1
|
Fava E, Colistra D, Fragale M, Cenzato M. A novel method of neurophysiological brainstem mapping in neurosurgery. J Neurosci Methods 2024; 405:110096. [PMID: 38428822 DOI: 10.1016/j.jneumeth.2024.110096] [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: 09/29/2023] [Revised: 02/03/2024] [Accepted: 02/22/2024] [Indexed: 03/03/2024]
Abstract
BACKGROUND Brainstem mapping with electrical stimulation allows functional identification of neural structures during resection of deep lesions. Single pulses or train of pulses are delivered to map cranial nerves and corticospinal tracts, respectively. NEW METHOD We introduce a hybrid stimulation technique for mapping the brainstem. The stimulus consists of an electrical single pulse followed by a short train of 3-5 pulses at 500 Hz, at an interval of 60-75 ms. The responses to this stimulation pattern are recorded from appropriate cranial and limb muscles. RESULTS Both the single pulse and the short train elicit electromyographic responses when motor fibers or motor nuclei of the cranial nerves are stimulated. Responses to the train but not to the preceding single pulse indicate activation of the descending motor tracts, in the mesencephalon and the pons. Conversely, in the medulla, limb responses to stimulation of the corticospinal tracts are elicited by a single pulse. Identification of the extra and intra-axial courses of the trigeminal motor and sensory fibers is possible by recording responses from the masseter and the tongue muscles. COMPARISON WITH EXISTING METHOD(S) To date, either a pulse or a train is delivered during brainstem mapping, switching from one to the other modality according to the expected target structure. This procedure can be time-consuming and may even lead to false negative responses to the stimulation, eventually leading to inaccurate neurosurgical procedures. CONCLUSIONS The novel hybrid pulse-train technique enhances the advantage of brainstem mapping procedure, minimizing pitfalls and improving patient safety.
Collapse
Affiliation(s)
- Enrica Fava
- Department of Neurosurgery, Great Metropolitan Hospital of Niguarda, University of Milano, Italy.
| | - Davide Colistra
- Department of Neurosurgery, Great Metropolitan Hospital of Niguarda, Milano, Italy
| | - Maria Fragale
- Department of Neurosurgery, Great Metropolitan Hospital of Niguarda, Milano, Italy
| | - Marco Cenzato
- Department of Neurosurgery, Great Metropolitan Hospital of Niguarda, Milano, Italy
| |
Collapse
|
2
|
Meneghelli P, Pasqualin A, Musumeci A, Pinna G, Berti PP, Polizzi GMV, Sinosi FA, Nicolato A, Sala F. Microsurgical removal of supratentorial and cerebellar cavernous malformations: what has changed? A single institution experience. J Clin Neurosci 2024; 123:162-170. [PMID: 38581776 DOI: 10.1016/j.jocn.2024.04.001] [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: 12/21/2023] [Revised: 03/09/2024] [Accepted: 04/02/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Features associated with a safe surgical resection of cerebral cavernous malformations (CMs) are still not clear and what is needed to achieve this target has not been defined yet. METHODS Clinical presentation, radiological features and anatomical locations were assessed for patients operated on from January 2008 to January 2018 for supratentorial and cerebellar cavernomas. Supratentorial CMs were divided into 3 subgroups (non-critical vs. superficial critical vs. deep critical). The clinical outcome was assessed through modified Rankin Scale (mRS) and was divided into favorable (mRS 0-1) and unfavorable (mRS ≥ 2). Post-operative epilepsy was classified according to the Maraire Scale. RESULTS A total of 144 were considered eligible for the current study. At 6 months follow-up the clinical outcome was excellent for patients with cerebellar or lobar CMs in non-critical areas (mRS ≤ 1: 91.1 %) and for patients with superficial CMs in critical areas (mRS ≤ 1: 92.3 %). Patients with deep-seated suprantentorial CMs showed a favorable outcome in 76.9 %. As for epilepsy 58.5 % of patients presenting with a history of epilepsy were free from seizures and without therapy (Maraire grade I) at last follow-up (mean 3.9 years) and an additional 41.5 % had complete control of seizures with therapy (Maraire grade II). CONCLUSIONS Surgery is safe in the management of CMs in non-critical but also in critical supratentorial locations, with a caveat for deep structures such as the insula, the basal ganglia and the thalamus/hypothalamus.
