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Pérez-Alfayate R, Torregrossa F, Rey-Picazo J, Matías-Guiu J, Sallabanda-Díaz K, Grasso G. Pilot Trial on Awake Surgery for Low-Grade Arteriovenous Malformations in Speech Area and Systematic Review of the Literature. World Neurosurg 2024; 189:154-160. [PMID: 38857871 DOI: 10.1016/j.wneu.2024.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Accepted: 06/04/2024] [Indexed: 06/12/2024]
Abstract
OBJECTIVE One of the pressing constraints in the treatment of arteriovenous malformations (AVM) is the potential development of new neurologic deficits, mainly when the AVM is in an eloquent area. The risk of ischemia when an en passage arterial supply is present is not negligible. In this regard, awake surgery holds promise in increasing the safety of low-grade AVM resection. METHODS We conducted a pilot trial on 3 patients with low-grade AVMs affecting speech areas to evaluate the safety of awake craniotomy using Conscious Sedation. Each feeder was temporarily clipped before the section. Also, we performed a systematic review to analyze the existing data about the impact of awake surgery in eloquent AVM resection. RESULTS None of the 3 patients presented with neurologic deficits after the procedure. Awake craniotomy was useful in 1 case, as it allowed the detection of speech arrest during the temporal clipping of 1 of the feeders. This vessel was identified as an en passage vessel, closer to the nidus. The second attempt revealed the feeder of the AVM, which was sectioned. Systematic review yielded 7 studies meeting our inclusion criteria. Twenty-six of 33 patients included in these studies presented with AVM affecting speech area. Only 2 studies included the motor evoked potentials. Six studies used direct cortical and subcortical stimulation. In all studies the asleep-awake-asleep technique was used. CONCLUSIONS Awake craniotomies are safe procedures and may be helpful in avoiding ischemic complications in low-grade AVMs, either affecting eloquent areas and/or when en passage feeders are present.
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Affiliation(s)
- Rebeca Pérez-Alfayate
- Department of Neurosurgery, Institute of Neuroscience, Hospital Clínico San Carlos, Madrid, Spain.
| | - Fabio Torregrossa
- Neurosurgical Unit, Department of Biomedicine, Neurosciences and Advanced Diagnostics (BiND), University of Palermo, Palermo, Italy
| | - Julio Rey-Picazo
- Department of Anesthesiolgy, Institute of Neuroscience, Hospital Clínico San Carlos, Madrid, Spain
| | - Jordi Matías-Guiu
- Department of Neurology, Institute of Neuroscience, Hospital Clínico San Carlos, Madrid, Spain
| | - Kita Sallabanda-Díaz
- Department of Neurosurgery, Institute of Neuroscience, Hospital Clínico San Carlos, Madrid, Spain
| | - Giovanni Grasso
- Neurosurgical Unit, Department of Biomedicine, Neurosciences and Advanced Diagnostics (BiND), University of Palermo, Palermo, Italy
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Zhang F, Tang F, Wang C, Feng Y. ROC Curve Analysis of Electrophysiological Monitoring and Early Warning During Intracranial Aneurysm Clipping. World Neurosurg 2021; 155:e49-e54. [PMID: 34358687 DOI: 10.1016/j.wneu.2021.07.131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 07/27/2021] [Accepted: 07/28/2021] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To explore the safe duration of temporary clipping of the parent artery under intraoperative electrophysiological monitoring. METHODS The clinical data of 97 patients who underwent intracranial aneurysm clipping under electrophysiological monitoring in the Department of Neurology, Affiliated Hospital of Qingdao University from June 2019 to June 2020 were retrospectively analyzed. The safety duration of temporary clipping was analyzed using receiver operating characteristic (ROC) curves, and the results were validated in clinical data. RESULTS Temporary clipping during operation (P < 0.05) and electrophysiological warning during operation (P < 0.05) were related risk factors of a cerebral ischemia event after operation. The ROC curve was drawn for the duration of temporary clipping and the occurrence of intraoperative electrophysiological warning, and the area under the curve was 0.78 (P < 0.05). The optimal cutoff value was 372.5 seconds, the sensitivity was 0.818, and the specificity was 0.762. After reviewing the clinical data, P < 0.05 was statistically significant after a χ2 test with 372.5 seconds equal to approximately 6 minutes. The ROC curve was drawn for the duration of temporary clipping and the time of postoperative ischemia, and the area under the curve was 0.667 (P < 0.05). The optimal cutoff value was 430.5 seconds, the sensitivity was 0.592, and the specificity was 0.842. CONCLUSION Temporary intraoperative block is the risk factor for cerebral ischemia after operation. In this study, the temporary clipping time of the parent artery should not be longer than 6 minutes, and there is approximately 1 minute to adjust the current procedure after the electrophysiological warning to restore the baseline of intraoperative electrophysiological monitoring.
