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Stone JL, Bailes JE, Hassan AN, Sindelar B, Patel V, Fino J. Brainstem Monitoring in the Neurocritical Care Unit: A Rationale for Real-Time, Automated Neurophysiological Monitoring. Neurocrit Care 2017; 26:143-156. [PMID: 27484878 DOI: 10.1007/s12028-016-0298-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Patients with severe traumatic brain injury or large intracranial space-occupying lesions (spontaneous cerebral hemorrhage, infarction, or tumor) commonly present to the neurocritical care unit with an altered mental status. Many experience progressive stupor and coma from mass effects and transtentorial brain herniation compromising the ascending arousal (reticular activating) system. Yet, little progress has been made in the practicality of bedside, noninvasive, real-time, automated, neurophysiological brainstem, or cerebral hemispheric monitoring. In this critical review, we discuss the ascending arousal system, brain herniation, and shortcomings of our current management including the neurological exam, intracranial pressure monitoring, and neuroimaging. We present a rationale for the development of nurse-friendly-continuous, automated, and alarmed-evoked potential monitoring, based upon the clinical and experimental literature, advances in the prognostication of cerebral anoxia, and intraoperative neurophysiological monitoring.
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Affiliation(s)
- James L Stone
- Department of Neurosurgery, NorthShore University HealthSystem, Evanston, IL, USA. .,Departments of Neurology and Neurological Surgery, University of Illinois at Chicago, Chicago, IL, USA. .,Division of Neurosurgery, Department of Surgery, Cook County Stroger Hospital, Chicago, IL, USA.
| | - Julian E Bailes
- Department of Neurosurgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - Ahmed N Hassan
- Departments of Neurology and Neurological Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Brian Sindelar
- Department of Neurosurgery, NorthShore University HealthSystem, Evanston, IL, USA.,Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Vimal Patel
- Department of Neurosurgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - John Fino
- Departments of Neurology and Neurological Surgery, University of Illinois at Chicago, Chicago, IL, USA
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Abstract
Findings for auditory brainstem response (ABR) before and after surgical removal of a cerebellar tumor in a 10-year-old female are presented. ABR improved markedly, although the tumor showed no direct invasion to the brainstem. The cause of the ABR change and the origin of wave III are discussed.
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Affiliation(s)
- M Kaga
- National Institute of Mental Health, National Center of Neurology and Psychiatry, Chiba, Japan
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Dauch WA. Prediction of secondary deterioration in comatose neurosurgical patients by serial recording of multimodality evoked potentials. Acta Neurochir (Wien) 1991; 111:84-91. [PMID: 1950693 DOI: 10.1007/bf01400493] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
In 75 comatose neurosurgical patients suffering from various types of intracranial lesions, multimodality evoked potentials (auditory, somatosensory, visual) were serially recorded at short intervals in order to evaluate their usefulness for early detection of secondary deterioration in the clinical course. The best parameter for prediction of secondary deterioration (as estimated by pupillary status) was a diminution in amplitude or disappearance of the primary cortical SEP peak. Considering these parameters, sensitivity of the prediction of pupillary behaviour was 71%, specificity 84%. Additional consideration of SEP latencies or BAEP or VEP parameters did not further increase the efficacy of prediction. In cases of correct positive prediction, deterioration of SEP occurred 4 to 144 hours before the deterioration of pupillary physiology.