Collapse
Affiliation(s)
- Pietro Meneghelli
- Institute of Neurosurgery, University and City Hospital, Verona, Italy.
| | - Alberto Pasqualin
- Section of Vascular Neurosurgery, Institute of Neurological Surgery, University and City Hospital, Verona, Italy
| | - Angelo Musumeci
- Institute of Neurosurgery, University and City Hospital, Verona, Italy
| | - Giampietro Pinna
- Institute of Neurosurgery, University and City Hospital, Verona, Italy
| | - Pier Paolo Berti
- Institute of Neurosurgery, University and City Hospital, Verona, Italy
| | | | | | - Antonio Nicolato
- Section of Radiosurgery and Stereotactic Neurosurgery, Institute of Neurosurgery, University and City Hospital, Verona, Italy
| | - Francesco Sala
- Section of Neurosurgery, Department of Neuroscience, Biomedicine and Movement, University of Verona
| |
Collapse
|
3
|
Deletis V, Seidel K, Fernández-Conejero I. Intraoperative Neurophysiologic Monitoring and Mapping in Children Undergoing Brainstem Surgery. J Clin Neurophysiol 2024; 41:108-115. [PMID: 38306218 DOI: 10.1097/wnp.0000000000001037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2024] Open
Abstract
SUMMARY Intraoperative neurophysiologic monitoring during surgery for brainstem lesions is a challenge for intraoperative neurophysiologists and surgeons. The brainstem is a small structure packed with vital neuroanatomic networks of long and short pathways passing through the brainstem or originating from it. Many central pattern generators exist within the brainstem for breathing, swallowing, chewing, cardiovascular regulation, and eye movement. During surgery around the brainstem, these generators need to be preserved to maintain their function postoperatively. This short review presents neurophysiologic and neurosurgical experiences of brainstem surgery in children.
Collapse
Affiliation(s)
- Vedran Deletis
- Department of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia
- Albert Einstein College of Medicine, New York, New York, U.S.A
| | - Kathleen Seidel
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; and
| | | |
Collapse
|
4
|
Pinto V, Liebsch M. Technical note: pre-positioning lower limb SSEP during semi-sitting positioning in posterior fossa surgery- does it matter? J Clin Monit Comput 2023; 37:1627-1633. [PMID: 37351761 DOI: 10.1007/s10877-023-01041-1] [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: 09/07/2022] [Accepted: 05/30/2023] [Indexed: 06/24/2023]
Abstract
Intra-operative monitoring has been a crucial tool in modern neurosurgery as it allows to optimize surgical outcome whilst reducing neurological deficits. Somatosensory evoked potentials are routinely monitored in most spinal and brain surgeries due to providing invaluable information regarding the functional integrity of sensory pathways. The use of this neurophysiological technique is particular useful when positioning patients in semi-sitting position during posterior fossa surgery. However, there is general agreement within the intra-operative neuromonitoring community that either upper or lower limb SSEPs monitoring typically suffice. Nonetheless, we report a case study of a patient in whom lower limb SSEPs were independently affected from upper limb SSEPs during positioning. In this respect, we suggest that both upper and lower limb SSEPs monitoring should be considered during semi-sitting positioning in patients undergoing posterior fossa surgery.
Collapse
Affiliation(s)
- Vania Pinto
- Neurological Institute, Cleveland Clinic Abu Dhabi, Al Maryah Island, P.O. Box 112412, Abu Dhabi, UAE.
