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Gorijala VK, Reddy RP, Anetakis KM, Balzer J, Crammond DJ, Shandal V, Shaw JD, Christie MR, Thirumala PD. Diagnostic utility of different types of somatosensory evoked potential changes in pediatric idiopathic scoliosis correction surgery. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:1644-1656. [PMID: 38285275 DOI: 10.1007/s00586-023-08063-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 09/24/2023] [Accepted: 11/21/2023] [Indexed: 01/30/2024]
Abstract
PURPOSE To evaluate the diagnostic accuracy of intraoperative somatosensory evoked potential (SSEP) monitoring and types of SSEP changes in predicting the risk of postoperative neurological outcomes during correction surgery for idiopathic scoliosis (IS) in the pediatric age group (≤ 21 years). METHODS Database review was performed to identify literature on pediatric patients with IS who underwent correction with intraoperative neuromonitoring. The sensitivity, specificity, and diagnostic odds ratio (DOR) of transient and persistent SSEP changes and complete SSEP loss in predicting postoperative neurological deficits were calculated. RESULTS Final analysis included 3778 patients. SSEP changes had a sensitivity of 72.9%, specificity of 96.8%, and DOR of 102.3, while SSEP loss had a sensitivity of 41.8%, specificity of 99.3%, and DOR of 133.2 for predicting new neurologic deficits. Transient and persistent SSEP changes had specificities of 96.8% and 99.1%, and DORs of 16.6 and 59, respectively. CONCLUSION Intraoperative SSEP monitoring can predict perioperative neurological injury and improve surgical outcomes in pediatric scoliosis fusion surgery. LEVEL OF EVIDENCE Level 2. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Vamsi Krishna Gorijala
- Department of Neurological Surgery, Center for Clinical Neurophysiology, University of Pittsburgh Medical Center, UPMC, Presbyterian-Suite-B-400, 200 Lothrop Suite, Pittsburgh, PA, 15213, USA
| | - Rajiv P Reddy
- Pittsburgh Orthopedic Spine Research, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Katherine M Anetakis
- Department of Neurological Surgery, Center for Clinical Neurophysiology, University of Pittsburgh Medical Center, UPMC, Presbyterian-Suite-B-400, 200 Lothrop Suite, Pittsburgh, PA, 15213, USA
| | - Jeffrey Balzer
- Department of Neurological Surgery, Center for Clinical Neurophysiology, University of Pittsburgh Medical Center, UPMC, Presbyterian-Suite-B-400, 200 Lothrop Suite, Pittsburgh, PA, 15213, USA
| | - Donald J Crammond
- Department of Neurological Surgery, Center for Clinical Neurophysiology, University of Pittsburgh Medical Center, UPMC, Presbyterian-Suite-B-400, 200 Lothrop Suite, Pittsburgh, PA, 15213, USA
| | - Varun Shandal
- Department of Neurological Surgery, Center for Clinical Neurophysiology, University of Pittsburgh Medical Center, UPMC, Presbyterian-Suite-B-400, 200 Lothrop Suite, Pittsburgh, PA, 15213, USA
| | - Jeremy D Shaw
- Pittsburgh Orthopedic Spine Research, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michelle R Christie
- Department of Neurology and Rehabilitation Medicine, Texas Scottish Rite Hospital, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Parthasarathy D Thirumala
- Department of Neurological Surgery, Center for Clinical Neurophysiology, University of Pittsburgh Medical Center, UPMC, Presbyterian-Suite-B-400, 200 Lothrop Suite, Pittsburgh, PA, 15213, USA.
