1
|
Roman A, Tufegdzic B, Pinto V, Lamperti M, Elhammady M, Roser F. After the Knife: A Detailed Roadmap for Vestibular Schwannoma Resection in the Semi-Sitting Position - How I do it. World Neurosurg 2023; 175:e1341-e1347. [PMID: 37169076 DOI: 10.1016/j.wneu.2023.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 04/29/2023] [Accepted: 05/01/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND Vestibular schwannoma surgery remains a neurosurgical challenge, with known risks, dependent on a number of factors, from patient selection to surgical experience of the team. The semi-sitting position has gained popularity as an alternative to the traditional supine position for vestibular schwannoma resection due to potential advantages such as improved surgical exposure due to clearer surgical field and anatomical orientation. However, there is a lack of standardized protocols for performing the procedure in the semi-sitting position, leading to variations in surgical techniques and outcomes. METHODS In this study, we aimed to establish a standardized approach for vestibular schwannoma resection using the semi-sitting position. Initiating after final position for semi-sitting, the authors have divided the surgical steps into five major parts for improved understanding and replication. Surgical techniques were analyzed through one hundred steps to identify commonalities, determining the optimal procedural steps for the semi-sitting position using surgical video for visual conceptualization. RESULTS The analysis described one hundred steps for vestibular schwannoma resection in the semi-sitting position, with visual demonstration of the various parts of the procedure through surgical videos. Specific recommendations for each step were outlined, including appropriate approach, monitoring strategies, and tumor and posterior fossa structures manipulation. Five major parts of the procedure were identified, leading to a reproducible standardization of the surgical procedure of vestibular schwannoma resection in the semi-sitting position. CONCLUSIONS This study provides a comprehensive standardized protocol for the semi-sitting procedure in vestibular schwannoma resection. By establishing a consistent approach, surgeons can minimize variations in surgical techniques and improve patient outcomes. The identified steps and recommendations can serve as a valuable resource for surgical teams involved in vestibular schwannoma resection and facilitate the dissemination and reproducibility of best practices.
Collapse
Affiliation(s)
- Alex Roman
- Neurological Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE.
| | - Boris Tufegdzic
- Anesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Vania Pinto
- Neurophysiology, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Massimo Lamperti
- Anesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | | | - Florian Roser
- Neurological Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| |
Collapse
|
2
|
Scheer M, Simmermacher S, Prell J, Leisz S, Scheller C, Mawrin C, Strauss C, Rampp S. Recurrences and progression following microsurgery of vestibular schwannoma. Front Surg 2023; 10:1216093. [PMID: 37416504 PMCID: PMC10322218 DOI: 10.3389/fsurg.2023.1216093] [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: 05/03/2023] [Accepted: 06/12/2023] [Indexed: 07/08/2023] Open
Abstract
Background The treatment approach of vestibular schwannoma (VS) has seen a change in recent years, with a trend away from radical surgery towards preservation of cranial nerve function. A recent study reported recurrences as long as 20 years after complete removal of VS. Objective To report the risk of recurrence and progression in our patient population the authors retrospectively reviewed outcomes of patients. Methods Cases with unilateral VS who had undergone primary microsurgery via retrosigmoidal approach between 1995 and 2021 were investigated. Complete tumor removal was defined as gross total resection (GTR), a capsular remnant was categorized as near total resection (NTR) and residual tumor was designated as subtotal resection (STR). The primary endpoint was radiological recurrence-free survival. Results 386 patients fulfilled the inclusion criteria of the study and were evaluated. GTR was achieved in 284 patients (73.6%), NTR was achieved in 63 patients (10.1%) and STR was present in 39 patients (16.3%). A total of 28 patients experienced recurrences with significant differences in the three subgroups. The strongest predictor of recurrence was the extent of resection, with patients who underwent STR having an almost 10-fold higher risk of recurrence and patients who had undergone NTR having an almost 3-fold higher risk than those treated with GTR. More than 20% of recurrences (6/28) occured after more than 5 years. Conclusion The degree of resection is an important guide to the interval of follow-up, but long-term follow-up should be considered also in the case of GTR. The majority of recurrences occurs after 3-5 years. Nevertheless, a follow-up of at least 10 years should be carried out.
