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Endoscopic Endonasal Skull Base Surgery Complication Avoidance: A Contemporary Review. Brain Sci 2022; 12:brainsci12121685. [PMID: 36552145 PMCID: PMC9776068 DOI: 10.3390/brainsci12121685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 12/03/2022] [Accepted: 12/05/2022] [Indexed: 12/13/2022] Open
Abstract
The endoscopic endonasal approach (EEA) provides a direct trajectory to ventral skull base lesions, avoidance of brain retraction, and clear visualization of cranial nerves as they exit skull base foramina. Despite these benefits, the EEA is not without complications. Here, we review published literature highlighting complications associated with the EEA including cerebrospinal fluid (CSF) leak, cranial nerve (CN) dysfunction, pituitary gland dysfunction, internal carotid artery (ICA) injury, infection, and others; we place special emphasis on discussing the prevention of these complications. As widespread adoption of the EEA continues, it becomes critical to educate surgeons regarding potential complications and their prevention while identifying gaps in the current literature to guide future research and advances in clinical care.
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Corniola MV, Roche PH, Bruneau M, Cavallo LM, Daniel RT, Messerer M, Froelich S, Gardner PA, Gentili F, Kawase T, Paraskevopoulos D, Régis J, Schroeder HW, Schwartz TH, Sindou M, Cornelius JF, Tatagiba M, Meling TR. Management of cavernous sinus meningiomas: Consensus statement on behalf of the EANS skull base section. BRAIN AND SPINE 2022; 2:100864. [PMID: 36248124 PMCID: PMC9560706 DOI: 10.1016/j.bas.2022.100864] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 01/08/2022] [Accepted: 01/16/2022] [Indexed: 01/04/2023]
Abstract
Introduction The evolution of cavernous sinus meningiomas (CSMs) might be unpredictable and the efficacy of their treatments is challenging due to their indolent evolution, variations and fluctuations of symptoms, heterogeneity of classifications and lack of randomized controlled trials. Here, a dedicated task force provides a consensus statement on the overall management of CSMs. Research question To determine the best overall management of CSMs, depending on their clinical presentation, size, and evolution as well as patient characteristics. Material and methods Using the PRISMA 2020 guidelines, we included literature from January 2000 to December 2020. A total of 400 abstracts and 77 titles were kept for full-paper screening. Results The task force formulated 8 recommendations (Level C evidence). CSMs should be managed by a highly specialized multidisciplinary team. The initial evaluation of patients includes clinical, ophthalmological, endocrinological and radiological assessment. Treatment of CSM should involve experienced skull-base neurosurgeons or neuro-radiosurgeons, radiation oncologists, radiologists, ophthalmologists, and endocrinologists. Discussion and conclusion Radiosurgery is preferred as first-line treatment in small, enclosed, pauci-symptomatic lesions/in elderly patients, while large CSMs not amenable to resection or WHO grade II-III are candidates for radiotherapy. Microsurgery is an option in aggressive/rapidly progressing lesions in young patients presenting with oculomotor/visual/endocrinological impairment. Whenever surgery is offered, open cranial approaches are the current standard. There is limited experience reported about endoscopic endonasal approach for CSMs and the main indication is decompression of the cavernous sinus to improve symptoms. Whenever surgery is indicated, the current trend is to offer decompression followed by radiosurgery. A thorough evaluation of cavernous sinus meningiomas by a multidisciplinary team is mandatory. Microsurgery should be considered for aggressive lesions in young patients. Extended endoscopic approaches can be effective when combined with radiotherapy. Stereotaxic radiotherapy and stereotaxic radiosurgery offer excellent tumour control in small/asymptomatic lesions .
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Jeong HN, Ahn SI, Na M, Yoo J, Kim W, Jung IH, Kang S, Kim SM, Shin HY, Chang JH, Kim EH. Triggered Electrooculography for Identification of Oculomotor and Abducens Nerves during Skull Base Surgery. J Korean Neurosurg Soc 2020; 64:282-288. [PMID: 33353290 PMCID: PMC7969041 DOI: 10.3340/jkns.2020.0179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 08/10/2020] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Electrooculography (EOG) records eyeball movements as changes in the potential difference between the negatively charged retina and the positively charged cornea. We aimed to investigate whether reliable EOG waveforms can be evoked by electrical stimulation of the oculomotor and abducens nerves during skull base surgery. METHODS We retrospectively reviewed the records of 18 patients who had undergone a skull base tumor surgery using EOG (11 craniotomies and seven endonasal endoscopic surgeries). Stimulation was performed at 5 Hz with a stimulus duration of 200 μs and an intensity of 0.1-5 mA using a concentric bipolar probe. Recording electrodes were placed on the upper (active) and lower (reference) eyelids, and on the outer corners of both eyes; the active electrode was placed on the contralateral side. RESULTS Reproducibly triggered EOG waveforms were observed in all cases. Electrical stimulation of cranial nerves (CNs) III and VI elicited positive waveforms and negative waveforms, respectively, in the horizontal recording. The median latencies were 3.1 and 0.5 ms for craniotomies and endonasal endoscopic surgeries, respectively (p=0.007). Additionally, the median amplitudes were 33.7 and 46.4 μV for craniotomies and endonasal endoscopic surgeries, respectively (p=0.40). CONCLUSION This study showed reliably triggered EOG waveforms with stimulation of CNs III and VI during skull base surgery. The latency was different according to the point of stimulation and thus predictable. As EOG is noninvasive and relatively easy to perform, it can be used to identify the ocular motor nerves during surgeries as an alternative of electromyography.
