, cohort-II: ICG-VAG-era, cohort-III: ICG-VAG&iCT-A/-P-era) were analyzed. RESULTS 1391 patients were enrolled (n = 74 were excluded), 779 patients were interventionally treated, 538 patients were surgically clipped by a specialized vascular team (cohort-I n = 167, cohort-II n = 284, cohort-III n = 87). Aneurysm size was larger in cohort-I (8.9 vs. 7.5/6.8 mm; p < 0.01) without differences concerning age (mean:55years), gender distribution (m: f = 1:2.6) and aneurysm location (MCA:61%, ICA:18%, ACA/AcomA:21%). There was a stepwise improvement in the rate of radiologically detected postoperative ischemia (16.2vs.12.0vs.8.0%; p = 0.161), complete aneurysm occlusion (68.3vs.83.6vs.91.0%; p < 0.01) and postoperative new deficits (10.8vs.7.7vs.5.7%; p = 0.335) from cohort-I to -III. After a mean follow-up of 12months, a median modified Rankin scale of 0 was achieved in all cohorts. DISCUSSION Associated with periprocedural technical achievements, surgical outcome in elective anterior circulation aneurysm surgery has improved in our service during the past 20 years.
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Affiliation(s)
- Sebastian Siller
- Department of Neurosurgery, University Hospital, Ludwig-Maximilians-University of Munich (LMU), Campus Grosshadern, Marchioninistrasse 15, 81377, Munich, Germany.
- Department of Neurosurgery, University Hospital, University of Regensburg, Franz-Josef-Strauss-Allee 11, D-93053, Regensburg, Germany.
| | - Josef Briegel
- Department of Anesthesiology, University Hospital, Ludwig-Maximilians-University of Munich (LMU), Campus Grosshadern, Marchioninistrasse 15, 81377, Munich, Germany
| | - Mathias Kunz
- Department of Neurosurgery, University Hospital, Ludwig-Maximilians-University of Munich (LMU), Campus Grosshadern, Marchioninistrasse 15, 81377, Munich, Germany
| | - Thomas Liebig
- Department of Neuroradiology, University Hospital, Ludwig-Maximilians-University of Munich (LMU), Campus Grosshadern, Marchioninistrasse 15, 81377, Munich, Germany
| | - Robert Forbrig
- Department of Neuroradiology, University Hospital, Ludwig-Maximilians-University of Munich (LMU), Campus Grosshadern, Marchioninistrasse 15, 81377, Munich, Germany
| | - Joerg-Christian Tonn
- Department of Neurosurgery, University Hospital, Ludwig-Maximilians-University of Munich (LMU), Campus Grosshadern, Marchioninistrasse 15, 81377, Munich, Germany
| | - Christian Schichor
- Department of Neurosurgery, University Hospital, Ludwig-Maximilians-University of Munich (LMU), Campus Grosshadern, Marchioninistrasse 15, 81377, Munich, Germany
| | - Jun Thorsteinsdottir
- Department of Neurosurgery, University Hospital, Ludwig-Maximilians-University of Munich (LMU), Campus Grosshadern, Marchioninistrasse 15, 81377, Munich, Germany
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Tang F, Guo P, Lan X, Shi M, Feng Y. Effectiveness of MEP and SSEP Monitoring in the Diagnosis of Neurological Dysfunction Immediately After Craniotomy Aneurysm Clipping. J Craniofac Surg 2024; 35:e38-e44. [PMID: 37943050 DOI: 10.1097/scs.0000000000009825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 09/12/2023] [Indexed: 11/10/2023] Open
Abstract
OBJECTIVE To explore the diagnostic accuracy of motor-evoked potential (MEP) and somatosensory-evoked potential (SSEP) monitoring in predicting immediate neurological dysfunction after craniotomy aneurysm clipping. METHODS A total of 184 patients with neurosurgery aneurysms in the Affiliated Hospital of Qingdao University from April 2019 to December 2021 were retrospectively included. All patients underwent craniotomy aneurysm clipping, and MEP and SSEP were used to monitor during the operation. Receiver operating characteristic (ROC) curve analysis was used to determine the optimal cutoff value for early warning of MEP and SSEP amplitude decline and to evaluate the effectiveness of MEP and SSEP changes in predicting immediate postoperative neurological dysfunction. RESULTS Among the 184 patients with intracranial aneurysms, the incidences of immediate postoperative neurological dysfunction were 44.4% (12/27) and 3.2% (5/157) in patients with intraoperative MEP changes and without changes, respectively. For SSEP, The incidence rates were 52.6% (10/19) and 4.2% (7/165), respectively, and the differences were statistically significant ( P <0.001). Significant changes in intraoperative MEP and SSEP were significantly associated with the development of immediate postoperative neurological deficits ( P <0.05). The critical values for early warning of MEP and SSEP amplitude decrease were: 61.6% ( P < 0.001, area under the curve 0.803) for MEP amplitude decrease and 54.6% ( P <0.001, area under the curve 0.770) for SSEP amplitude decrease. The sensitivity and specificity of MEP amplitude change in predicting immediate postoperative neurological dysfunction were 70.6% and 91.0%, respectively. For SSEP amplitude changes, the sensitivity and specificity were 58.8% and 95.8%, respectively. CONCLUSIONS Motor-evoked potential and SSEP monitoring have moderate sensitivity and high specificity for immediate postoperative neurological dysfunction after craniotomy aneurysm clipping. Motor-evoked potential is more accurate than SSEP. Patients with changes in MEP and SSEP are at greatly increased risk of immediate postoperative neurologic deficits.