Collapse
Affiliation(s)
- Maximilian Scheer
- Department of Neurosurgery, Medical Faculty, University Hospital Halle, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Sebastian Simmermacher
- Department of Neurosurgery, Medical Faculty, University Hospital Halle, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Julian Prell
- Department of Neurosurgery, Medical Faculty, University Hospital Halle, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Sandra Leisz
- Department of Neuropathology, University Magdeburg, Magdeburg, Germany
| | | | - Christian Mawrin
- Department of Neuropathology, University Magdeburg, Magdeburg, Germany
| | - Christian Strauss
- Department of Neurosurgery, Medical Faculty, University Hospital Halle, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Stefan Rampp
- Department of Neurosurgery, Medical Faculty, University Hospital Halle, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| |
Collapse
|
3
|
Rampp S, Holze M, Scheller C, Strauss C, Prell J. Neural networks for estimation of facial palsy after vestibular schwannoma surgery. J Clin Monit Comput 2023; 37:575-583. [PMID: 36333576 PMCID: PMC10068649 DOI: 10.1007/s10877-022-00928-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 09/22/2022] [Accepted: 10/04/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE Facial nerve damage in vestibular schwannoma surgery is associated with A-train patterns in free-running EMG, correlating with the degree of postoperative facial palsy. However, anatomy, preoperative functional status, tumor size and occurrence of A-trains clusters, i.e., sudden A-trains in most channels may further contribute. In the presented study, we examine neural networks to estimate postoperative facial function based on such features. METHODS Data from 200 consecutive patients were used to train neural feed-forward networks (NN). Estimated and clinical postoperative House and Brackmann (HB) grades were compared. Different input sets were evaluated. RESULTS Networks based on traintime, preoperative HB grade and tumor size achieved good estimation of postoperative HB grades (chi2 = 54.8), compared to using tumor size or mean traintime alone (chi2 = 30.6 and 31.9). Separate intermediate nerve or detection of A-train clusters did not improve performance. Removal of A-train cluster traintime improved results (chi2 = 54.8 vs. 51.3) in patients without separate intermediate nerve. CONCLUSION NN based on preoperative HB, traintime and tumor size provide good estimations of postoperative HB. The method is amenable to real-time implementation and supports integration of information from different sources. NN could enable multimodal facial nerve monitoring and improve postoperative outcomes.
Collapse
Affiliation(s)
- Stefan Rampp
- Department of Neurosurgery, University Hospital Halle (Saale), Ernst-Grube Str. 40, 06120, Halle, Germany.
- Department of Neurosurgery, University Hospital Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany.
| | - Magdalena Holze
- Department of Neurosurgery, University Hospital Halle (Saale), Ernst-Grube Str. 40, 06120, Halle, Germany
| | - Christian Scheller
- Department of Neurosurgery, University Hospital Halle (Saale), Ernst-Grube Str. 40, 06120, Halle, Germany
| | - Christian Strauss
- Department of Neurosurgery, University Hospital Halle (Saale), Ernst-Grube Str. 40, 06120, Halle, Germany
| | - Julian Prell
- Department of Neurosurgery, University Hospital Halle (Saale), Ernst-Grube Str. 40, 06120, Halle, Germany
| |
Collapse
|
4
|
Machetanz K, Grimm F, Schäfer R, Trakolis L, Hurth H, Haas P, Gharabaghi A, Tatagiba M, Naros G. Design and Evaluation of a Custom-Made Electromyographic Biofeedback System for Facial Rehabilitation. Front Neurosci 2022; 16:666173. [PMID: 35310106 PMCID: PMC8931662 DOI: 10.3389/fnins.2022.666173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 01/12/2022] [Indexed: 11/19/2022] Open
Abstract
Background In the rehabilitation of postoperative facial palsy, physical therapy is of paramount importance. However, in the early rehabilitation phase, voluntary movements are often limited, and thus, the motivation of patients is impacted. In these situations, biofeedback of facial electromyographic (EMG) signals enables the visual representation of the rehabilitation progress, even without apparent facial movements. In the present study, we designed and evaluated a custom-made EMG biofeedback system enabling cost-effective facial rehabilitation. Methods This prospective study describes a custom-made EMG system, consisting of a microcontroller board and muscle sensors, which was used to record the EMG of frontal and zygomatic facial muscles during frowning and smiling. First, the mean EMG amplitudes and movement onset detection rates (ACC) achieved with the custom-made EMG system were compared with a commercial EMG device in 12 healthy subjects. Subsequently, the custom-made device was applied to 12 patients with and without postoperative facial paresis after neurosurgical intervention. Here, the ratio [laterality index (LI)] between the mean EMG amplitude of the healthy and affected side was calculated and related to the facial function as measured by the House and Brackmann scale (H&B) ranging from 1 (normal) to 6 (total paralysis). Results In healthy subjects, a good correlation was measured between the mean EMG amplitudes of the custom-made and commercial EMG device for both frontal (r = 0.84, p = 0.001) and zygomatic muscles (r = 0.8, p = 0.002). In patients, the LI of the frontal and zygomatic muscles correlated significantly with the H&B (r = −0.83, p = 0.001 and r = −0.65, p = 0.023). The ACC of the custom-made EMG system varied between 65 and 79% depending on the recorded muscle and cohort. Conclusion The present study demonstrates a good application potential of our custom-made EMG biofeedback device to detect facial EMG activity in healthy subjects as well as patients with facial palsies. There is a correlation between the electrophysiological measurements and the clinical outcome. Such a device might enable cost-efficient home-based facial EMG biofeedback. However, movement detection accuracy should be improved in future studies to reach ranges of commercial devices.