| | - Marina Liebsch
- Neurosurgery Department, Tübingen University Hospital, Tübingen, Germany
| |
Collapse
|
5
|
Carrai R, Morone F, Baldanzi F, Martinelli C, Bonaudo C, Tola S, Muscas G, Caramelli R, Spalletti M, Grippo A, Bucciardini L, Amadori A, Della Puppa A. Intraoperative Mapping of the Sensory Root of the Trigeminal Nerve in Patients with Pontocerebellar Angle Pathology. World Neurosurg 2023; 178:e104-e112. [PMID: 37454910 DOI: 10.1016/j.wneu.2023.06.146] [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: 06/29/2023] [Accepted: 06/30/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE The aim of the present study was to determine the position of the 3 sensory branches of the trigeminal nerve in the preganglionic tract using intraoperative neurophysiological mapping. METHODS We included consecutive adult patients who underwent neurosurgical treatment of cerebellopontine angle lesions. The trigeminal nerve was antidromically stimulated at 3 sites along its circumference with different stimulus intensities at a distance of ≤1 cm from the brainstem. The sensory nerve action potentials (SNAPs) were recorded from each main trigeminal branch (V1 [ophthalmic branch], V2 [maxillary branch], and V3 [mandibular branch]). RESULTS We analyzed 13 patients. The stimulation points at which we obtained the greatest number of congruous and exclusive SNAPs (SNAPs only on the stimulated branch) was the stimulation point for V3 (20.7%). The stimulation intensity at which we obtained the highest number of congruent and exclusive SNAPs with the stimulated branch was 0.5 mA. CONCLUSIONS Using our recording conditions, trigeminal stimulation is a reliable technique for mapping the V3 and V1 branches using an intensity not exceeding 0.5. However, reliable identification of the fibers of V2 is more difficult. Stimulation of the trigeminal nerve can be a reliable technique to identify the V3 and V1 branches if rhizotomy of these branches is necessary.
Collapse
Affiliation(s)
- Riccardo Carrai
- SODc Neurophysiopathology, AOU Careggi, University Hospital, Florence, Italy
| | - Francesca Morone
- Neurosurgery Unit, Head and Neck Department, AORN San G. Moscati Hospital, Avellino, Italy
| | - Fabrizio Baldanzi
- SODc Neurophysiopathology, AOU Careggi, University Hospital, Florence, Italy
| | | | - Camilla Bonaudo
- Neurosurgery Clinic, AOU Careggi University Hospital, Florence, Italy
| | - Serena Tola
- Neurosurgery Clinic, AOU Careggi University Hospital, Florence, Italy
| | - Giovanni Muscas
- Neurosurgery Clinic, AOU Careggi University Hospital, Florence, Italy
| | - Riccardo Caramelli
- SODc Neurophysiopathology, AOU Careggi, University Hospital, Florence, Italy
| | - Maddalena Spalletti
- SODc Neurophysiopathology, AOU Careggi, University Hospital, Florence, Italy
| | - Antonello Grippo
- SODc Neurophysiopathology, AOU Careggi, University Hospital, Florence, Italy.
| | - Luca Bucciardini
- Neuro-Anesthesiology and Intensive Care Unit, AOU Careggi University Hospital, Florence, Italy
| | - Andrea Amadori
- Neuro-Anesthesiology and Intensive Care Unit, AOU Careggi University Hospital, Florence, Italy
| | | |
Collapse
|
6
|
Sala F. Intraoperative neurophysiology in pediatric neurosurgery: a historical perspective. Childs Nerv Syst 2023; 39:2929-2941. [PMID: 37776333 PMCID: PMC10613152 DOI: 10.1007/s00381-023-06155-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 09/07/2023] [Indexed: 10/02/2023]
Abstract
INTRODUCTION Intraoperative neurophysiology (ION) has been established over the past three decades as a valuable discipline to improve the safety of neurosurgical procedures with the main goal of reducing neurological morbidity. Neurosurgeons have substantially contributed to the development of this field not only by implementing the use and refinement of ION in the operating room but also by introducing novel techniques for both mapping and monitoring of neural pathways. METHODS This review provides a personal perspective on the evolution of ION in a variety of pediatric neurosurgical procedures: from brain tumor to brainstem surgery, from spinal cord tumor to tethered cord surgery. RESULTS AND DISCUSSION The contribution of pediatric neurosurgeons is highlighted showing how our discipline has played a crucial role in promoting ION at the turn of the century. Finally, a view on novel ION techniques and their potential implications for pediatric neurosurgery will provide insights into the future of ION, further supporting the view of a functional, rather than merely anatomical, approach to pediatric neurosurgery.