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Affiliation(s)
- Fengyue Zhang
- Department of Neurosurgery, the Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Fengjiao Tang
- Department of Neurosurgery, the Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Chao Wang
- Department of Neurosurgery, the Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Yugong Feng
- Department of Neurosurgery, the Affiliated Hospital of Qingdao University, Qingdao, Shandong, China.
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3
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You H, Fan X, Guo D, Li Z, Tao X, Qi L, Ling M, Liu J, Qiao H. Efficacy of evoked potential monitoring for predicting postoperative motor status in internal carotid artery aneurysm surgeries. J Clin Monit Comput 2021; 36:667-673. [PMID: 33755845 DOI: 10.1007/s10877-021-00693-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 03/12/2021] [Indexed: 12/17/2022]
Abstract
This study aimed to investigate the efficacy of intraoperative motor evoked potential (MEP) and somatosensory evoked potential (SSEP) monitoring for predicting postoperative motor deficits (PMDs) in patients with internal carotid artery (ICA) aneurysms. The data for 138 patients with ICA aneurysms who underwent surgical clipping as well as their intraoperative neuromonitoring data were retrospectively reviewed. The efficacy of MEP/SSEP changes for predicting PMDs was assessed using binary logistic regression analysis. Subsequently, receiver operating characteristic curve analysis was used to obtain a supplementary critical value of the MEP/SSEP deterioration duration. The sensitivity and specificity of MEP changes for predicting PMDs were 0.824 and 0.843, respectively. For SSEP changes, the sensitivity and specificity were 0.529 and 0.959, respectively. MEP and SSEP changes were identified as independent predictors for short-term (p = 0.002 and 0.011, respectively) and long-term PMDs (p = 0.040 and 0.006, respectively). The supplementary critical value for MEP deterioration duration for predicting PMDs was 14 min (p = 0.007, AUC = 0.805). For SSEP, the value was 14.5 min (p = 0.042, AUC = 0.875). The MEP/SSEP changes adjusted by those optimal values were also identified as independent predictors for short-term (p < 0.001 and p = 0.005, respectively) and long-term PMDs (p = 0.019 and 0.003, respectively). Intraoperative MEP and SSEP deterioration durations are effective in predicting PMDs in patients with ICA aneurysms.
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Affiliation(s)
- Hao You
- Department of Neurophysiology, Beijing Neurosurgical Institute, Capital Medical University, 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Xing Fan
- Department of Neurophysiology, Beijing Neurosurgical Institute, Capital Medical University, 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Dongze Guo
- Department of Neurophysiology, Beijing Neurosurgical Institute, Capital Medical University, 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Zhibao Li
- Department of Neurophysiology, Beijing Neurosurgical Institute, Capital Medical University, 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Xiaorong Tao
- Department of Neurophysiology, Beijing Neurosurgical Institute, Capital Medical University, 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Lei Qi
- Department of Neurophysiology, Beijing Neurosurgical Institute, Capital Medical University, 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Miao Ling
- Department of Neurophysiology, Beijing Neurosurgical Institute, Capital Medical University, 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Jiajia Liu
- Department of Neurophysiology, Beijing Neurosurgical Institute, Capital Medical University, 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Hui Qiao
- Department of Neurophysiology, Beijing Neurosurgical Institute, Capital Medical University, 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, China.