Collapse
Affiliation(s)
- Kathrin Machetanz
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University of Tübingen, Tübingen, Germany
- Institute for Neuromodulation and Neurotechnology, Eberhard Karls University of Tübingen, Tübingen, Germany
- *Correspondence: Kathrin Machetanz,
| | - Florian Grimm
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University of Tübingen, Tübingen, Germany
- Institute for Neuromodulation and Neurotechnology, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Ruth Schäfer
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Clinic, Tübingen, Germany
| | - Leonidas Trakolis
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Helene Hurth
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Patrick Haas
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Alireza Gharabaghi
- Institute for Neuromodulation and Neurotechnology, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Marcos Tatagiba
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Georgios Naros
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University of Tübingen, Tübingen, Germany
- Institute for Neuromodulation and Neurotechnology, Eberhard Karls University of Tübingen, Tübingen, Germany
- Georgios Naros,
| |
Collapse
|
5
|
Abstract
While most neurophysiologists are familiar with electromyography (EMG) for the purpose of clinical diagnostics, this technique also has a long tradition for neuro-monitoring. In short, intra-operative use of EMG can be divided into stimulated EMG on the one hand and monitoring of the free-running EMG and its spontaneous activity on the other hand. Methods for utilization of stimulated EMG are covered elsewhere in this book. This chapter focuses on the monitoring of spontaneous, or, more correctly, "surgically evoked" EMG. The history and underlying physiologic principles of intra-operative EMG are covered in this chapter as well as a detailed overview of the methodology. Building up from the basis of this background, we describe examples of how EMG can be used to help in intra-operative detection of adverse events and also in the prediction of postoperative outcomes. In the opinion of the authors, EMG should not be used as a "standalone" technique in contemporary neuro-monitoring. Most of its significant potential may be realized when it is used in a complementary way together with other modalities, mainly motor evoked potentials. Bearing this in mind, we sketch out how such a complementary setup may be used for improved neuro-monitoring.
Collapse
Affiliation(s)
- Julian Prell
- Department of Neurosurgery, University Halle-Wittenberg, Halle, Germany.