Collapse
Affiliation(s)
- Francesco Sala
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, Verona, Italy.
| |
Collapse
|
7
|
Roman A, Anzolin E, Bianchini L. The Infratrigeminal Suprafloccular Approach to Intrapontine Lesions: An Anatomical Overview and Relevance for the Approach to Intrapontine Lesions. Cureus 2023; 15:e45708. [PMID: 37868499 PMCID: PMC10590180 DOI: 10.7759/cureus.45708] [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] [Accepted: 09/20/2023] [Indexed: 10/24/2023] Open
Abstract
Background and objectives Brainstem lesions have long been considered complex pathologies that may lead to permanent deficits or life-threatening complications, posing significant challenges for surgical removal. Among these lesions, intrapontine lesions are particularly challenging in the field of neurosurgery. However, with advancements in microsurgical anatomy knowledge and technology, these lesions have become more amenable to surgical treatment. In this study, the authors examine an infratrigeminal suprafloccular approach, which has been shown to be a safe surgical route, resulting in fewer postoperative complications, while evaluating the anatomical nuances of the approach and route. Methods Twenty cadaveric brainstem specimens were analyzed to assess the anatomy, focusing on the lateral aspect of the pons as a potential safe entry zone for intrapontine lesions. The authors consistently analyzed twenty brainstem specimens, carefully examining the pontine microsurgical anatomy. A triangular area of entrance was measured, with three sides or walls (X, Y, and Z) aiming to identify the safe zone that would spare the distinct pontine nuclei, ascending sensory pathways, corticospinal, corticonuclear, and corticopontine tracts of the brainstem. An illustrative case was adapted to the described safe entry zone for corroboration purposes. Results The authors measured three distinct lines on the lateral surface of the pons, named X, Y, and Z, forming a triangle in shape. Line X extended from the midpoint anteroposteriorly of the flocculus of the cerebellum to the apparent trigeminal exit in the lateral aspect of the pons. Line Y ran from the trigeminal exit in the pons to the apparent exit of the facial-vestibulocochlear complex in the far lateral aspect of the pontomedullary sulcus in the cerebellopontine fissure. Line Z represented the measurement from the vestibulocochlear complex to the midpoint anteroposteriorly of the flocculus of the cerebellum. The mean measurements were as follows: X = 14.41mm (range: 10mm to 20mm), Y = 13.1mm (range: 10mm to 21mm), and Z = 3mm (range: 2mm to 5mm). The mean surface area of the analyzed specimens within the triangle (formed by X, Y, and Z) was 20.1mm² (range: 10mm² to 40mm²). This area was identified as a safe zone for the entry of microsurgical approaches to intrapontine lesions, involving less retraction of the anterior pons and potentially sparing critical structures, such as the corticospinal tracts, pontine perforating arteries, tegmentum pontis, cranial nerve nuclei, substantia reticulata dorsally, and transverse pontine fibers. Microsurgical anatomical findings, combined with intraoperative monitoring in an illustrative case, consistently demonstrated that this entry area predicted less functional instability of the analyzed tracts and resulted in fewer postoperative complications. Conclusion Deep-seated pontine lesions present a complex range of pathologies with a high potential for devastating outcomes, particularly those involving hemorrhage. This study identifies and describes a presumed safe entry zone that allows for the creation of a surgical corridor for biopsy or microsurgical resection of these lesions, reducing morbidity in a previously considered impenetrable region.