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Zhu F, Chui J, Herrick I, Martin J. Intraoperative evoked potential monitoring for detecting cerebral injury during adult aneurysm clipping surgery: a systematic review and meta-analysis of diagnostic test accuracy. BMJ Open 2019; 9:e022810. [PMID: 30760514 PMCID: PMC6377512 DOI: 10.1136/bmjopen-2018-022810] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES We aim to evaluate the diagnostic test accuracy (DTA) of intraoperative evoked potential (EP) monitoring to detect cerebral injury during clipping of cerebral aneurysms. DESIGN Systematic review. DATA SOURCES Major electronic databases including MEDLINE, EMBASE, LILACS. ELIGIBILITY CRITERIA We included studies that reported the DTA of intraoperative EP monitoring during intracranial aneurysm clipping procedures in adult patients. DATA EXTRACTION AND SYNTHESIS After quality assessment, we performed a meta-analysis using the bivariate random effects model, and calculated the possible range of DTA point estimates using a new best-case/worst-case scenario approach to quantify the impact of rescue intervention on DTA. RESULTS A total of 35 studies involving 4011 patients were included. The quality of the primary studies was modest and the heterogeneity across studies was high. The pooled sensitivity and specificity for predicting postoperative neurological deficits for the somatosensory evoked potential (SSEP) monitoring was 59% (95% CI: 39% to 76%; I2: 76%) and 86% (95% CI: 77% to 92%; I2: 94%), for motor evoked potential (MEP) monitoring was 81% (95% CI: 58% to 93%; I2: 54%) and 90% (95% CI: 86% to 93%; I2: 81%), and for combined SSEP and MEP monitoring was 92% (95% CI: 62% to 100%) and 88% (95% CI: 83% to 93%). The best-case/worst-case range for the pooled point estimates for sensitivity and specificity for SSEP was 50%-63% and 81%-100%, and for MEP was 59%-74% and 93%-100%, and for combined SSEP and MEP was 89%-94% and 83%-100%. CONCLUSIONS Due to the modest quality and high heterogeneity of the existing primary studies, it is not possible to confidently support or refute the diagnostic value of EP monitoring in cerebral aneurysm clipping surgery. However, combined SSEP and MEP appears to provide the best DTA for predicting postoperative stroke. Contrary to popular assertion, the modest sensitivity of SSEP monitoring is not explained by the use of rescue intervention. PROSPERO REGISTRATION NUMBER CRD42015016884.
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Affiliation(s)
- Fang Zhu
- Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Centre for Medical Evidence Decision Integrity and Clinical Impact (MEDICI), Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Jason Chui
- Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Ian Herrick
- Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Janet Martin
- Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Centre for Medical Evidence Decision Integrity and Clinical Impact (MEDICI), Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
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Thomas B, Guo D. The Diagnostic Accuracy of Evoked Potential Monitoring Techniques During Intracranial Aneurysm Surgery for Predicting Postoperative Ischemic Damage: A Systematic Review and Meta-Analysis. World Neurosurg 2017; 103:829-840.e3. [PMID: 28433839 DOI: 10.1016/j.wneu.2017.04.071] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 04/09/2017] [Accepted: 04/10/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate the diagnostic accuracy of various evoked potential monitoring techniques in predicting postoperative neurologic deficit in intracranial aneurysm surgery. METHODS A literature search of the MEDLINE, Embase, and Cochrane databases was conducted for English language articles published between March 31, 1983 and March 31, 2016. Original studies that reported the use of evoked potential monitoring during intracranial aneurysm surgery in predicting postoperative neurologic damage were selected, and their relevant reference lists were hand searched. Test performance characteristics were summarized using hierarchic summary receiver operating characteristic (ROC) curves and bivariable random-effects models. RESULTS Thirteen qualifying studies (1597 patients; 1689 aneurysms) from 6 countries were identified. Eight studies investigated the use of the somatosensory evoked potential (SSEP) monitoring technique, 5 investigated transcranial motor evoked potential (TcMEP) and another 5 investigated direct cortical motor evoked potential (DMEP). Bivariable pooled sensitivity and specificity were 48% (95% confidence interval [CI], 30.7-65.0) and 92% (CI, 88%-94.4%), respectively, for SSEP; 73% (CI, 21.0%-96.7%) and 94% (CI, 87.1%-97.5%) for TcMEP; and 97% (CI, 74.43%-99.99%) and 89% (CI, 84.0%-94.5%) for DMEP. ROC curve analysis showed that TcMEP had the highest accuracy (area under ROC curve 0.95; 95% CI, 0.93-0.97), followed by DMEP (0.91, 0.89-0.94) and SSEP (0.88, 0.85-0.91). CONCLUSIONS TcMEP and DMEP have higher diagnostic accuracy than SSEP in predicting postoperative neurologic deficit. The type of anesthetic agent, the use of neuromuscular blocking drugs, and the choice of diagnostic criteria for significant change in cerebral blood flow during aneurysm surgery affect the diagnostic accuracy of evoked potential techniques in predicting postoperative neurologic deficit.