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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Alvi MA, Kwon BK, Hejrati N, Tetreault LA, Evaniew N, Skelly AC, Fehlings MG. Accuracy of Intraoperative Neuromonitoring in the Diagnosis of Intraoperative Neurological Decline in the Setting of Spinal Surgery-A Systematic Review and Meta-Analysis. Global Spine J 2024; 14:105S-149S. [PMID: 38632716 PMCID: PMC10964897 DOI: 10.1177/21925682231196514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2024] Open
Abstract
STUDY DESIGN Systematic review and meta-analysis. OBJECTIVES In an effort to prevent intraoperative neurological injury during spine surgery, the use of intraoperative neurophysiological monitoring (IONM) has increased significantly in recent years. Using IONM, spinal cord function can be evaluated intraoperatively by recording signals from specific nerve roots, motor tracts, and sensory tracts. We performed a systematic review and meta-analysis of diagnostic test accuracy (DTA) studies to evaluate the efficacy of IONM among patients undergoing spine surgery for any indication. METHODS The current systematic review and meta-analysis was performed using the Preferred Reporting Items for a Systematic Review and Meta-analysis statement for Diagnostic Test Accuracy Studies (PRISMA-DTA) and was registered on PROSPERO. A comprehensive search was performed using MEDLINE, EMBASE and SCOPUS for all studies assessing the diagnostic accuracy of neuromonitoring, including somatosensory evoked potential (SSEP), motor evoked potential (MEP) and electromyography (EMG), either on their own or in combination (multimodal). Studies were included if they reported raw numbers for True Positives (TP), False Negatives (FN), False Positives (FP) and True Negative (TN) either in a 2 × 2 contingency table or in text, and if they used postoperative neurologic exam as a reference standard. Pooled sensitivity and specificity were calculated to evaluate the overall efficacy of each modality type using a bivariate model adapted by Reitsma et al, for all spine surgeries and for individual disease groups and regions of spine. The risk of bias (ROB) of included studies was assessed using the quality assessment tool for diagnostic accuracy studies (QUADAS-2). RESULTS A total of 163 studies were included; 52 of these studies with 16,310 patients reported data for SSEP, 68 studies with 71,144 patients reported data for MEP, 16 studies with 7888 patients reported data for EMG and 69 studies with 17,968 patients reported data for multimodal monitoring. The overall sensitivity, specificity, DOR and AUC for SSEP were 71.4% (95% CI 54.8-83.7), 97.1% (95% CI 95.3-98.3), 41.9 (95% CI 24.1-73.1) and .899, respectively; for MEP, these were 90.2% (95% CI 86.2-93.1), 96% (95% CI 94.3-97.2), 103.25 (95% CI 69.98-152.34) and .927; for EMG, these were 48.3% (95% CI 31.4-65.6), 92.9% (95% CI 84.4-96.9), 11.2 (95% CI 4.84-25.97) and .773; for multimodal, these were found to be 83.5% (95% CI 81-85.7), 93.8% (95% CI 90.6-95.9), 60 (95% CI 35.6-101.3) and .895, respectively. Using the QUADAS-2 ROB analysis, of the 52 studies reporting on SSEP, 13 (25%) were high-risk, 10 (19.2%) had some concerns and 29 (55.8%) were low-risk; for MEP, 8 (11.7%) were high-risk, 21 had some concerns and 39 (57.3%) were low-risk; for EMG, 4 (25%) were high-risk, 3 (18.75%) had some concerns and 9 (56.25%) were low-risk; for multimodal, 14 (20.3%) were high-risk, 13 (18.8%) had some concerns and 42 (60.7%) were low-risk. CONCLUSIONS These results indicate that all neuromonitoring modalities have diagnostic utility in successfully detecting impending or incident intraoperative neurologic injuries among patients undergoing spine surgery for any condition, although it is clear that the accuracy of each modality differs.PROSPERO Registration Number: CRD42023384158.