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Affiliation(s)
- Fengjiao Tang
- Department of Neurosurgery, The Affiliated Hospital of Qingdao University, Qingdao, China
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Silverstein JW, Shah HA, Ellis JA, D'Amico RS. Neuromonitoring Guided Vessel Identification in Iatrogenic Arterial Injury During Meningioma Resection. Neurodiagn J 2023; 63:47-57. [PMID: 36940463 DOI: 10.1080/21646821.2023.2168971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2023]
Abstract
Neuromonitoring is commonly used in neurosurgery and allows intraoperative assessment of functional pathways in the brain during surgery. Monitoring alerts can guide surgical decision making in real-time allowing surgeons to mitigate or avoid potential iatrogenic injury and subsequent postoperative neurologic sequelae that may result from cerebral ischemia or malperfusion. Here we present a case of a patient undergoing a right pterional craniotomy for the resection of a tumor which crosses midline with multimodal intraoperative neuromonitoring including somatosensory evoked potentials, transcranial motor evoked potentials, and visual evoked potentials. During the final portion of tumor resection, arterial bleeding was noted of unknown origin shortly followed by loss of right lower extremity motor evoked potential recordings. Motor evoked potential recordings in the right upper, and left upper and lower extremities were stable, as well as all somatosensory evoked potentials and visual evoked potentials. This distinct pattern of right lower extremity motor-evoked potential loss suggested compromise of the contralateral anterior cerebral artery and guided the surgeons to a rapid intervention. The patient awoke from surgery with moderate postoperative weakness in the affected limb that resolved to preoperative status by postoperative day 2, and back to normal strength prior to three-month follow-up. In this case the neuromonitoring data suggested compromise to the contralateral anterior cerebral artery which guided the surgeons to investigate and identify the site of vascular injury. The present case reinforces the utility of neuromonitoring in emergent surgical situations to guide surgical decision making.
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Affiliation(s)
- Justin W Silverstein
- Department of Neurology, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra, New York, New York
- Department of Clinical Neurophysiology, Neuro Protective Solutions, New York, New York
| | - Harshal A Shah
- Department of Neurological Surgery, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra, New York, New York
| | - Jason A Ellis
- Department of Neurological Surgery, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra, New York, New York
| | - Randy S D'Amico
- Department of Neurological Surgery, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra, New York, New York
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Silverstein JW, Doron O, Ellis JA. Temporary vessel occlusion in cerebral aneurysm surgery guided by direct cortical motor evoked potentials. Acta Neurochir (Wien) 2023; 165:645-646. [PMID: 36534185 DOI: 10.1007/s00701-022-05447-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 11/24/2022] [Indexed: 12/23/2022]
Affiliation(s)
- Justin W Silverstein
- Department of Neurology, Lenox Hill Hospital, Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
- Neuro Protective Solutions, New York, NY, USA
| | - Omer Doron
- Department of Neurosurgery, Lenox Hill Hospital, Zucker School of Medicine at Hofstra/Northwell, 130 East 77Th Street, Black Hall Bldg, Third Floor, New York, NY, 10075, USA
- Biomedical Engineering Department, The Iby and Aladar, Fleischman Faculty of Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Jason A Ellis
- Department of Neurosurgery, Lenox Hill Hospital, Zucker School of Medicine at Hofstra/Northwell, 130 East 77Th Street, Black Hall Bldg, Third Floor, New York, NY, 10075, USA.