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Affiliation(s)
- Ha-Neul Jeong
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea.,Department of Neurology, Myongji Hospital, Goyang, Korea
| | - Sang-Il Ahn
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Minkyun Na
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jihwan Yoo
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - Woohyun Kim
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - In-Ho Jung
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - Soobin Kang
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Min Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Ha Young Shin
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Hee Chang
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea.,Brain Tumor Center, Severance Hospital, Seoul, Korea
| | - Eui Hyun Kim
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea.,Brain Tumor Center, Severance Hospital, Seoul, Korea
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Jahangiri FR, Azam A, Asdi RA, Ahmad I, Basha SI. Intraoperative Neurophysiological Monitoring During Trigeminal Schwannoma Surgery. Cureus 2020; 12:e10218. [PMID: 33042663 PMCID: PMC7535875 DOI: 10.7759/cureus.10218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 09/03/2020] [Indexed: 11/06/2022] Open
Abstract
Surgical manipulation during skull base surgeries places various cranial nerves (CN) at risk, including the nerves innervating the extraocular muscles. It could be very challenging for the surgeon to identify these cranial nerves due to the distortion of the normal anatomy by the tumors. Despite the recent advancement in technology, surgeries involving the third, fourth, fifth, and sixth cranial nerves still carry a risk of temporary or permanent paralysis of the muscles supplied by these cranial nerves. Intraoperative Neurophysiological Monitoring (IONM) with spontaneous and triggered electromyography (EMG) can help in guiding the surgeon in locating the nerves and avoiding any injury to them during the resection. IONM for extraocular cranial nerves requires highly skilled personnel with knowledge of anatomy and expertise in the placement of the electrodes. Benign tumors of the nerve sheath that arise from the perineural Schwann cells are known as schwannomas. Various cranial nerves might be involved in schwannomas of the head and neck. Trigeminal schwannomas are rare tumors. In this report, we describe the setup and stimulation technique and parameters as well as the benefits of utilizing IONM during the aggressive resection of a trigeminal schwannoma. The main purpose of utilizing IONM during these high-risk surgical procedures is to minimize any intraoperative damage to the neural structures involved.
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Affiliation(s)
- Faisal R Jahangiri
- Neurophysiology, Axis Neuromonitoring, Richardson, USA
- Neurophysiology, Global Innervation, Dallas, USA
- Behavioral and Brain Sciences, The University of Texas at Dallas, Richardson, USA
| | - Abeera Azam
- Neurophysiology, Axis Neuromonitoring, Richardson, USA
| | - Rabehah A Asdi
- Behavioral and Brain Sciences, The University of Texas at Dallas, Richardson, USA
- Neurophysiology, Axis Neuromonitoring, Richardson, USA
| | - Imtiaz Ahmad
- Neuronavigation, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, SAU
| | - Shaik I Basha
- Ear, Nose, and Throat Surgery, Sheikh Khalifa Medical City, Abu Dhabi, ARE
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Wang EW, Zanation AM, Gardner PA, Schwartz TH, Eloy JA, Adappa ND, Bettag M, Bleier BS, Cappabianca P, Carrau RL, Casiano RR, Cavallo LM, Ebert CS, El-Sayed IH, Evans JJ, Fernandez-Miranda JC, Folbe AJ, Froelich S, Gentili F, Harvey RJ, Hwang PH, Jane JA, Kelly DF, Kennedy D, Knosp E, Lal D, Lee JYK, Liu JK, Lund VJ, Palmer JN, Prevedello DM, Schlosser RJ, Sindwani R, Solares CA, Tabaee A, Teo C, Thirumala PD, Thorp BD, de Arnaldo Silva Vellutini E, Witterick I, Woodworth BA, Wormald PJ, Snyderman CH. ICAR: endoscopic skull-base surgery. Int Forum Allergy Rhinol 2020; 9:S145-S365. [PMID: 31329374 DOI: 10.1002/alr.22326] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 02/12/2019] [Accepted: 02/15/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS). METHODS Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus. RESULTS The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated. CONCLUSION A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Adam J Folbe
- Michigan Sinus and Skull Base Institute, Royal Oak, MI
| | | | | | - Richard J Harvey
- University of Toronto, Toronto, Canada.,University of New South Wales, Sydney, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Charles Teo
- Prince of Wales Hospital, Randwick, Australia
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Shkarubo AN, Chernov IV, Ogurtsova AA, Chernov VE, Borisov OV, Koval KV, Andreev DN. Cranial nerve monitoring in endoscopic endonasal surgery of skull base tumors (observing of 23 cases). Chin Neurosurg J 2018; 4:38. [PMID: 32922898 PMCID: PMC7398298 DOI: 10.1186/s41016-018-0146-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 11/01/2018] [Indexed: 12/03/2022] Open