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Affiliation(s)
- W A Dauch
- Department of Neurosurgery, Philipps University, Marburg, Federal Republic of Germany
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Liu CW, Chu NS, Ryu SJ. CT, somatosensory and brainstem auditory evoked potentials in the early prediction of functional outcome in putaminal hemorrhage. Acta Neurol Scand 1991; 84:28-32. [PMID: 1927258 DOI: 10.1111/j.1600-0404.1991.tb04898.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The CT and median somatosensory and brainstem auditory evoked potentials (SEP and BAEP) were studied in 80 patients with spontaneous putaminal hemorrhage for their values in the early prediction of functional outcome. The CT scan was performed within 2 days and EPs within a week after the onset of symptoms. The activities of daily living was assessed at 6 months. Patients with good functional recovery had the following findings: 1) the hemorrhage had not involved the thalamus or the posterior limb of the internal capsule; 2) the SEPs were normal or had prolonged central conduction time; and 3) the BAEP was normal. When the cortical SEPs were absent, the majority of patients were moderately or severely disabled. Attenuation or absence of BAEP wave V always forecast a grave prognosis. It is concluded that the combined use of CT, SEP and BAEP is an objective and reliable method for the early prediction of functional outcome in patients with putaminal hemorrhage.
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Affiliation(s)
- C W Liu
- Department of Neurology, Chang Gung Medical College, Taipei, Taiwan
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Ghaly RF, Stone JL, Subramanian KS, Roccaforte P, Hughes JR. Modified auditory brainstem responses (MABR). Part 2--Studies in patients with intracranial lesions. CLINICAL EEG (ELECTROENCEPHALOGRAPHY) 1988; 19:95-107. [PMID: 3396211 DOI: 10.1177/155005948801900211] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- R F Ghaly
- Department of Surgery, Cook County Hospital, Chicago, Illinois 60612
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Docherty TB, Herbaut AG, Sedgwick EM. Brainstem auditory evoked potential abnormalities in myelomeningocoele in the older child. J Neurol Neurosurg Psychiatry 1987; 50:1318-22. [PMID: 3681310 PMCID: PMC1032458 DOI: 10.1136/jnnp.50.10.1318] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Brainstem auditory evoked potentials and clinical findings were examined in 18 children over the age of 5 years who were born with myelomeningocoele which was closed at birth, and whose hydrocephalus was managed by long term shunting in most of them. The potentials were compared with age and sex matched normal subjects and with four patients with hydrocephalus only. All but one had an abnormal brainstem auditory evoked potential with 72% showing a delay in the II-V and I-V interpeak latencies of more than three standard deviations. It is proposed that the abnormalities are a reflection of brainstem dysgenesis which is part of an associated Arnold-Chiari malformation, though the malformation was clinically asymptomatic in all. The usefulness of the brainstem auditory evoked potential for assessing the course of hydrocephalus and for predicting symptomatic Arnold-Chiari malformation is questioned.
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Shigemori M, Yuge T, Kawasaki K, Tokutomi T, Kawaba T, Nakashima H, Watanabe M, Kuramoto S. Evaluation of brain dysfunction in hypertensive putaminal hemorrhage with multimodality evoked potentials. Stroke 1987; 18:72-6. [PMID: 3810773 DOI: 10.1161/01.str.18.1.72] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Changes in multimodality evoked potentials (MEP's), consisting of somatosensory evoked potentials (SEP's), visual evoked potentials (VEP's), and auditory evoked brainstem responses (AEBR's), were studied in 36 patients with hypertensive putaminal hemorrhage to ascertain the relation among areas and distribution of brain dysfunction, the size of hemorrhage on computerized tomographic scan, and the clinical outcome. Among MEP's, SEP's were most significantly involved in all patients. Abnormalities in VEP's and AEBR's remained mild or moderate when the hemorrhage did not extend to the diencephalon. If SEP's were normal or mildly abnormal, they improved early the ictus. These patients did well clinically. If SEP's were absent, the patients had poor outcome even when the hemorrhage was small and located outside the internal capsule. In contrast, deterioration or persistence of MEP's indicated secondary insult to the brain and poor patient outcome. Early and serial MEP studies are useful in evaluating primary and secondary brain dysfunction and in predicting patient outcome in hypertensive putaminal hemorrhage.