| | - Stanley Skinner
- Department of Intraoperative Neurophysiology, Abbott Northwestern Hospital, Minneapolis, MN, United States
| |
Collapse
|
6
|
Prell J, Scheller C, Simmermacher S, Strauss C, Rampp S. Facial Nerve EMG: Low-Tech Monitoring with a Stopwatch. J Neurol Surg A Cent Eur Neurosurg 2021; 82:308-316. [PMID: 33418594 DOI: 10.1055/s-0040-1701616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The quantity of A-trains, a high-frequency pattern of free-running facial nerve electromyography, is correlated with the risk for postoperative high-grade facial nerve paresis. This correlation has been confirmed by automated analysis with dedicated algorithms and by visual offline analysis but not by audiovisual real-time analysis. METHODS An investigator was presented with 29 complete data sets measured during actual surgeries in real time and without breaks in a random order. Data were presented either strictly via loudspeaker (audio) or simultaneously by loudspeaker and computer screen (audiovisual). Visible and/or audible A-train activity was then quantified by the investigator with the computerized equivalent of a stopwatch. The same data were also analyzed with quantification of A-trains by automated algorithms. RESULTS Automated (auto) traintime (TT), known to be a small, yet highly representative fraction of overall A-train activity, ranged from 0.01 to 10.86 s (median: 0.58 s). In contrast, audio-TT ranged from 0 to 1,357.44 s (median: 29.69 s), and audiovisual-TT ranged from 0 to 786.57 s (median: 46.19 s). All three modalities were correlated to each other in a highly significant way. Likewise, all three modalities correlated significantly with the extent of postoperative facial paresis. As a rule of thumb, patients with visible/audible A-train activity < 1 minute presented with a more favorable clinical outcome than patients with > 1 minute of A-train activity. CONCLUSION Detection and even quantification of A-trains is technically possible not only with intraoperative automated real-time calculation or postoperative visual offline analysis, but also with very basic monitoring equipment and real-time good quality audiovisual analysis. However, the investigator found audiovisual real-time-analysis to be very demanding; thus tools for automated quantification can be very helpful in this respect.
Collapse
Affiliation(s)
- Julian Prell
- Department of Neurosurgery, University of Halle, Halle, Germany
| | | | | | | | - Stefan Rampp
- Department of Neurosurgery, University of Halle, Halle, Germany
| |
Collapse
|
7
|
Pu JKS, Wong SCS, So KHT, Tsang ACO, Li LF. Acupuncture as Part of Iatrogenic Facial Nerve Palsy Rehabilitation-First Report. World Neurosurg 2020; 140:e343-e347. [PMID: 32434036 DOI: 10.1016/j.wneu.2020.05.079] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 05/09/2020] [Accepted: 05/09/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Facial paresis is one of the complications after treatment for vestibular schwannoma (VS). Acupuncture has been used for Bell palsy but not in iatrogenic facial paresis. The objective of this study is to measure the efficacy of using acupuncture for iatrogenic facial nerve palsy and patients' satisfaction. METHODS This is a single-center retrospective study with patients from 2007-2019 received treatment for newly diagnosed or recurrent VS. Some patients who suffered facial paresis after surgery had self-initiated acupuncture. All patients who had facial paresis were included. Their facial nerve status before and immediately after surgery, postoperative 6 months and 12 months, were recorded. Those who received acupuncture also answered 6- and 12-month patient satisfaction surveys over the phone. Adverse effects were also assessed. RESULTS There were 123 patients in this period. Of these, 29 patients had iatrogenic facial paresis and 23 of them received acupuncture. There was significant improvement of facial paresis for the acupuncture group compared with the nonacupuncture group at 6 and 12 months. More than 80% of patients who received acupuncture were satisfied. They had motor improvement and experienced less pain and tightness. No adverse effects were reported. CONCLUSIONS Acupuncture for postresection VS facial paresis seemed to speed up its recovery. Both patients' recovery and satisfaction were good after acupuncture, and it seemed to be a safe procedure in trained hands.
Collapse
Affiliation(s)
- Jenny Kan-Suen Pu
- Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, Hong Kong
| | - Sanna Ching-Shan Wong
- Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, Hong Kong
| | - Karen Hoi-Ting So
- Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, Hong Kong
| | - Anderson Chun-On Tsang
- Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, Hong Kong
| | - Lai-Fung Li
- Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, Hong Kong.