Abstract
Background Preservation of anatomic integrity and function of the cranial nerves during the removal of skull base tumors is one of the most challenging procedures in endoscopic endonasal surgery. It is possible to use intraoperative mapping and identification of the cranial nerves in order to facilitate their preservation. The purpose of this study was to evaluate the effectiveness of intraoperative trigger electromyography in prevention of iatrogenic damage to the cranial nerves. Methods Twenty three patients with various skull base tumors (chordomas, neuromas, pituitary adenomas, meningiomas, cholesteatomas) underwent mapping and identification of cranial nerves during tumor removal using the endoscopic endonasal approach in Department of Neurooncology of Federal State Autonomous Institution “N.N. Burdenko National Medical Research Center of Neurosurgery” of the Ministry of Health of the Russian Federation from 2013 to 2018. During the surgical interventions, mapping and identification of the cranial nerves were carried out using electromyography in triggered mode. The effectiveness of the method was evaluated based on a comparison with a control group (41 patients). Results In the main group of patients, 44 nerves were examined during surgery using triggered electromyography. During the study, the III, V, VI, VII, and XII cranial nerves were identified intraoperatively. Postoperative cranial nerve deficiency was observed in 5 patients in the study group and in 13 patients in the control group. The average length of hospitalization was 9 days. Conclusion We did not receive statistically significant data supporting the fact that intraoperative identification of cranial nerves using trigger electromyography reduces the incidence of postoperative complications in the form of cranial nerve deficits (p = 0.56), but the odds ratio (0.6) suggests a less frequent occurrence of complications in the study group. Based on our experience, the trigger electromyography methodology appears quite promising and requires further research.
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Affiliation(s)
- A N Shkarubo
- Department of Neurooncology, Federal State Autonomous Institution "N.N. Burdenko National Medical Research Center of Neurosurgery" of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - I V Chernov
- Department of Neurooncology, Federal State Autonomous Institution "N.N. Burdenko National Medical Research Center of Neurosurgery" of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - A A Ogurtsova
- Department of Neurophysiology, Federal State Autonomous Institution "N.N. Burdenko National Medical Research Center of Neurosurgery" of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - V E Chernov
- Department of Neurosurgery, N.N. Burdenko Main Military Clinical Hospital of the Ministry of Defense of the Russian Federation, Moscow, Russia
| | - O V Borisov
- Laboratory of Molecular Human Genetics, Federal Research and Clinical Center of Physical-Chemical Medicine of Federal Medical Biological Agency, Moscow, Russia
| | - K V Koval
- Department of Neurooncology, Federal State Autonomous Institution "N.N. Burdenko National Medical Research Center of Neurosurgery" of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - D N Andreev
- Department of Neurooncology, Federal State Autonomous Institution "N.N. Burdenko National Medical Research Center of Neurosurgery" of the Ministry of Health of the Russian Federation, Moscow, Russia
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Electrophysiology of Extraocular Cranial Nerves: Oculomotor, Trochlear, and Abducens Nerve. J Clin Neurophysiol 2018; 35:11-15. [PMID: 29298208 DOI: 10.1097/wnp.0000000000000417] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The utility of extraocular cranial nerve electrophysiologic recordings lies primarily in the operating room during skull base surgeries. Surgical manipulation during skull base surgeries poses a risk of injury to multiple cranial nerves, including those innervating extraocular muscles. Because tumors distort normal anatomic relationships, it becomes particularly challenging to identify cranial nerve structures. Studies have reported the benefits of using intraoperative spontaneous electromyographic recordings and compound muscle action potentials evoked by electrical stimulation in preventing postoperative neurologic deficits. Apart from surgical applications, electromyography of extraocular muscles has also been used to guide botulinum toxin injections in patients with strabismus and as an adjuvant diagnostic test in myasthenia gravis. In this article, we briefly review the rationale, current available techniques to monitor extraocular cranial nerves, technical difficulties, clinical and surgical applications, as well as future directions for research.