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Stone JL, Subramanian KS, Nagao S. Brain-stem evoked responses to CPA compression. J Neurosurg 1986; 65:128-9. [PMID: 3486949 DOI: 10.3171/jns.1986.65.1.0128a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Tsutsui T, Nitta M, Ladds A, Symon L. Effects of an expanding supratentorial mass on the auditory brain-stem responses in baboons. Acta Neurochir (Wien) 1986; 79:132-8. [PMID: 3962743 DOI: 10.1007/bf01407457] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
This study was carried out to investigate the effects of an expanding supratentorial mass on auditory brain-stem responses (ABRs). A balloon was inserted into the supratentorial epidural space of seven baboons (in two cases, in the right occipital area; in five cases, in the right temporal area). The balloons were inflated at a rate of 0.2 ml/minute to increase intracranial pressure (ICP). ICP (right frontal epidural pressure) and blood pressure (BP) were continuously recorded. Recordings of ABRs (vertex to mastoid on both sides) were made serially. Pupillary changes were also recorded. At 30 mmHg ICP, the amplitude of wave V on the right side was observed to be significantly attenuated (p less than 0.02). At 50 mm Hg ICP, the latency of wave V on the right side was significantly prolonged compared with that at 30 mm Hg ICP (p less than 0.02). At 70 mmHg ICP, significantly decreased amplitude of wave V on the left side was also observed (p less than 0.02, from the control), associated with significant increased latency of wave IV on the right side (p less than 0.01, from the control; p less than 0.05, from 50 mm Hg ICP). Finally, waves IV and V on both sides substantially disappeared at 100 mm Hg ICP. Anisocoria appeared in four animals at 30-50 mm Hg (mean +/- SD; 45 +/- 8.7) ICP. The amplitude of wave V was significantly decreased in these circumstances (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)
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Pediatric applications of serial auditory brainstem and middle-latency evoked response recordings. Int J Pediatr Otorhinolaryngol 1985; 9:201-18. [PMID: 2414242 DOI: 10.1016/s0165-5876(85)80036-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Serial auditory brainstem (ABR) and middle-latency (AMR) response recordings were made for 12 children (8 male, 4 female) ranging in age from 2 weeks to 10 years. A total of 40 ABR and 32 AMR assessments were carried out at bedside in varied hospital environments, including a pediatric intensive care unit (ICU), a neonatal ICU and an operating room. Clinical entities were distributed as follows: acute, severe head injury (5), hydrocephalus (2), meningomyelocele (2), hyperbilirubinemia (1), ototoxic drug overdose (1), severe developmental delay (1). Auditory evoked responses were applied in monitoring peripheral and central auditory system status, and contributed to medical, surgical and audiologic management. Abnormalities of the ABR were reversed in some children, such as those with hydrocephalus, with medical or surgical therapy. In other cases, such as a hyperbilirubinemic child, a marked ABR abnormality apparently reversed spontaneously. We present five cases to illustrate diverse applications of serial auditory evoked response measures in children.
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Stone JL, Bouffard A, Morris R, Hovsepian W, Meyers HL. Clinical and electrophysiologic recovery in Arnold-Chiari malformation. SURGICAL NEUROLOGY 1983; 20:313-7. [PMID: 6623343 DOI: 10.1016/0090-3019(83)90087-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The case of a 16-year-old boy with occipital headache, diplopia, ataxia, and weakness in the lower extremities of 1-month duration is reported. Slowness of mentation, speech, and motor action was also present. Massive chronic hydrocephalus was indicated by an enlarged head. The prominent clinical features suggested involvement of the brainstem, and contrast studies showed compression of the brainstem and a filling defect posteriorly at C1-2. Brainstem auditory evoked potential latency suggested bilateral lesions of the brainstem. Posterior fossa decompression confirmed the presence of an Arnold-Chiari malformation, with the cerebellar tonsils as low as C-3. The fourth ventricle was microdissected and opened. Remarkable clinical and evoked potential recovery ensued over several months. Clinical-anatomic and anatomic-physiologic correlations in Arnold-Chiari malformation are discussed.
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