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Affiliation(s)
- Mohammed Ali Alvi
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Brian K Kwon
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
- Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada
| | - Nader Hejrati
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | | | - Nathan Evaniew
- McCaig Institute for Bone and Joint Health, Department of Surgery, Orthopaedic Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | | | - Michael G Fehlings
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
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Intraoperative Monitoring During Neurosurgical Procedures and Patient Outcomes. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-022-00542-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Diagnostic Accuracy of SSEP Changes During Lumbar Spine Surgery for Predicting Postoperative Neurological Deficit: A Systematic Review and Meta-Analysis. Spine (Phila Pa 1976) 2021; 46:E1343-E1352. [PMID: 33958542 DOI: 10.1097/brs.0000000000004099] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN This study is a meta-analysis of prospective and retrospective studies identified in PubMed, Web of Science, and Embase with outcomes of patients who received intraoperative somatosensory-evoked potential (SSEP) monitoring during lumbar spine surgery. OBJECTIVE The objective of this study is to determine the diagnostic accuracy of intraoperative lower extremity SSEP changes for predicting postoperative neurological deficit. As a secondary analysis, we evaluated three subtypes of intraoperative SSEP changes: reversible, irreversible, and total signal loss. SUMMARY OF BACKGROUND DATA Lumbar decompression and fusion surgery can treat lumbar spinal stenosis and spondylolisthesis but carry a risk for nerve root injury. Published neurophysiological monitoring guidelines provide no conclusive evidence for the clinical utility of intraoperative SSEP monitoring during lumbar spine surgery. METHODS A systematic review was conducted to identify studies with outcomes of patients who underwent lumbar spine surgeries with intraoperative SSEP monitoring. The sensitivity, specificity, and diagnostic odds ratio (DOR) were calculated and presented with forest plots and a summary receiver operating characteristic curve. RESULTS The study cohort consisted of 5607 patients. All significant intraoperative SSEP changes had a sensitivity of 44% and specificity of 97% with a DOR of 22.13 (95% CI, 11.30-43.34). Reversible and irreversible SSEP changes had sensitivities of 28% and 33% and specificities of 97% and 97%, respectively. The DORs for reversible and irreversible SSEP changes were 13.93 (95% CI, 4.60-40.44) and 57.84 (95% CI, 15.95-209.84), respectively. Total loss of SSEPs had a sensitivity of 9% and specificity of 99% with a DOR of 23.91 (95% CI, 7.18-79.65). CONCLUSION SSEP changes during lumbar spine surgery are highly specific but moderately sensitive for new postoperative neurological deficits. Patients who had postoperative neurological deficit were 22 times more likely to have exhibited intraoperative SSEP changes.Level of Evidence: 2.
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Mao G, Elhamdani S, Gigliotti MJ, Mace Z, Sclabassi R, Oh M, Whiting D. Neurologic Complications in Monitored versus Unmonitored Image-Guidance Assisted Posterior Lumbar Instrumentation. World Neurosurg 2021; 152:e155-e160. [PMID: 34052456 DOI: 10.1016/j.wneu.2021.05.074] [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: 04/03/2021] [Revised: 05/16/2021] [Accepted: 05/17/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Intraoperative neurophysiologic monitoring (IOM) has been used clinically since the 1970s and is a reliable tool for detecting impending neurologic compromise. However, there are mixed data as to whether long-term neurologic outcomes are improved with its use. We investigated whether IOM used in conjunction with image guidance produces different patient outcomes than with image guidance alone. METHODS We reviewed 163 consecutive cases between January 2015 and December 2018 and compared patients undergoing posterior lumbar instrumentation with image guidance using and not using multimodal IOM. Monitored and unmonitored surgeries were performed by the same surgeons, ruling out variability in intersurgeon technique. Surgical and neurologic complication rates were compared between these 2 cohorts. RESULTS A total of 163 patients were selected (110 in the nonmonitored cohort vs. 53 in the IOM cohort). Nineteen signal changes were noted. Only 3 of the 19 patients with signal changes had associated neurologic deficits postoperatively (positive predictive value 15.7%). There were 5 neurologic deficits that were observed in the nonmonitored cohort and 8 deficits observed in the monitored cohort. Transient neurologic deficit was significantly higher in the monitored cohort per case (P < 0.0198) and per screw (P < 0.0238); however, there was no difference observed between the 2 cohorts when considering permanent neurologic morbidity per case (P < 0.441) and per screw (P < 0.459). CONCLUSIONS The addition of IOM to cases using image guidance does not appear to decrease long-term postoperative neurologic morbidity and may have a reduced diagnostic role given availability of intraoperative image-guidance systems.