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Li ZY, Li MC, Liang JT, Bao YH, Chen G, Guo HC, Ling F. Usefulness of intraoperative electromyographic monitoring of oculomotor and abducens nerves during skull base surgery. Acta Neurochir (Wien) 2017; 159:1925-1937. [PMID: 28766024 DOI: 10.1007/s00701-017-3268-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 07/05/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Intraoperative neurophysiologic monitoring of the extraocular cranial nerve (EOCN) is not commonly performed because of technical difficulty and risk, reliability of the result and predictability of the postoperative function of the EOCN. METHODS We performed oculomotor nerve (CN III) and abducens nerve (CN VI) intraoperative monitoring in patients with skull base surgery by recording the spontaneous muscle activity (SMA) and compound muscle action potential (CMAP). Two types of needle electrodes of different length were percutaneously inserted into the extraocular muscles with the free-hand technique. We studied the relationships between the SMA and CMAP and postoperative function of CN III and CN VI. RESULTS A total of 23 patients were included. Nineteen oculomotor nerves and 22 abducens nerves were monitored during surgery, respectively. Neurotonic discharge had a positive predictive value of less than 50% and negative predictive value of more than 80% for postoperative CN III and CN VI dysfunction. The latency of patients with postoperative CN III dysfunction was 2.79 ± 0.13 ms, longer than that with intact CN III function (1.73 ± 0.11 ms). One patient had transient CN VI dysfunction, whose CMAP latency (2.54 ms) was longer than that of intact CN VI function (2.11 ± 0.38 ms). There was no statistically significant difference between patients with paresis and with intact function. CONCLUSIONS The method of intraoperative monitoring of EOCNs described here is safe and useful to record responses of SMA and CMAP. Neurotonic discharge seems to have limited value in predicting the postoperative function of CN III and CN VI. The onset latency of CMAP longer than 2.5 ms after tumor removal is probably relevant to postoperative CN III and CN VI dysfunction. However, a definite quantitative relationship has not been found between the amplitude and stimulation intensity of CMAP and the postoperative outcome of CN III and CN VI.
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Shkarubo AN, Ogurtsova AA, Moshchev DA, Lubnin AY, Andreev DN, Koval' KV, Chernov IV. [Neurophysiological identification of the cranial nerves in endoscopic endonasal surgery of skull base tumors]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2017; 80:35-49. [PMID: 27296536 DOI: 10.17116/neiro201680335-49] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Intraoperative identification of the cranial nerves is a useful technique in removal of skull base tumors through the endoscopic endonasal approach. Searching through the scientific literature found one pilot study on the use of triggered electromyography (t-EMG) for identification of the VIth nerve in endonasal endoscopic surgery of skull base tumors (D. San-Juan, et al, 2014). AIM The study objective was to prevent iatrogenic injuries to the cranial nerves without reducing the completeness of tumor tissue resection. MATERIAL AND METHODS In 2014, 5 patients were operated on using the endoscopic endonasal approach. Surgeries were performed for large skull base chordomas (2 cases) and trigeminal nerve neurinomas located in the cavernous sinus (3). Intraoperatively, identification of the cranial nerves was performed by triggered electromyography using a bipolar electrode (except 1 case of chordoma where a monopolar electrode was used). Evaluation of the functional activity of the cranial nerves was carried out both preoperatively and postoperatively. RESULTS Tumor resection was total in 4 out of 5 cases and subtotal (chordoma) in 1 case. Intraoperatively, the IIIrd (2 patients), Vth (2), and VIth (4) cranial nerves were identified. No deterioration in the function of the intraoperatively identified nerves was observed in the postoperative period. In one case, no responses from the VIth nerve on the right (in the cavernous sinus region) were intraoperatively obtained, and deep paresis (up to plegia) of the nerve-innervated muscles developed in the postoperative period. The nerve function was not impaired before surgery. CONCLUSION The t-EMG technique is promising and requires further research.