Collapse
Affiliation(s)
- Alex Roman
- Neurological Surgery, Instituto de Neurocirurgia e Cirurgia de Coluna, Passo Fundo, BRA
| | - Eduardo Anzolin
- Neurosurgery Department, Hospital Cristo Redentor, Porto Alegre, BRA
| | | |
Collapse
|
8
|
Pathak S, Gupta P, Kaushal A, Biswas K. Effect of Ketamine and Dexmedetomidine as Adjuvant to Total Intravenous Anesthesia on Intraoperative Cranial Nerve Monitoring in the Patients Undergoing Posterior Fossa Craniotomies-A Randomized Quadruple Blind Placebo-Controlled Study. Asian J Neurosurg 2023; 18:587-596. [PMID: 38152535 PMCID: PMC10749862 DOI: 10.1055/s-0043-1772762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023] Open
Abstract
Objectives Total intravenous anesthesia (TIVA) is used during surgery with intraoperative neurophysiological monitoring. Addition of adjuvant may minimize suppression of potentials by reducing doses of propofol. We studied the effect of addition of ketamine or dexmedetomidine to propofol-fentanyl-based TIVA on corticobulbar motor evoked potential (CoMEP) in patients undergoing posterior fossa surgeries. Materials and Methods Forty-two patients were assigned to three groups ( n = 14 each), Group S-saline, Group D-dexmedetomidine (0.25 μg/kg/h), and Group K-ketamine (0.25 mg/kg/h). Patients received propofol and fentanyl infusions along with study drugs. CoMEPs were recorded from muscles innervated by cranial nerves bilaterally at predefined intervals (T baseline , T 2 , T 3 , T 4 , and T 5 ). Effect on amplitude and latency of CoMEPs was assessed. Results A significant fall in CoMEP amplitude was observed across all analyzed muscles at time T 4 and T 5 in saline and dexmedetomidine group as compared with ketamine group, p -value less than 0.05. A significant increase in latency was observed at T4 and T5 among groups ( p -value, D vs. K = 0.239, D vs. S = 0.123, and K vs. S = 0.001). Conclusion Both ketamine and dexmedetomidine provide and allow effective recording of CoMEPs. Ketamine emerges as a better agent especially when prolonged surgical duration is expected as even propofol-fentanyl-based TIVA adversely affects CoMEPs when used for long duration.
Collapse
Affiliation(s)
- Sharmishtha Pathak
- Department of Anaesthesiology, Pain Medicine and Critical Care, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, Ansari Nagar, Delhi, India
| | - Priyanka Gupta
- Department of Anaesthesiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Ashutosh Kaushal
- Department of Anaesthesiology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Konish Biswas
- Department of Neuroanaesthesiology and Critical Care, Medanta, Patna, Bihar, India
| |
Collapse
|
9
|
Chen LP, Wang MR, Wang R, Li D, Zhang LW, Wu Z, Zhang JT, Qiao H, Wang L. Utility of Dual Monitoring of the Lower Cranial Nerve Motor-Evoked Potentials Threshold Level Criterion to Predict Swallowing Function in Skull Base and Brainstem Surgery. J Clin Neurophysiol 2023; 40:355-363. [PMID: 34817444 DOI: 10.1097/wnp.0000000000000895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Evaluate the value of bilateral final/baseline threshold level changes of lower cranial nerve MEPs in postoperative swallowing function deterioration prediction. METHODS Bilateral lower cranial nerve motor-evoked potentials (MEPs) were recorded in 51 patients who underwent treatment for skull base and brainstem tumors. Corkscrew-like electrodes were positione 2 cm below C3/C4 and Cz. The MEPs were recorded from different muscle groups, including the posterior pharyngeal wall muscle, tongue muscle, genioglossus muscle, and cricothyroid muscle through paired needle electrodes. Swallowing function was assessed clinically using the Mann Assessment of Swallowing Ability score before and after the procedure at 7 days, 1 month, and 3 months. RESULTS Bilateral final/baseline threshold level increases in lower cranial nerve MEPs under the dual monitoring were significantly correlated with postoperative swallowing function deterioration ( r = 0.660 at 7 days, r = 0.735 at 1 month, and r = 0.717 at 3 months; p < 0.05). Bilateral final/baseline threshold level changes of more than 20% were recorded in 23 of the 51 patients, with 21 patients experiencing swallowing function deterioration postoperatively. The other 28 patients had bilateral threshold level changes of less than 20%, with 26 patients maintaining or improving their swallowing function, and 12 of those patients presented transient deterioration of swallowing function in the early postoperative period. CONCLUSIONS Dual monitoring of lower cranial nerves and their different muscle groups MEPs was a safe and effective way to predict postoperative swallowing function. An increase in bilateral final/baseline threshold level change of more than 20% was predictive of permanent swallowing deterioration, especially in patients with poor swallowing function preoperatively.