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Affiliation(s)
- Gordon Mao
- Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Shahed Elhamdani
- Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Michael J Gigliotti
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA.
| | - Zachary Mace
- Computational Diagnostics, Pittsburgh, Pennsylvania, USA
| | - Robert Sclabassi
- Neuroscience Institute, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Michael Oh
- Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Donald Whiting
- Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
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Melachuri SR, Melachuri MK, Mina A, Anetakis K, Crammond DJ, Balzer JR, Shandal V, Thirumala PD. Optimal "Low" Pedicle Screw Stimulation Threshold to Predict New Postoperative Lower-Extremity Neurologic Deficits During Lumbar Spinal Fusions. World Neurosurg 2021; 151:e250-e256. [PMID: 33872842 DOI: 10.1016/j.wneu.2021.04.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 04/06/2021] [Accepted: 04/06/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Previous studies have shown that pedicle screw stimulation thresholds ≤6-8 mA yield a high diagnostic accuracy of detecting misplaced screws. Our objective was to determine the optimal "low" stimulation threshold to predict new postoperative neurologic deficits and identify additional risk factors associated with deficits. METHODS We included patients with complete pedicle screw stimulation testing who underwent posterior lumbar spinal fusion surgeries from 2010-2012. We calculated the diagnostic accuracy of pedicle screw responses of ≤4 mA, ≤6 mA, ≤8 mA, ≤10 mA, ≤12 mA, and ≤20 mA to predict new postoperative lower-extremity (LE) neurologic deficits. We used multivariate modeling to determine the best logistic regression model to predict LE deficits and identify additional risk factors. Statistics software packages used were Python3.8.5, NumPy 1.19.1, Pandas 1.1.1, and SPSS26. RESULTS We studied 1179 patients who underwent 8584 pedicle screw stimulations with somatosensory evoked potential and free-run electromyographic monitoring for posterior lumbar spinal fusion. Twenty-five (2.1%) patients had new LE neurologic deficits. A stimulation threshold of ≤8 mA had a sensitivity/specificity of 32%/90% and a diagnostic odds ratio/area under the curve of 4.34 [95% confidence interval: 1.83, 10.27]/0.61 [0.49, 0.74] in predicting postoperative deficit. Multivariate analysis showed that patients who had pedicle screws with stimulation thresholds ≤8 mA are 3.15 [1.26, 7.83]× more likely to have postoperative LE deficits while patients who have undergone a revision lumbar spinal fusion surgery are 3.64 [1.38, 9.61]× more likely. CONCLUSIONS Our results show that low thresholds are indicative of not only screw proximity to the nerve but also an increased likelihood of postoperative neurologic deficit. Thresholds ≤8 mA prove to be the optimal "low" threshold to help guide a correctly positioned pedicle screw placement and detect postoperative deficits.
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Affiliation(s)
- Samyuktha R Melachuri
- Departments of Neurological Surgery and Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Manasa K Melachuri
- Departments of Neurological Surgery and Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Amir Mina
- Departments of Neurological Surgery and Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Katherine Anetakis
- Departments of Neurological Surgery and Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Donald J Crammond
- Departments of Neurological Surgery and Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jeffrey R Balzer
- Departments of Neurological Surgery and Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Varun Shandal
- Departments of Neurological Surgery and Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Parthasarathy D Thirumala
- Departments of Neurological Surgery and Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
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Cui HY, Wu YX, Li R, Li GS, Hu Y. A translational study of somatosensory evoked potential time-frequency components in rats, goats, and humans. Neural Regen Res 2021; 16:2269-2275. [PMID: 33818512 PMCID: PMC8354111 DOI: 10.4103/1673-5374.310693] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Somatosensory evoked potentials (SEPs) have been widely used to assess neurological function in clinical practice. A good understanding of the association between SEP signals and neurological function is helpful for precise diagnosis of impairment location. Previous studies on SEPs have been reported in animal models. However, few studies have reported the relationships between SEP waveforms in animals and those in humans. In this study, we collected normal SEP waveforms and decomposed them into specific time-frequency components (TFCs). Our results showed three stable TFC distribution regions in intact goats and rats and in humans. After we induced spinal cord injury in the animal models, a greater number of small TFC distribution regions were observed in the injured goat and rat groups than in the normal group. Moreover, there were significant correlations (P < 0.05) and linear relationships between the main SEP TFCs of the human group and those of the goat and rat groups. A stable TFC distribution of SEP components was observed in the human, goat and rat groups, and the TFC distribution modes were similar between the three groups. Results in various animal models in this study could be translated to future clinical studies based on SEP TFC analysis. Human studies were approved by the Institutional Review Board of the University of Hong Kong/Hospital Authority Hong Kong West Cluster (approval No. UM 05-312 T/975) on December 5, 2005. Rat experiments were approved by the Committee on the Use of Live Animals in Teaching and Research of Li Ka Shing Faculty of Medicine of the University of Hong Kong (approval No. CULART 2912-12) on January 28, 2013. Goat experiments were approved by the Animal Ethics Committee of Affiliated Hospital of Guangdong Medical University (approval No. GDY2002132) on March 5, 2018.