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Affiliation(s)
- A N Shkarubo
- Burdenko Neurosurgical Institute, Moscow, Russia
| | | | - D A Moshchev
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - A Yu Lubnin
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - D N Andreev
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - K V Koval'
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - I V Chernov
- Sechenov First Moscow State Medical University, Moscow, Russia
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Shkarubo AN, Chernov IV, Ogurtsova AA, Moshchev DA, Lubnin AJ, Andreev DN, Koval KV. Neurophysiological Identification of Cranial Nerves During Endoscopic Endonasal Surgery of Skull Base Tumors: Pilot Study Technical Report. World Neurosurg 2016; 98:230-238. [PMID: 27989971 DOI: 10.1016/j.wneu.2016.10.089] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 10/16/2016] [Accepted: 10/18/2016] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Intraoperative identification of cranial nerves is crucial for safe surgery of skull base tumors. Currently, only a small number of published papers describe the technique of trigger electromyography (t-EMG) in endoscopic endonasal removal of such tumors. OBJECTIVE To assess the effectiveness of t-EMG in preventing intraoperative cranial nerve damage in endoscopic endonasal surgery of skull base tumors. MATERIALS AND METHODS Nine patients were operated on using the endoscopic endonasal approach within a 1-year period. The tumors included large skull base chordomas and trigeminal neurinomas localized in the cavernous sinus. During the surgical process, cranial nerve identification was carried out using monopolar and bipolar t-EMG methods. Assessment of cranial nerve functional activity was conducted both before and after tumor removal. RESULTS We mapped 17 nerves in 9 patients. Third, fifth, and sixth cranial nerves were identified intraoperatively. There were no cases of postoperative functional impairment of the mapped cranial nerves. In one case we were unable to get an intraoperative response from the fourth cranial nerve and observed its postoperative transient plegia (the function was normal before surgery). CONCLUSION t-EMG allows surgeons to control the safety of cranial nerves both during and after skull base tumor removal.
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Affiliation(s)
| | - Ilia Valerievich Chernov
- Department of Neurooncology, N. N. Burdenko Institute of Neurosurgery, Moscow, Russian Federation
| | | | | | - Andrew Jurievich Lubnin
- Department of Anesthesiology and Reanimatology, N. N. Burdenko Institute of Neurosurgery, Moscow, Russian Federation
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Sheshadri V, Bharadwaj S, Chandramouli BA. Intra-operative electrooculographic monitoring to prevent post-operative extraocular motor nerve dysfunction during skull base surgeries. Indian J Anaesth 2016; 60:560-5. [PMID: 27601738 PMCID: PMC4989806 DOI: 10.4103/0019-5049.187784] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND AND AIMS Intra-operative identification and preservation of extraocular motor nerves is one of the main goals of surgeries for skull base tumours and this is done by monitoring the extraocular movement (EOM). Intra-operative electromyographic monitoring has been reported, but it is a complex and skilful process. Electrooculography (EOG) is a simple and reliable technique for monitoring EOMs. We aimed to assess the utility of EOG monitoring in preventing extraocular motor nerve dysfunction during skull base surgeries. METHODS In this retrospective cohort study, intra-operative EOG recordings were obtained using disposable needle electrodes placed on the periorbital skin and the polarity of the waves noted for interpretation. Triggered as well as continuous EOG responses were recorded after monopolar electrode stimulation of cranial nerve (CN) during tumour removal which helped the surgeon with careful dissection and avoiding potential nerve injuries. RESULTS Of the 11 cases monitored, oculomotor and abducent nerves were identified in all cases, but the trochlear nerve could not be definitively identified. Six patients had no pre- or post-operative extraocular motor nerve dysfunction. The other five patients had pre-existing deficits before surgery, which recovered completely in two, significantly in one, and did not improve in two patients at 3-6 months follow-up. CONCLUSIONS EOG was found to be a simple and reliable method of monitoring extraocular motor nerves (CNs III and VI) intraoperatively.
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Affiliation(s)
- Veena Sheshadri
- Department of Anaesthesia, Toronto Western Hospital, Toronto, Canada
| | - Suparna Bharadwaj
- Department of Anaesthesia and Perioperative Medicine, Schulich School of Medicine and Dentistry, London, Ontario, Canada
| | - B A Chandramouli
- Department of Neurosurgery, Vikram Hospitals, Bengaluru, Karnataka, India
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Singh H, Vogel RW, Lober RM, Doan AT, Matsumoto CI, Kenning TJ, Evans JJ. Intraoperative Neurophysiological Monitoring for Endoscopic Endonasal Approaches to the Skull Base: A Technical Guide. SCIENTIFICA 2016; 2016:1751245. [PMID: 27293965 PMCID: PMC4886091 DOI: 10.1155/2016/1751245] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 04/04/2016] [Accepted: 04/11/2016] [Indexed: 06/06/2023]
Abstract
Intraoperative neurophysiological monitoring during endoscopic, endonasal approaches to the skull base is both feasible and safe. Numerous reports have recently emerged from the literature evaluating the efficacy of different neuromonitoring tests during endonasal procedures, making them relatively well-studied. The authors report on a comprehensive, multimodality approach to monitoring the functional integrity of at risk nervous system structures, including the cerebral cortex, brainstem, cranial nerves, corticospinal tract, corticobulbar tract, and the thalamocortical somatosensory system during endonasal surgery of the skull base. The modalities employed include electroencephalography, somatosensory evoked potentials, free-running and electrically triggered electromyography, transcranial electric motor evoked potentials, and auditory evoked potentials. Methodological considerations as well as benefits and limitations are discussed. The authors argue that, while individual modalities have their limitations, multimodality neuromonitoring provides a real-time, comprehensive assessment of nervous system function and allows for safer, more aggressive management of skull base tumors via the endonasal route.