| |
Collapse
|
8
|
Hendriks T, Kunst HPM, Huppelschoten M, Doorduin J, Ter Laan M. TcMEP threshold change is superior to A-train detection when predicting facial nerve outcome in CPA tumour surgery. Acta Neurochir (Wien) 2020; 162:1197-1203. [PMID: 32146526 PMCID: PMC7156349 DOI: 10.1007/s00701-020-04275-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 02/26/2020] [Indexed: 11/30/2022]
Abstract
Object Surgery of tumours in the cerebellopontine angle (CPA) can lead to loss of facial nerve function. Different methods of intra-operative nerve monitoring (IOM) (including free-running EMG, direct nerve stimulation and transcranial motor evoked potentials (TcMEP)) have been used to predict facial nerve outcome during surgery. Recent research has shown TcMEP threshold increase and the occurrence of A-trains on the EMG to have great potential in doing so. This study compares these two methods and correlates them to House-Brackmann (HB) scores post-op in patients with tumours in the cerebellopontine angle. Method Forty-three patients (one was operated twice) with large CPA tumours treated surgically in the Radboud University Medical Center between 2015 and 2019 were included in this study. During surgery, TcMEP threshold increases and A-train activity were measured. Because our treatment paradigm aims at facial nerve preservation (accepting residual tumour), TcMEP threshold increase of over 20 mA or occurrence of A-trains were considered as warning signs and used as a guide for terminating surgery. HB scores were measured post-op, at 6 weeks, 6 months and 1 year after surgery. Spearman’s correlation was calculated between the IOM-values and the HB scores for a homogeneous subgroup of 30 patients with vestibular schwannoma (VS) without neurofibromatosis type II (NF-II) and all patients collectively. Results TcMEP threshold was successfully measured in 39 (90.7%) procedures. In the homogeneous VS non-NFII group, we found a statistically significant moderate-to-strong correlation between TcMEP threshold increase and House Brackmann score immediately post-op, at 6 weeks, 6 months and 1 year after surgery (Spearman’s rho of 0.79 (p < 0.001), 0.74 (p < 0.001), 0.64 (p < 0.001) and 0.58 (p = 0.002), respectively). For A-trains, no correlation was found. Similar results were found when including all patients with CPA tumours. A threshold increase of < 20 mA was a predictor of good facial nerve outcome. Conclusion These results show that TcMEP threshold increases are strongly correlated to post-operative HB scores, while A-trains are not. This suggests TcMEP threshold increases can be a valuable predictor for facial nerve outcome in patients with large tumours when facial nerve preservation is prioritized over total resection. In this study, we found no use for A-trains to prevent facial nerve deficits.
Collapse
Affiliation(s)
- Tom Hendriks
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Henricus P M Kunst
- Department of Otorhinolaryngology, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Otorhinolaryngology, Medical Center, Maastricht, Netherlands
| | - Maarten Huppelschoten
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jonne Doorduin
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Mark Ter Laan
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands.
| |
Collapse
|
9
|
Predictive Value of Preoperative and Intraoperative Neurophysiology in Evaluating Long-term Facial Function Outcome in Acoustic Neuroma Surgery. Otol Neurotol 2020; 41:530-536. [DOI: 10.1097/mao.0000000000002553] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
10
|
Rampp S, Illert J, Krempler K, Strauss C, Prell J. A-train clusters and the intermedius nerve in vestibular schwannoma patients. Clin Neurophysiol 2019; 130:722-726. [PMID: 30901633 DOI: 10.1016/j.clinph.2019.02.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 01/25/2019] [Accepted: 02/13/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE EMG "A-train" activity correlates with postoperative facial palsy after vestibular schwannoma (VS) surgery. An intermedius nerve separate from the facial nerve increases A-trains without significant impact on function. We investigate occurrence of A-train "clusters", A-trains over a majority of channels within a short time frame. METHODS Data from 217 patients with first surgery for VS were evaluated retrospectively. Continuous EMG recorded with 9 channels was evaluated for A-train patterns. "Clusters" of A-trains were identified, i.e. A-trains within 3 seconds over a majority of channels. Relation to a separate intermedius, tumor size and facial palsy was evaluated. RESULTS Correlations between A-trains and postoperative facial palsy were higher in patients without separate intermedius (r = 0.562 versus r = 0.194). Clusters were identified in 107 patients (49.3%), separate intermedius in 109 (50.2%), with significant association of both (p < 0.001, Chi-Square test). Excluding clusters slightly increased correlation of A-trains to facial nerve function. CONCLUSIONS A-train clusters have limited relevance for predicting postoperative paresis. However, they should be regarded as warning signs, suggesting the presence of a separate intermedius nerve. SIGNIFICANCE A-train "clusters" are a sign of hyperactivity of the facial nerve due to a separate intermedius nerve and may confound intraoperative monitoring during VS surgery.