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Affiliation(s)
- Benjamin Thomas
- Department of Surgery, Port Moresby General Hospital, Boroko, National Capital District, Papua New Guinea.
| | - Dongsheng Guo
- Department of Neurosurgery, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
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Platz J, Wagner M, Güresir E, You SJ, Konczalla J, de Rochemont RDM, Berkefeld J, Seifert V. Early diffusion-weighted MRI lesions after treatment of unruptured intracranial aneurysms: a prospective study. J Neurosurg 2017; 126:1070-1078. [DOI: 10.3171/2016.2.jns152456] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Diffusion-weighted MRI was used to assess periprocedural lesion load after repair of unruptured intracranial aneurysms (UIA) by microsurgical clipping (MC) and endovascular coiling (EC).
METHODS
Patients with UIA were assigned to undergo MC or EC according to interdisciplinary consensus and underwent diffusion-weighted imaging (DWI) 1 day before and 1 day after aneurysm treatment. Newly detected lesions by DWI after treatment were the primary end point of this prospective study. Lesions detected by DWI were categorized as follows: A) 1–3 DWI spots < 10 mm, B) > 3 DWI spots < 10 mm, C) single DWI lesion > 10 mm, or D) DWI lesion related to surgical access.
RESULTS
Between 2010 and 2014, 99 cases were included. Sixty-two UIA were treated by MC and 37 by EC. There were no significant differences between groups in age, sex, aneurysm size, occurrence of multiple aneurysms in 1 patient, or presence of lesions detected by DWI before treatment. Aneurysms treated by EC were significantly more often located in the posterior circulation (p < 0.001). Diffusion-weighted MRI detected new lesions in 27 (43.5%) and 20 (54.1%) patients after MC and EC, respectively (not significant). The pattern of lesions detected by DWI varied significantly between groups (p < 0.001). Microembolic lesions (A and B) found on DWI were detected more frequently after EC (A, 14 cases; B, 5 cases) than after MC (A, 5 cases), whereas C and D were rare after EC (C, 1 case) and occurred more often after MC (C, 12 cases and D, 10 cases). No procedure-related unfavorable outcomes were detected.
CONCLUSIONS
According to the specific techniques, lesion patterns differ between MC and EC, whereas the frequency of new lesions found on DWI is similar after occlusion of UIA. In general, the lesion load was low in both groups, and lesions were clinically silent.