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Affiliation(s)
- Harminder Singh
- Stanford Hospitals and Clinics, Department of Neurosurgery, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Richard W. Vogel
- Safe Passage Neuromonitoring, 915 Broadway, Suite 1200, New York, NY 10010, USA
| | - Robert M. Lober
- Stanford Hospitals and Clinics, Department of Neurosurgery, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Adam T. Doan
- Safe Passage Neuromonitoring, 915 Broadway, Suite 1200, New York, NY 10010, USA
| | - Craig I. Matsumoto
- Sentient Medical Systems, 11011 McCormick Road, Suite 200, Hunt Valley, MD 21031, USA
| | - Tyler J. Kenning
- Department of Neurosurgery, Albany Medical Center, Physicians Pavilion, First Floor, 47 New Scotland Avenue, MC 10, Albany, NY 12208, USA
| | - James J. Evans
- Thomas Jefferson University Hospital, Department of Neurosurgery, 909 Walnut Street, Third Floor, Philadelphia, PA 19107, USA
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Acioly MA, Liebsch M, de Aguiar PHP, Tatagiba M. Facial Nerve Monitoring During Cerebellopontine Angle and Skull Base Tumor Surgery: A Systematic Review from Description to Current Success on Function Prediction. World Neurosurg 2013; 80:e271-300. [DOI: 10.1016/j.wneu.2011.09.026] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2011] [Accepted: 09/06/2011] [Indexed: 11/17/2022]
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Thirumala PD, Mohanraj SK, Habeych M, Wichman K, Chang YF, Gardner P, Snyderman C, Crammond DJ, Balzer J. Value of Free-Run Electromyographic Monitoring of Extraocular Cranial Nerves during Expanded Endonasal Surgery (EES) of the Skull Base. J Neurol Surg Rep 2013; 74:43-50. [PMID: 23943720 PMCID: PMC3713562 DOI: 10.1055/s-0033-1346975] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Accepted: 03/05/2013] [Indexed: 12/04/2022] Open
Abstract
Objective To evaluate the value of free-run electromyography (f-EMG) monitoring of extraocular cranial nerves (EOCN) III, IV, and VI during expanded endonasal surgery (EES) of the skull base in reducing iatrogenic cranial nerve (CN) deficits. Design We retrospectively identified 200 patients out of 990 who had at least one EOCN monitored during EES. We further separated patients into groups according to the specific CN monitored. In each CN group, we classified patients who had significant (SG) f-EMG activity as Group I and those who did not as Group II. Results A total of 696 EOCNs were monitored. The number of muscles supplied by EOCNs that had SG f-EMG activity was 88, including CN III = 46, CN IV = 21, and CN VI = 21. There were two deficits involving CN VI in patients who had SG f-EMG activity during surgery. There were 14 deficits observed, including CN III = 3, CN IV = 2, and CN VI = 9 in patients who did not have SG f-EMG activity during surgery. Conclusions f-EMG monitoring of EOCN during EES can be useful in identifying the location of the nerve. It seems to have limited value in predicting postoperative neurological deficits. Future studies to evaluate the EMG of EOCN during EES need to be done with both f-EMG and triggered EMG.
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Affiliation(s)
- Parthasarathy D Thirumala
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA ; Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Neurophysiologic intraoperative monitoring of the oculomotor, trochlear, and abducens nerves. J Clin Neurophysiol 2012; 28:543-50. [PMID: 22146351 DOI: 10.1097/wnp.0b013e31823da47e] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Kawaguchi M, Ohnishi H, Sakamoto T, Shimizu K, Karasawa J, Furuya H. Intraoperative electrophysiologic monitoring of ocular motor nerves under conditions of partial neuromuscular blockade during skull base surgery. Skull Base Surg 2011; 6:9-15. [PMID: 17170948 PMCID: PMC1656506 DOI: 10.1055/s-2008-1058908] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The feasibility and usefulness of intraoperative electromyographic monitoring of the oculomotor nerve (CN III), trochlear nerve (CN IV), and abducens nerve (CN IV) were evaluated under conditions of partial neuromuscular blockade in 21 patients undergoing skill base surgery. Intracranial electrical stimulation of each nerve was performed, and compound muscle action potentials (CMAPs) were reconded from the inferior or superior rectus muscle, the superior oblique muscle, and the lateral rectus muscle for monitoring of CN III, IV, and VI, respectively. Partial neuromuscular blockade was achieved by controlled infusion of vecuronium titrated to eliminate about 90% of the twitch response of the abductor pollicis brevis to electrical stimulation of the median nerve. A total of 30 cranial nerves were stimulated intraoperatively. Of these, 29 were successfully monitored (19 CN III, 6 CN IV, 4 CN VI). A relationship was found between intraoperative findings of cranial nerve monitoring, such as disappearance of response and increase in latency and stimulus threshold during manipulation of a lesion, and the presence of postoperative nerve deficits. We conclude that intraoperative electromyographic monitoring of ocular motor nerves is feasible during partial neuromuscular blockade, and that partial neuromuscular blockade does not affect the relationship between findings of intraoperative monitoring and postoperative nerve function.