Collapse
Affiliation(s)
- Liang-Peng Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Brain Tumor, National Clinical Research Center for Neurological Diseases, Center of Brain Tumor, Beijing Institute for Brain Disorders, Beijing, China ; and
| | - Ming-Ran Wang
- Department of Neuroelectrophysiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Rong Wang
- Department of Neuroelectrophysiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Da Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Brain Tumor, National Clinical Research Center for Neurological Diseases, Center of Brain Tumor, Beijing Institute for Brain Disorders, Beijing, China ; and
| | - Li-Wei Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Brain Tumor, National Clinical Research Center for Neurological Diseases, Center of Brain Tumor, Beijing Institute for Brain Disorders, Beijing, China ; and
| | - Zhen Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Brain Tumor, National Clinical Research Center for Neurological Diseases, Center of Brain Tumor, Beijing Institute for Brain Disorders, Beijing, China ; and
| | - Jun-Ting Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Brain Tumor, National Clinical Research Center for Neurological Diseases, Center of Brain Tumor, Beijing Institute for Brain Disorders, Beijing, China ; and
| | - Hui Qiao
- Department of Neuroelectrophysiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Liang Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Brain Tumor, National Clinical Research Center for Neurological Diseases, Center of Brain Tumor, Beijing Institute for Brain Disorders, Beijing, China ; and
| |
Collapse
|
10
|
Morota N, Deletis V. Brainstem Surgery: Functional Surgical Anatomy with the Use of an Advanced Modern Intraoperative Neurophysiological Procedure. Adv Tech Stand Neurosurg 2023; 48:21-55. [PMID: 37770680 DOI: 10.1007/978-3-031-36785-4_2] [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] [Indexed: 09/30/2023]
Abstract
Intraoperative neurophysiology (ION) in brainstem surgery evolved as brainstem surgery advanced.The original idea of brainstem mapping (BSM) is a neurophysiological procedure to locate cranial nerve motor nuclei (CNMN) on the floor of the fourth ventricle. With the introduction of various skull base approaches to the brainstem, BSM is carried out on any surface of the brainstem to expose the safe entry zone to the intrinsic brainstem lesion. It is the modern concept of BSM, a broader definition of BSM. BSM enables to avoid direct damage to the CNMN when approaching the brainstem through the negative mapping region.The corticobulbar tract (CBT) motor evoked potential (MEP) is another ION procedure in brainstem surgery. It enables monitoring of the functional integrity of the whole cranial motor pathway without interrupting surgical procedures. Combined application of both BSM and CBT-MEP monitoring is indispensable for the functional preservation of the CNMN and their supranuclear innervation during the brainstem surgery.In this paper, the neurophysiological aspect of BSM and the CBT-MEP was fully described. Normal anatomical background of the floor of the fourth ventricle and the detail of the CBT anatomy were demonstrated to better understand their clinical usefulness, limitations, and surgical implications derived from ION procedures. Finally, a future perspective in the role of ION procedures in brainstem surgery was presented. The latest magnetic resonance imaging (MRI) technology can allow surgeons to find an "on the image" safe entry zone to the brainstem. However, the role of BSM and the CBT-MEP monitoring in terms of safe brainstem surgery stays unshakable. Special attention was paid for the recent trend of management in diffuse intrinsic pontine gliomas. A new role of BSM during a stereotactic biopsy was discussed.It is the authors' expectation that the paper enhances the clinical application of a contemporary standard of the ION in brainstem surgery and supports safer brainstem surgery more than ever and in the future.