Collapse
Affiliation(s)
- Stefan Rampp
- Department of Neurosurgery, University Hospital Halle (Saale), Ernst-Grube-Str. 40, 06120 Halle (Saale), Germany.
| | - Jörg Illert
- Department of Neurosurgery, University Hospital Halle (Saale), Ernst-Grube-Str. 40, 06120 Halle (Saale), Germany
| | - Katja Krempler
- Department of Neurosurgery, University Hospital Halle (Saale), Ernst-Grube-Str. 40, 06120 Halle (Saale), Germany
| | - Christian Strauss
- Department of Neurosurgery, University Hospital Halle (Saale), Ernst-Grube-Str. 40, 06120 Halle (Saale), Germany
| | - Julian Prell
- Department of Neurosurgery, University Hospital Halle (Saale), Ernst-Grube-Str. 40, 06120 Halle (Saale), Germany
| |
Collapse
|
11
|
Continuous and Dynamic Facial Nerve Mapping During Surgery of Cerebellopontine Angle Tumors: Clinical Pilot Series. World Neurosurg 2018; 119:e855-e863. [DOI: 10.1016/j.wneu.2018.07.286] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 07/30/2018] [Accepted: 07/31/2018] [Indexed: 11/19/2022]
|
12
|
Seidel K, Biner MS, Zubak I, Rychen J, Beck J, Raabe A. Continuous dynamic mapping to avoid accidental injury of the facial nerve during surgery for large vestibular schwannomas. Neurosurg Rev 2018; 43:241-248. [PMID: 30367353 DOI: 10.1007/s10143-018-1044-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 09/23/2018] [Accepted: 10/16/2018] [Indexed: 11/24/2022]
Abstract
In vestibular schwannoma (VS) surgery postoperative facial nerve (CN VII) palsy is reducing quality of life. Recently, we have introduced a surgical suction device for continuous dynamic mapping to provide feedback during tumor resection without switching to a separate stimulation probe. The objective was to evaluate the reliability of this method to avoid CN VII injury. Continuous mapping for CN VII was performed in large VS (08/2014 to 11/2017) additionally to standard neurophysiological techniques. A surgical suction-and-mapping probe was used for surgical dissection and continuous monopolar stimulation. Stimulation was performed with 0.05-2 mA intensities (0.3 msec pulse duration, 2.0 Hz). Postoperative CNVII outcome was assessed by the House-Brackmann-Score (HBS) after 1 week and 3 months following surgery. Twenty patients with Koos III (n = 2; 10%) and Koos IV (n = 18; 90%) VS were included. Preoperative HBS was 1 in 19 patients and 2 in 1 patient. Dynamic mapping reliably indicated the facial nerve when resection was close to 5-10 mm. One week after surgery, 7 patients presented with worsening in HBS. At 3 months, 4 patients' facial weakness had resolved and 3 patients (15%) had an impairment of CN VII (HBS 3 and 4). Of the 3 patients, near-total removal was attempted in 2. The continuous dynamic mapping method using an electrified surgical suction device might be a valuable additional tool in surgery of large VS. It provides real-time feedback indicating the presence of the facial nerve within 5-10 mm depending on stimulation intensity and may help in avoiding accidental injury to the nerve.
Collapse
Affiliation(s)
- Kathleen Seidel
- Department of Neurosurgery, Inselspital, Bern University Hospital, 3010, Bern, Switzerland.
| | - Matthias S Biner
- Department of Neurosurgery, Inselspital, Bern University Hospital, 3010, Bern, Switzerland
| | - Irena Zubak
- Department of Neurosurgery, Inselspital, Bern University Hospital, 3010, Bern, Switzerland
| | - Jonathan Rychen
- Department of Neurosurgery, Inselspital, Bern University Hospital, 3010, Bern, Switzerland
| | - Jürgen Beck
- Department of Neurosurgery, University of Freiburg, Freiburg, Germany
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, 3010, Bern, Switzerland
| |
Collapse
|
13
|
Hatch J, Oyer SL. Vestibular Schwannoma Complicated by Facial Paralysis: Considerations of Techniques and Timing for Facial Reanimation. CURRENT OTORHINOLARYNGOLOGY REPORTS 2018. [DOI: 10.1007/s40136-018-0201-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
14
|
The utility of “low current” stimulation threshold of intraoperative electromyography monitoring in predicting facial nerve function outcome after vestibular schwannoma surgery: a prospective cohort study of 103 large tumors. J Neurooncol 2018; 138:383-390. [DOI: 10.1007/s11060-018-2806-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 02/14/2018] [Indexed: 10/18/2022]