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Fukaya C, Katayama Y, Kasai M, Kurihara J, Yamamoto T. Intraoperative electro-oculographic Monitoring for Skull Base Surgery. Skull Base Surg 2011; 10:11-5. [PMID: 17171096 PMCID: PMC1656743 DOI: 10.1055/s-2000-6788] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
During surgery on the skull base, preservation of the integrity of the ocular motor nerves is vitally important. Intraoperative electrophysiological monitoring methods for protecting such functions have been reported by several investigators. However, these methods so far have not been popularized sufficiently, due to the difficulty and complexity of the procedures involved. The authors have developed an extremely simple but far more reliable method using electro-oculography under total intravenous anesthesia with propofol to preserve the integrity of the ocular motor nerves. The ocular motor nerves were stimulated with a monopolar electrode intracranially, and the polarity of the waves was recorded using surface electrodes placed around the eyeball, yielding precise information concerning the locations of the oculomotor nerve and/or abducent nerve. In addition, by performing continuous monitoring, invasive procedures affecting the ocular motor nerves could be detected as spontaneous ocular movements. In practice at our department, this method has been applied in 12 cases with tumors close to the ocular motor nerves, and has produced excellent results.
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Ortler M, Fiegele T, Walser G, Trinka E, Eisner W. Cranial nerve monitoring during subpial dissection in temporomesial surgery. Acta Neurochir (Wien) 2011; 153:1181-9. [PMID: 21424600 DOI: 10.1007/s00701-011-0987-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2009] [Accepted: 02/22/2011] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Cranial nerves (CNs) crossing between the brainstem and skull base at the level of the tentorial hiatus may be at risk in temporomesial surgery involving subpial dissection and/or tumorous growth leading to distorted anatomy. We aimed to identify the surgical steps most likely to result in CN damage in this type of surgery. METHODS Electromyographic responses obtained with standard neuromonitoring techniques and a continuous free-running EMG were graded as either contact activity or pathological spontaneous activity (PSA) during subpial resection of temporomesial structures in 16 selective amygdalohippocampectomy cases. Integrity of peripheral motor axons was tested by transpial/transarachnoidal electrical stimulation while recording compound muscle action potentials from distal muscle(s). RESULTS Continuous EMG showed pathological activity in five (31.2%) patients. Nine events with PSA (slight activity, n = 8; strong temporary activity, n = 1) were recorded. The oculomotor nerve was involved three times, the trochlear nerve twice, the facial nerve once, and all monitored nerves on three occasions. Surgical maneuvers associated with PSA were the resection of deep parts of the hippocampus and parahippocampal gyrus (CN IV, twice; CN III, once), lining with or removing cotton patties from the resection cavity (III, twice; all channels, once) and indirect exertion of tension on the intact pia/arachnoid of the uncal region while mobilizing the hippocampus and parahippocampal gyrus en bloc (all channels, once; III, once). CMAPs were observed at 0.3 mA in two patients and at 0.6 mA in one patient, and without registering the exact amount of intensity in three patients. CONCLUSION The most dangerous steps leading to cranial nerve damage during mesial temporal lobe surgery are the final stages of the intervention while the resection is being completed in the deep posterior part and the resection cavity is being lined with patties. Distant traction may act on nerves crossing the tentorial hiatus via the intact arachnoid.
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Affiliation(s)
- Martin Ortler
- Clinical Department of Neurosurgery, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria.