Clinical trial registration no.: NCT01490463 (clinicaltrials.gov)
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Affiliation(s)
| | - Marlies Wagner
- 2Neuroradiology, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | | | - Se-Jong You
- 2Neuroradiology, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | | | | | - Joachim Berkefeld
- 2Neuroradiology, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
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7
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The incidence of and risk factors for ischemic complications after microsurgical clipping of unruptured middle cerebral artery aneurysms and the efficacy of intraoperative monitoring of somatosensory evoked potentials: A retrospective study. Clin Neurol Neurosurg 2016; 151:128-135. [DOI: 10.1016/j.clineuro.2016.10.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 10/11/2016] [Accepted: 10/13/2016] [Indexed: 11/16/2022]
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8
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Thirumala PD, Udesh R, Muralidharan A, Thiagarajan K, Crammond DJ, Chang YF, Balzer JR. Diagnostic Value of Somatosensory-Evoked Potential Monitoring During Cerebral Aneurysm Clipping: A Systematic Review. World Neurosurg 2016; 89:672-80. [DOI: 10.1016/j.wneu.2015.12.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 12/10/2015] [Accepted: 12/12/2015] [Indexed: 10/22/2022]
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9
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Durand A, Penchet G, Thines L. Intraoperative monitoring by imaging and electrophysiological techniques during giant intracranial aneurysm surgery. Neurochirurgie 2016; 62:14-9. [DOI: 10.1016/j.neuchi.2015.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2014] [Revised: 02/05/2015] [Accepted: 03/01/2015] [Indexed: 12/30/2022]
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10
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Jin SH, Chung CK, Kim JE, Choi YD. A new measure for monitoring intraoperative somatosensory evoked potentials. J Korean Neurosurg Soc 2014; 56:455-62. [PMID: 25628803 PMCID: PMC4303719 DOI: 10.3340/jkns.2014.56.6.455] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Revised: 09/15/2014] [Accepted: 09/15/2014] [Indexed: 11/27/2022] Open
Abstract
Objective To propose a new measure for effective monitoring of intraoperative somatosensory evoked potentials (SEP) and to validate the feasibility of this measure for evoked potentials (EP) and single trials with a retrospective data analysis study. Methods The proposed new measure (hereafter, a slope-measure) was defined as the relative slope of the amplitude and latency at each EP peak compared to the baseline value, which is sensitive to the change in the amplitude and latency simultaneously. We used the slope-measure for EP and single trials and compared the significant change detection time with that of the conventional peak-to-peak method. When applied to single trials, each single trial signal was processed with optimal filters before using the slope-measure. In this retrospective data analysis, 7 patients who underwent cerebral aneurysm clipping surgery for unruptured aneurysm middle cerebral artery (MCA) bifurcation were included. Results We found that this simple slope-measure has a detection time that is as early or earlier than that of the conventional method; furthermore, using the slope-measure in optimally filtered single trials provides warning signs earlier than that of the conventional method during MCA clipping surgery. Conclusion Our results have confirmed the feasibility of the slope-measure for intraoperative SEP monitoring. This is a novel study that provides a useful measure for either EP or single trials in intraoperative SEP monitoring.
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Affiliation(s)
- Seung-Hyun Jin
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea. ; Neuroscience Research Institute, Seoul National University Medical Research Center, Seoul, Korea
| | - Chun Kee Chung
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea. ; Neuroscience Research Institute, Seoul National University Medical Research Center, Seoul, Korea. ; Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea. ; Department of Brain and Cognitive Sciences, Seoul National University College of Natural Sciences, Seoul, Korea
| | - Jeong Eun Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea. ; Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Young Doo Choi
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
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Yue Q, Zhu W, Gu Y, Xu B, Lang L, Song J, Cai J, Xu G, Chen L, Mao Y. Motor evoked potential monitoring during surgery of middle cerebral artery aneurysms: a cohort study. World Neurosurg 2014; 82:1091-9. [PMID: 25220340 DOI: 10.1016/j.wneu.2014.09.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 08/07/2014] [Accepted: 09/03/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Motor evoked potential (MEP) monitoring has been widely used in brain or spine surgery to recognize potential damage of the pyramidal motor system. However, its ability to detect ischemic injury during middle cerebral artery (MCA) aneurysm surgery remains unclear. A prospective cohort study was designed to evaluate MEP changes during MCA aneurysm surgery. METHODS From January 2009 to August 2011, 89 patients underwent MCA aneurysm surgery and were prospectively divided into 2 groups: MEP monitoring group and control group. Based on an amplitude decrement of >50% or loss, a 2-stage warning criterion of MEP changes was established. Concomitant somatosensory evoked potential changes were also recorded. MEP changes occurred in 15 patients, and various methods were used to avoid continued brain ischemia. Indocyanine green angiography and Doppler ultrasonography were performed if needed. A head computed tomography scan was performed immediately and the day after the operation. RESULTS At discharge, neither motor status nor Glasgow Coma Scale score was significantly different between the 2 groups. However, at the latest follow-up (mean, 31.9 months), motor status of the patients in the monitoring group was better (P = 0.037). MEP monitoring was identified as an independent prognostic factor for motor outcome in long-term results by multivariate analysis (P = 0.042). Both wave loss and >50% amplitude decrement of MEP monitoring showed good predictive value when used as part of a 2-stage warning criterion. CONCLUSIONS MEP monitoring is reliable for evaluation of the ischemic status of the pyramidal motor system during MCA aneurysm surgery and can improve surgical outcomes when used appropriately.