|
15
|
|
16
|
Predictive value of intraoperative neurophysiologic monitoring in assessing long-term facial function in grade IV vestibular schwannoma removal. Acta Neurochir (Wien) 2015; 157:1991-7; discussion 1998. [PMID: 26347044 DOI: 10.1007/s00701-015-2571-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 08/27/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Despite routine use of intraoperative neuromonitoring in acoustic neuroma removal, its application in predicting long-term facial function is limited. METHODS Prospective recording of facial nerve function and subsequent review of intraoperative neurophysiologic data. Stimulation of the facial nerve was performed proximal and distal to the tumor locus after tumor removal with measurement of amplitude and latency responses in the orbicularis oculi and oris muscles. Prospective review of current facial nerve function was performed using the House-Brackmann (HB) scoring system. Good facial function was determined as HB I/II and HB III-VI was considered poor facial function. Minimum follow-up time was 15 months, and averaged 40 months. RESULTS Twenty-four grade IV acoustic neuromas (54 % larger than 4 cm) were completely removed from October 2008 to November 2013. Nine patients (37.5 %) had HB I/II and 15 (62.5 %) had HB III-VI. The poor prognosis group had a higher latency than the good prognosis group (p = 0.045). Lower proximal amplitude was detected in the poor prognosis group (p = 0.046). Lower proximal-to-distal amplitude ratio was also detected in the poor prognosis group (p = 0.052). Amplitude ratio cut-offs of 0.44 and 0.25 were able to predict poor prognosis with sensitivity of 0.73 and 0.4 and specificity of 0.78 and 1, respectively (p = 0.046). CONCLUSIONS Lower proximal amplitude and proximal-distal amplitude ratio were previously reported as predictors of poor facial function in different sizes of vestibular schwannomas. We observed that the same applies specifically for large-sized, completely removed, grade IV tumors. Additionally, we describe a difference in proximal latency time between the good and poor prognosis groups, which was not previously reported.
Collapse
|
17
|
Chen H, Liu C, Yin J, Chen Z, Xu J, Wang D, Zhu J, Zhang Z, Sun Y, Li A. Mitochondrial Cyclophilin D as a Potential Therapeutic Target for Ischemia-Induced Facial Palsy in Rats. Cell Mol Neurobiol 2015; 35:931-41. [PMID: 25820785 DOI: 10.1007/s10571-015-0188-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Accepted: 03/25/2015] [Indexed: 10/23/2022]
Abstract
Many studies have demonstrated that ischemia could induce facial nerve (FN) injury. However, there is a lack of a suitable animal model for FN injury study and thus little knowledge is available about the precise mechanism for FN injury. The aims of this study were to establish a reliable FN injury model induced by blocking the petrosal artery and to investigate whether dysfunctional interaction between cyclophilin D (CypD) and mitochondrial permeability transition pore (MPTP) can mediate cell dysfunction in ischemic FN injury. The outcomes of ischemia-induced FN injury rat model were evaluated by behavioral assessment, histological observation, electrophysiology, and electron microscopy. Then the levels of CypD and protein that forms the MPTP were evaluated under the conditions with or without the treatment of Cyclosporin A (CsA), which has been found to disrupt MPTP through the binding of CypD. The blocking of petrosal artery caused significant facial palsy signs in the ischemia group but not in the sham group. Furthermore, ischemia can induce the dysfunction of facial nucleus neurons and destruction of the myelin sheath and increase the protein levels of CypD and MPTP protein compared with sham group. Interestingly, treatment with CsA significantly improved neurological function and reversed the ischemia-induced increase of CypD and MPTP proteins in ischemia group. These results demonstrated that blocking of petrosal artery in rats can induce FN injury and the mechanism may be related to the disruption of MPTP by CypD.