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Affiliation(s)
- Hong-Yan Cui
- Institute of Biomedical Engineering, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Yi-Xin Wu
- Institute of Biomedical Engineering, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Rong Li
- Institute of Biomedical Engineering, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Guang-Sheng Li
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong Special Administrative Region; Spinal Division, Department of Orthopaedics, Affiliated Hospital of Guangdong Medical University, Guangdong Province, China
| | - Yong Hu
- Institute of Biomedical Engineering, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin; Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong Special Administrative Region; Department of Orthopaedics and Traumatology, The University of Hong Kong -Shenzhen Hospital, Shenzhen, Guangdong Province, China
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Anetakis KM, Dolia JN, Desai SM, Balzer JR, Crammond DJ, Thirumala PD, Castellano JF, Gross BA, Jadhav AP. Last Electrically Well: Intraoperative Neurophysiological Monitoring for Identification and Triage of Large Vessel Occlusions. J Stroke Cerebrovasc Dis 2020; 29:105158. [PMID: 32912500 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105158] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 07/12/2020] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Intra-operative stroke (IOS) is associated with poor clinical outcome as detection is often delayed and time of symptom onset or patient's last known well (LKW) is uncertain. Intra-operative neurophysiological monitoring (IONM) is uniquely capable of detecting onset of neurological dysfunction in anesthetized patients, thereby precisely defining time last electrically well (LEW). This novel parameter may aid in the detection of large vessel occlusion (LVO) and prompt treatment with endovascular thrombectomy (EVT). METHODS We performed a retrospective analysis of a prospectively maintained AIS and LVO database from May 2018-August 2019. Inclusion criteria required any surgical procedure under general anesthesia (GA) utilizing EEG (electroencephalography) and/or SSEP (somatosensory evoked potentials) monitoring with development of intraoperative focal persistent changes using predefined alarm criteria and who were considered for EVT. RESULT Five cases were identified. LKW to closure time ranged from 66 to 321 minutes, while LEW to closure time ranged from 43 to 174 min. All LVOs were in the anterior circulation. Angiography was not pursued in two cases due to large established infarct (both patients expired in the hospital). EVT was pursued in two cases with successful recanalization and spontaneous recanalization was noted in one patient (mRS 0-3 at 90 days was achieved in all 3 cases). CONCLUSIONS This study demonstrates that significant IONM changes can accurately identify patients with an acute LVO in the operative setting. Given the challenges of recognizing peri-operative stroke, LEW may be an appropriate surrogate to quickly identify and treat IOS.
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Affiliation(s)
- Katherine M Anetakis
- The Departments of Neurology and Neurological Surgery, University of Pittsburgh Medical, Center, Pittsburgh, PA USA
| | - Jay N Dolia
- The Departments of Neurology and Neurological Surgery, University of Pittsburgh Medical, Center, Pittsburgh, PA USA
| | - Shashvat M Desai
- The Departments of Neurology and Neurological Surgery, University of Pittsburgh Medical, Center, Pittsburgh, PA USA
| | - Jeffrey R Balzer
- The Departments of Neurology and Neurological Surgery, University of Pittsburgh Medical, Center, Pittsburgh, PA USA
| | - Donald J Crammond
- The Departments of Neurology and Neurological Surgery, University of Pittsburgh Medical, Center, Pittsburgh, PA USA
| | - Parthasarathy D Thirumala
- The Departments of Neurology and Neurological Surgery, University of Pittsburgh Medical, Center, Pittsburgh, PA USA
| | - James F Castellano
- The Departments of Neurology and Neurological Surgery, University of Pittsburgh Medical, Center, Pittsburgh, PA USA
| | - Bradley A Gross
- The Departments of Neurology and Neurological Surgery, University of Pittsburgh Medical, Center, Pittsburgh, PA USA
| | - Ashutosh P Jadhav
- The Departments of Neurology and Neurological Surgery, University of Pittsburgh Medical, Center, Pittsburgh, PA USA.
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