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Affiliation(s)
- Qi Yue
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Wei Zhu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Yuxiang Gu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Bin Xu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Liqin Lang
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Jianping Song
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Jiajun Cai
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Geng Xu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Liang Chen
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China.
| | - Ying Mao
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China.
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12
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Phillips JL, Chalouhi N, Jabbour P, Starke RM, Bovenzi CD, Rosenwasser RH, Wilent WB, Romo VM, Tjoumakaris SI. Somatosensory Evoked Potential Changes in Neuroendovascular Procedures. Neurosurgery 2014; 75:560-7; discussion 566-7; quiz 567. [DOI: 10.1227/neu.0000000000000510] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Neurophysiological monitoring is routinely used during neurosurgical procedures. Use of neurophysiological monitoring has extended to neuroendovascular procedures, but evidence of its impact on clinical outcome in this arena is limited.
OBJECTIVE:
To report the incidence of significant intraoperative somatosensory evoked potential (SSEP) changes during neuroendovascular surgery and to correlate SSEP changes with clinical outcomes.
METHODS:
Patients who underwent neuroendovascular surgery at our institution between 2011 and 2013 were included in the analysis. Medical charts and imaging studies were reviewed retrospectively for sex, age, lesion type and size, clinical presentation, type of endovascular procedure, duration of SSEP change, reversibility of SSEP change, incidence of intraoperative complications and related mortalities, presence of new infarction within 72 hours of intervention, and discharge outcome.
RESULTS:
Of 873 consecutive patients, 52 (6%) had clinically significant intraoperative SSEP changes. Twenty-four patients (46%) had SSEP changes that were corrected, and 28 patients (54%) had changes that were not reversed before the end of surgery. Both decreased duration and reversal of SSEP changes were associated with a lower incidence of postoperative infarction and more favorable clinical outcome on discharge. The positive predictive value of an irreversible SSEP change for postoperative infarction in our study was 21%, and the negative predictive value was 83%.
CONCLUSION:
The approximate incidence of SSEP changes is 6% during neuroendovascular procedures. Rapid reversal of SSEP changes is associated with better outcomes. SSEP monitoring may be a valuable tool for preventing complications after neuroendovascular interventions.
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Affiliation(s)
- Jessica L.H. Phillips
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Nohra Chalouhi
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Robert M. Starke
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Cory D. Bovenzi
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Robert H. Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - W. Bryan Wilent
- Sentient Medical Systems, Hunt Valley, Maryland; and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Victor M. Romo
- Department of Neurosurgical Anesthesia, Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Stavropoula I. Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
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13
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Controversies in the anesthetic management of intraoperative rupture of intracranial aneurysm. Anesthesiol Res Pract 2014; 2014:595837. [PMID: 24723946 PMCID: PMC3958760 DOI: 10.1155/2014/595837] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2013] [Accepted: 01/26/2014] [Indexed: 01/08/2023] Open
Abstract
Despite great advancements in the management of aneurysmal subarachnoid hemorrhage (SAH), outcomes following SAH rupture have remained relatively unchanged. In addition, little data exists to guide the anesthetic management of intraoperative aneurysm rupture (IAR), though intraoperative management may have a significant effect on overall neurological outcomes. This review highlights the various controversies related to different anesthetic management related to aneurysm rupture. The first controversy relates to management of preexisting factors that affect risk of IAR. The second controversy relates to diagnostic techniques, particularly neurophysiological monitoring. The third controversy pertains to hemodynamic goals. The neuroprotective effects of various factors, including hypothermia, various anesthetic/pharmacologic agents, and burst suppression, remain poorly understood and have yet to be further elucidated. Different management strategies for IAR during aneurysmal clipping versus coiling also need further attention.
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Mukerji N, Cook DJ, Steinberg GK. Temporary artery occlusion in ruptured aneurysms. World Neurosurg 2013; 82:43-5. [PMID: 23920285 DOI: 10.1016/j.wneu.2013.07.095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 07/27/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Nitin Mukerji
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Douglas J Cook
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Gary K Steinberg
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA.