Collapse
Affiliation(s)
- Huizhen Chen
- Department of Neurosurgery, The First People's Hospital of Lianyungang, 182 Tong Guan North Road, Lianyungang, Jiangsu, 222002, People's Republic of China
| | - Chnagtao Liu
- Department of Neurosurgery, The First People's Hospital of Lianyungang, 182 Tong Guan North Road, Lianyungang, Jiangsu, 222002, People's Republic of China
| | - Jie Yin
- Department of Neurosurgery, Xuzhou Central Hospital, Xuzhou, Jiangsu, 221009, People's Republic of China
| | - Zhen Chen
- Department of Neurosurgery, The First People's Hospital of Lianyungang, 182 Tong Guan North Road, Lianyungang, Jiangsu, 222002, People's Republic of China
| | - Jinwang Xu
- Department of Neurosurgery, The First People's Hospital of Lianyungang, 182 Tong Guan North Road, Lianyungang, Jiangsu, 222002, People's Republic of China
| | - Duanlei Wang
- Department of Neurosurgery, The First People's Hospital of Lianyungang, 182 Tong Guan North Road, Lianyungang, Jiangsu, 222002, People's Republic of China
| | - Jiaqiu Zhu
- Department of Neurosurgery, The First People's Hospital of Lianyungang, 182 Tong Guan North Road, Lianyungang, Jiangsu, 222002, People's Republic of China
| | - Ziyuan Zhang
- Department of Neurosurgery, The First People's Hospital of Lianyungang, 182 Tong Guan North Road, Lianyungang, Jiangsu, 222002, People's Republic of China
| | - Yong Sun
- Department of Neurosurgery, The First People's Hospital of Lianyungang, 182 Tong Guan North Road, Lianyungang, Jiangsu, 222002, People's Republic of China
| | - Aimin Li
- Department of Neurosurgery, The First People's Hospital of Lianyungang, 182 Tong Guan North Road, Lianyungang, Jiangsu, 222002, People's Republic of China.
| |
Collapse
|
18
|
Take the A Train. Clin Neurophysiol 2015; 126:1647-9. [DOI: 10.1016/j.clinph.2015.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 01/09/2015] [Accepted: 01/09/2015] [Indexed: 11/21/2022]
|
19
|
Prell J, Strauss C, Rachinger J, Scheller C, Alfieri A, Herfurth K, Rampp S. The intermedius nerve as a confounding variable for monitoring of the free-running electromyogram. Clin Neurophysiol 2015; 126:1833-9. [PMID: 25655939 DOI: 10.1016/j.clinph.2014.11.028] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 10/08/2014] [Accepted: 11/10/2014] [Indexed: 11/26/2022]
Abstract
OBJECTIVE A-trains, a facial nerve EMG-pattern, are correlated with postoperative functional impairment. However, an unknown confounder is suspected to cause false positive monitoring results. The intermedius nerve contains motor fibers targeting lower facial muscles; their significance for facial nerve monitoring is yet unknown. METHODS Intraoperative videotapes and free-running 9-channel facial nerve EMG assessed from 87 patients undergoing surgery for vestibular schwannoma were evaluated, and presence/absence of an identifiable intermedius nerve was determined. The prognostic value of train time, a quantitative measure for A-train activity, was evaluated for both the groups with and without an identifiable intermedius nerve. RESULTS Correlation between traintime and outcome (Spearman's Rho) rose to 0.73 (p<0.001) when only patients without an identified intermedius nerve were considered, and fell to 0.43 (p<0.05) with the other patient group. This difference was statistically significant (p=0.036), was more prominent in the channels monitoring perioral facial muscles, and resulted from additional A-train activity in patients with an identifiable intermedius nerve. CONCLUSIONS A separate intermedius nerve may be more prone to manipulation, leading to A-train activity without clinical correlate, thus causing false positive monitoring results. SIGNIFICANCE For interpretation of the free-running EMG, the intermedius nerve needs to be taken into account as a confounder.
Collapse
Affiliation(s)
- Julian Prell
- Department of Neurosurgery, University of Halle, Ernst-Grube-Str. 40, 06097 Halle, Germany.
| | - Christian Strauss
- Department of Neurosurgery, University of Halle, Ernst-Grube-Str. 40, 06097 Halle, Germany
| | - Jens Rachinger
- Department of Neurosurgery, University of Halle, Ernst-Grube-Str. 40, 06097 Halle, Germany
| | - Christian Scheller
- Department of Neurosurgery, University of Halle, Ernst-Grube-Str. 40, 06097 Halle, Germany
| | - Alex Alfieri
- Department of Neurosurgery, University of Halle, Ernst-Grube-Str. 40, 06097 Halle, Germany
| | - Kirsten Herfurth
- Department of Neurosurgery, University of Halle, Ernst-Grube-Str. 40, 06097 Halle, Germany
| | - Stefan Rampp
- Department of Neurosurgery, University of Halle, Ernst-Grube-Str. 40, 06097 Halle, Germany
| |
Collapse
|