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Silverstein JW, Doron O, Ellis JA. Deliberate Parent Artery Sacrifice Guided by Intraoperative Neurophysiological Monitoring During Complex Surgical Clipping of a Ruptured Anterior Communicating Artery Aneurysm. Neurodiagn J 2022; 62:108-119. [PMID: 35709517 DOI: 10.1080/21646821.2022.2072156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 04/26/2022] [Indexed: 06/15/2023]
Abstract
Aneurysms arising from the anterior communicating artery (ACOA) are the most common intracranial aneurysms encountered. Most aneurysms can be treated with surgical clipping or endovascular coiling; however, there are times when parent vessel sacrifice (PVS) is necessary such as aneurysms with fragile necks or large/giant aneurysms. Application of intraoperative neurophysiological monitoring (IONM) can assist in guiding permissive temporary vessel occlusion during complex aneurysm clippings. However, to-date there is no literature that describes how IONM can be used as a predictor of post-operative neurological status when PVS is employed or as a guide to determine whether PVS is safe. We present a case where IONM guided the sacrifice of the A1 and anterior communicating arteries after 2 hours and 25 min of temporary vessel occlusion. No attenuation was noted in the IONM at any point during the procedure, and the IONM predicted the patient would awake neurologically intact.
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Affiliation(s)
- Justin W Silverstein
- Department of Neurology, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra, New York, New York
- Department of Clinical Neurophysiology, Neuro Protective Solutions, New York, New York
| | - Omer Doron
- Department of Neurological Surgery, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra, New York, New York
| | - Jason A Ellis
- Department of Neurological Surgery, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra, New York, New York
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Doron O, Silverstein JW, Likowski D, Kohut K, Ellis JA. Temporary vessel occlusion in cerebral aneurysm surgery guided by direct cortical motor evoked potentials. Acta Neurochir (Wien) 2022; 164:1255-1263. [PMID: 35233664 DOI: 10.1007/s00701-022-05158-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 02/16/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Temporary clipping is an important tool in the vascular neurosurgeon's armamentarium. We routinely utilize intraoperative neurophysiological monitoring (IONM) for complex brain aneurysm surgery cases, relying on direct cortical motor evoked potential (DCMEP) alerts to guide the duration of temporary clipping. Previous studies have argued for relatively short and intermittent temporary clipping strategies. In this study, we sought to assess the maximal permissive temporary clipping time during complex aneurysm surgery. To do this, we assessed patient outcome in relation to temporary clip duration guided by DCMEP. METHODS We queried our prospectively collected neuromonitoring database for anterior circulation aneurysm cases where temporary clipping was utilized by a single cerebrovascular surgeon between 2018 and 2021. Operative and IONM reports were reviewed. Patients in whom the duration of temporary clipping could not be determined were excluded. The operative strategy permissively allowed continuous temporary clipping as long as no neuromonitoring alerts were encountered. Maximal permissive parent artery occlusion time (Clipmax) was recorded as the longest duration of tolerated temporary vessel clipping without decrement in DCMEP. RESULTS A total of 41 complex anterior circulation aneurysm clipping cases met criteria for this study. The mean Clipmax for all cases was just over 19 min and did not differ between ruptured and unruptured aneurysms. Initial alert times were not found to be predictive of final permissive temporary clip duration after re-perfusion. In 100% (41/41) of cases, the aneurysm was completely clip occluded without residual on catheter angiogram. Stable or improved modified Rankin Score was achieved in 98% (40/41) of cases at 3-month follow-up. CONCLUSIONS This study demonstrates that using DCMEP can facilitate relatively long but safe temporary clipping durations in complex anterior circulation aneurysm surgery. In the endovascular era with only a limited subset of technically challenging aneurysms needing open surgical treatment, extended permissive temporary clipping guided by DCMEPs can significantly enhance a surgeon's ability to achieve excellent technical and clinical outcomes.
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Affiliation(s)
- Omer Doron
- Department of NeurosurgeryZucker School of Medicine at Hofstra/NorthwellThird Floor, Lenox Hill Hospital, 130 East 77th Street, Black Hall Bldg, New York, NY, 10075, USA
- Biomedical Engineering Department, The Iby and Aladar Fleischman Faculty of Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Justin W Silverstein
- Department of Neurology, Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, NY, USA
- Neuro Protective Solutions, New York, NY, USA
| | - Desir Likowski
- Department of NeurosurgeryZucker School of Medicine at Hofstra/NorthwellThird Floor, Lenox Hill Hospital, 130 East 77th Street, Black Hall Bldg, New York, NY, 10075, USA
| | | | - Jason A Ellis
- Department of NeurosurgeryZucker School of Medicine at Hofstra/NorthwellThird Floor, Lenox Hill Hospital, 130 East 77th Street, Black Hall Bldg, New York, NY, 10075, USA.