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Kang D, Yao P, Wu Z, Yu L. Ischemia changes and tolerance ratio of evoked potential monitoring in intracranial aneurysm surgery. Clin Neurol Neurosurg 2012; 115:552-6. [PMID: 22795547 DOI: 10.1016/j.clineuro.2012.06.029] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2010] [Revised: 06/12/2012] [Accepted: 06/22/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE We assessed the relationship between cerebral ischemia-induced changes in evoked potentials and the degree of ischemia tolerance. METHODS 47 patients underwent somatosensory evoked potential (SEP) and motor evoked potential (MEP) monitoring in intracranial aneurysm surgery. Three duration parameters (time) were recorded: Time 1, from the starting of temporary occlusion unavoidable in aneurysm surgery to the time the evoked potentials decrease from basal level to reaching the warning criterion; Time 2, from evoked potentials reaching the warning criterion to the time the blood flow was resumed; Time 3, after resuming the blood flow, the time it took the evoked potentials to recover to baseline. All three times can be reliably calculated in the SEP recording, but not in the MEP recording which consisted of either unchanged amplitudes or abruptly changing amplitudes, making it impossible to obtain Time 1. The ischemic tolerance ratio (ITR) was calculated as ITR=time 2/time 1×100%. New decreasing myodynamia and fresh infarction after the surgery were employed for evaluating neurological deficits postoperatively, and their correlations with the ischemia-induced changes of evoked potentials recorded during the surgery were analyzed. RESULTS We found a change in SEPs in 12 patients whose cerebral ischemia was induced by temporary occlusion of the aneurysm's parent artery. We also found the development of postoperative neurological deficits in 4 patients whose ischemic tolerance ratio (ITR) reached over 80%, while no deficits were found in the other 8 patients whose ITR was less than 50%. MEP changes were seen in 4 patients whose cerebral ischemia was caused by accidentally clamping the perforating branches, causing the development of postoperative neurological deficits but not necessarily leading to significant SEP changes. CONCLUSION The Ischemia tolerance ratio (ITR) in SEP recordings is valuable to predicting postoperative neurological deficits caused by temporary occlusion of aneurysm's parent artery. Maintaining the ITR under 50% during operation can effectively avoid postoperative neurological deficits, while an ITR above 80% reliably forecasts postoperative neurological deficits. Complementary to SEPs, MEP recordings are particularly valuable in monitoring ischemic effects caused by accidentally clamping perforating branches. Taken together, this system of monitoring makes it possible to promptly adjust surgery procedures and minimize postoperative neurological deficits.
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Affiliation(s)
- Dezhi Kang
- Neurosurgery of The First Affiliated Hospital of Fujian Medical University, No. 88, Jiaotong Road, Taijiang District, Fuzhou, China
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Bacigaluppi S, Fontanella M, Manninen P, Ducati A, Tredici G, Gentili F. Monitoring techniques for prevention of procedure-related ischemic damage in aneurysm surgery. World Neurosurg 2011; 78:276-88. [PMID: 22381314 DOI: 10.1016/j.wneu.2011.11.034] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2011] [Revised: 10/05/2011] [Accepted: 11/22/2011] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To describe the application of intraoperative monitoring techniques during aneurysm surgery and to discuss the advantages and limitations of these techniques in prevention of postoperative neurologic deficits. METHODS Articles found in the literature through PubMed for the time frame 1980-2011 and the authors' personal files were reviewed. RESULTS Various techniques for detection of vascular insufficiency are available, including direct methods to measure cerebral blood flow and indirect methods to evaluate the integrity of neurologic pathways. CONCLUSIONS The choice of monitoring modality should be governed by the vessel and by the vascular territory most at risk during the planned procedure with proper awareness of the potential limits related to each technique. Aneurysm surgery monitoring should help to address issues of continuity and provide a morphologic and functional assessment. Although the use of monitoring devices is still not routine in aneurysm surgery and no standards have been established, combining different monitoring techniques is crucial to optimize aneurysm surgery and avoid or minimize complications.
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Affiliation(s)
- Susanna Bacigaluppi
- Department of Neurosciences and Biomedical Technologies, University of Milano Bicocca, Monza, Italy.
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