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Lefaucheur JP, Neves D, Vial C. Évaluation électrophysiologique des nerfs crâniens moteurs (V, VII, IX, X, XI, XII). Neurochirurgie 2009; 55:136-41. [DOI: 10.1016/j.neuchi.2009.01.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2009] [Accepted: 01/14/2009] [Indexed: 11/29/2022]
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Edwards BM, Kileny PR. Intraoperative Neurophysiologic Monitoring: Indications and Techniques for Common Procedures in Otolaryngology–Head and Neck Surgery. Otolaryngol Clin North Am 2005; 38:631-42, viii. [PMID: 16005722 DOI: 10.1016/j.otc.2005.03.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Intraoperative cranial nerve monitoring can be an effective adjunct in otolaryngology-head and neck surgery. Monitoring is not considered standard of care, despite indications of cost effectiveness and improved functional outcomes. Lessons learned performing facial nerve monitoring are applicable to upper and lower cranial motor nerves. Auditory nerve monitoring can be modified accord-ing to need for selected otologic and neurotologic surgery. Process standardization and effective communication can lead to improved patient outcomes.
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Affiliation(s)
- Bruce M Edwards
- Division of Audiology and Electrophysiology, Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health System, 1500 East Medical Center Drive, TC 1904, Ann Arbor, Michigan 43109, USA.
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Sasaki T, Suzuki K, Matsumoto M, Sato T, Kodama N, Yago K. Origins of surface potentials evoked by electrical stimulation of oculomotor nerves: are they related to electrooculographic or electromyographic events? J Neurosurg 2002; 97:941-4. [PMID: 12405385 DOI: 10.3171/jns.2002.97.4.0941] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Evoked potentials elicited by electrical stimulation of the oculomotor nerve and recorded from surface electrodes placed on the skin around the eyeball reportedly originate in the eye and are represented on electrooculograms. Because evoked potentials recorded from surface electrodes are extremely similar to those of extraocular muscles, which are represented on electromyograms, the authors investigated the true origin of these potentials. METHODS Evoked potentials elicited by electrical stimulation of the canine oculomotor nerve were recorded from surface electrodes placed on the skin around the eyeball. A thread sutured to the center of the cornea was pulled and the potentials that were evoked during the resultant eye movement were recorded. These potentials were confirmed to originate in the eye and to be represented on electrooculograms because their waveforms were unaffected by the administration of muscle relaxant. To eliminate the influence of this source, the retina, a main origin of standing potentials of the eyeball, was removed. This resulted in the disappearance of electrooculography (EOG) waves elicited by eye movement. Surface potentials elicited by oculomotor nerve stimulation were the same before and after removal of the retina. Again the oculomotor nerve was electrically stimulated and electromyography (EMG) response of the extraocular muscles was recorded at the same time that potentials were recorded from the surface electrodes. In their peak latencies, amplitudes, and waveforms, the evoked potentials obtained from surface electrodes were almost identical to EMG responses of extraocular muscles. CONCLUSIONS Evoked potentials elicited by electrical stimulation of the oculomotor nerves and obtained from surface electrodes originated from EMG responses of extraocular muscles. These evoked potentials do not derive from the eye.
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Affiliation(s)
- Tatsuya Sasaki
- Department of Neurosurgery, Fukushima Medical University, Japan.
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Sasaki T, Sato M, Suzuki K, Kikuchi Y, Itakura T, Matsumoto M, Kodama N. Intraoperative Monitoring of the Upper Cranial Nerves. ACTA ACUST UNITED AC 2001. [DOI: 10.7887/jcns.10.99] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
| | - Masanori Sato
- Department of Neurosurgery, Fukushima Medical School
| | | | | | | | | | - Namio Kodama
- Department of Neurosurgery, Fukushima Medical School
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Fukaya C, Katayama Y, Kasai M, Kurihara J, Yamamoto T. Intraoperative electrooculographic monitoring of oculomotor nerve function during skull base surgery. Technical note. J Neurosurg 1999; 91:157-9. [PMID: 10389898 DOI: 10.3171/jns.1999.91.1.0157] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Intraoperative monitoring techniques for protecting the integrity of the oculomotor nerves during skull base surgery have been reported by several investigators, all of which involved the use of electromyographic responses to extraocular muscles. However, these techniques have not yet become popular because of the complexity of the procedures. The authors report an extremely simple and far more reliable technique in which electrooculographic (EOG) monitoring is used. The oculomotor nerves were stimulated with a monopolar electrode during skull base exposure. The polarity of the EOG responses recorded with surface electrodes placed on the skin around the eyeball yielded precise information concerning the location and function of the oculomotor and abducent nerves. In addition, with the aid of continuous EOG monitoring that detected transient changes in the background waves, surgical procedures that might impinge on oculomotor nerve function could be avoided. The present technique has been used in eight patients with skull base tumors and with it, the authors have achieved excellent results.
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Affiliation(s)
- C Fukaya
- Department of Neurological Surgery, Nihon University School of Medicine, Tokyo, Japan.
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