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Ma RX, Qiao RQ, Xu MY, Li RF, Hu YC. Application of Controlled Hypotension During Surgery for Spinal Metastasis. Technol Cancer Res Treat 2022; 21:15330338221105718. [PMID: 35668701 PMCID: PMC9178972 DOI: 10.1177/15330338221105718] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
With advances in tumor treatment, metastasis to bone is increasing, and surgery has become the only choice for most terminal patients. However, spinal surgery has a high risk and is prone to heavy bleeding. Controlled hypotension during surgery has outstanding advantages in reducing intraoperative bleeding and ensuring a clear field of vision, thus avoiding damage to important nerves and vessels. Antihypertensive drugs should be carefully selected after considering the patient's age, different diseases, etc, and a single or combined regimen can be used. Hypotension also inevitably leads to a decrease in perfusion of important organs, so the threshold of hypotension and the maintenance time of hypotension should be strictly limited, and the monitoring of important organs during the operation is particularly important. Information such as blood perfusion, blood oxygen saturation, cardiac output, and neurophysiological conduction potential changes should be obtained in a timely fashion, which will help to reduce the risk of hypotension. In short, when applying controlled hypotension, it is necessary to choose an appropriate threshold and duration, and appropriate monitoring should be conducted during the operation to ensure the safety of the patient.
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Affiliation(s)
- Rong-Xing Ma
- 74768Tianjin Hospital, Tianjin, China.,Graduate School, 12610Tianjin Medical University, Tianjin, China
| | - Rui-Qi Qiao
- 74768Tianjin Hospital, Tianjin, China.,Graduate School, 12610Tianjin Medical University, Tianjin, China
| | - Ming-You Xu
- 74768Tianjin Hospital, Tianjin, China.,Graduate School, 12610Tianjin Medical University, Tianjin, China
| | - Rui-Feng Li
- 74768Tianjin Hospital, Tianjin, China.,Graduate School, 12610Tianjin Medical University, Tianjin, China
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Rabai F, Dorey CM, Fox WC, Fitzgerald KM, Seubert CN, Robicsek SA. Utility of evoked potentials during anterior cerebral artery and anterior communicating artery aneurysm clipping. Clin Neurophysiol Pract 2022; 7:228-238. [PMID: 35935596 PMCID: PMC9352509 DOI: 10.1016/j.cnp.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 06/30/2022] [Accepted: 07/15/2022] [Indexed: 11/28/2022] Open
Abstract
For anterior cerebral artery aneurysm clipping dual SSEPs and tcMEPs enhance detection of lower extremity deficits. Evoked potentials have limited utility in predicting upper extremity deficits related to subcortical ischemia. Four-extremity dual-modality monitoring can also detect pathogenetic mechanisms that are remote from the surgical site.
Objective To investigate the optimal combination of somatosensory- and transcranial motor-evoked potential (SSEP/tcMEP) modalities and monitored extremities during clip reconstruction of aneurysms of the anterior cerebral artery (ACA) and its branches. Methods A retrospective review of 104 cases of surgical clipping of ruptured and unruptured aneurysms was performed. SSEP/tcMEP changes and postoperative motor deficits (PMDs) were assessed from upper and lower extremities (UE/LE) to determine the diagnostic accuracy of each modality separately and in combination. Results PMDs were reported in 9 of 104 patients; 7 LE and 8 UE (3.6% of 415 extremities). Evoked potential (EP) monitoring failed to predict a PMD in 8 extremities (1.9%). Seven of 8 false negatives had subarachnoid hemorrhage. Sensitivity and specificity in LE were 50% and 97% for tcMEP, 71% and 98% for SSEP, and 83% and 98% for dual-monitoring of both tcMEP/SSEP. Sensitivity and specificity in UE were 38% and 99% for tcMEP, and 50% and 97% for tcMEP/SSEP, respectively. Conclusions Combined tcMEP/SSEP is more accurate than single-modality monitoring for LE but is relatively insensitive for UE PMDs. Significance During ACA aneurysm clipping, multiple factors may confound the ability of EP monitoring to predict PMDs, especially brachiofacial hemiparesis caused by perforator insufficiency.
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Affiliation(s)
- Ferenc Rabai
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224, USA
- Department of Anesthesiology, College of Medicine, University of Florida, 1600 Archer Road, PO Box 100254, Gainesville, FL 32610, USA
- Corresponding author at: Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
| | - Claire M. Dorey
- Department of Speech, Language and Hearing, University of Florida College of Health and Health Professions, PO Box 100174, Gainesville, FL 32610, USA
| | - W. Christopher Fox
- Department of Neurosurgery, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224, USA
| | - Krista M. Fitzgerald
- Department of Speech, Language and Hearing, University of Florida College of Health and Health Professions, PO Box 100174, Gainesville, FL 32610, USA
| | - Christoph N. Seubert
- Department of Anesthesiology, College of Medicine, University of Florida, 1600 Archer Road, PO Box 100254, Gainesville, FL 32610, USA
| | - Steven A. Robicsek
- Department of Anesthesiology, College of Medicine, University of Florida, 1600 Archer Road, PO Box 100254, Gainesville, FL 32610, USA
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