Collapse
Affiliation(s)
- Nobuhito Morota
- Department of Neurosurgery, Kitasato University Hospital, Sagamihara, Japan
| | - Vedran Deletis
- Department of Neurosurgery, University Hospital, Zagreb, Croatia
| |
Collapse
|
11
|
Della Pepa GM, Stifano V, D'Alessandris QG, Menna G, Burattini B, Di Domenico M, Izzo A, D'Ercole M, Lauretti L, Olivi A, Montano N. Intraoperative Corticobulbar Motor Evoked Potential in Cerebellopontine Angle Surgery: A Clinically Meaningful Tool to Predict Early and Late Facial Nerve Recovery. Neurosurgery 2022; 91:406-413. [PMID: 35612564 DOI: 10.1227/neu.0000000000002039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 04/03/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Intraoperative neuromonitoring is crucial for facial nerve preservation in cerebellopontine angle (CPA) surgery. Among the available techniques, the role of intraoperative corticobulbar facial motor evoked potentials (FMEPs) is unclear. OBJECTIVE To evaluate the significance of intraoperative FMEPs as indicators for early and late postoperative facial nerve function (FNF) in CPA tumor resection and the feasibility of their integration with standard monitoring techniques. METHODS An institutional series of 83 patients who underwent surgery under intraoperative monitoring for CPA extra-axial tumor resection was reported. A pair of needle electrodes was used to record FMEP from orbicularis oculi (OOc) and orbicularis oris (OOr) muscles at baseline, at the end of surgery and minimum values recorded. From FMEP amplitudes, minimum-to-baseline amplitude ratio (MBR), final-to-baseline amplitude ratio (FBR), and recovery value, intended as FBR minus MBR, were calculated. These indices were correlated with early and late postoperative FNF. RESULTS Our analysis demonstrated that higher FBR (both from OOc and OOr) and MBR (from OOr only) were associated with a good early and late FNF; a higher MBR from OOc was significantly associated with a good late FNF. The most accurate index in predicting early FNF was FBR measured from OOr with a cutoff of 35.56%, whereas the most accurate index in predicting late FNF was FBR as measured from OOc with a cutoff of 14.29%. CONCLUSION Our study confirmed that FMEPs are reliable predictors of early and late postoperative FNF in CPA surgery and could be easily integrated with standard intraoperative neuromonitoring techniques.
Collapse
Affiliation(s)
- Giuseppe Maria Della Pepa
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Vito Stifano
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Quintino Giorgio D'Alessandris
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Grazia Menna
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy.,Department of Neuroscience, Neurosurgery Section, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Benedetta Burattini
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy.,Department of Neuroscience, Neurosurgery Section, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Michele Di Domenico
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alessandro Izzo
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Manuela D'Ercole
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Liverana Lauretti
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy.,Department of Neuroscience, Neurosurgery Section, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alessandro Olivi
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy.,Department of Neuroscience, Neurosurgery Section, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Nicola Montano
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy.,Department of Neuroscience, Neurosurgery Section, Università Cattolica del Sacro Cuore, Rome, Italy
| |
Collapse
|
12
|
Szelényi A, Fava E. Long latency responses in tongue muscle elicited by various stimulation sites in anesthetized humans - New insights into tongue-related brainstem reflexes. Brain Stimul 2022; 15:566-575. [PMID: 35341967 DOI: 10.1016/j.brs.2022.03.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 03/15/2022] [Accepted: 03/16/2022] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Long Latency Responses (LLR) in tongue muscles are a scarcely described phenomenon, the physiology of which is uncertain. OBJECTIVES The aim of this exploratory, observational study was to describe tongue-LLR elicited by direct trigeminal nerve (DTNS), dorsal column (DoColS), transcranial electric (TES) and peripheral median nerve (MNS) stimulation in a total of 93 patients undergoing neurosurgical procedures under general anesthesia. METHODS Bilateral tongue responses were derived concurrently after each of the following stimulations: (1) DTNS applied with single monophasic or train-of-three pulses, ≤5 mA; (2) DoColS applied with a train-of-three pulses, ≤10 mA; (3) TES consisting of an anodal train-of-five stimulation, ≤250 mA; (4) MNS at wrist consisting of single or train-of-three monophasic pulses, ≤50 mA. Polyphasic tongue muscle responses exceeding the latencies of tongue compound muscle action potentials or motor evoked potentials were classified as LLR. RESULTS Tongue-LLR were evoked from all stimulation sites, with latencies as follows: (1) DTNS: solely ipsilateral 20.2 ± 3.3 msec; (2) DoColS: ipsilateral 25.9 ± 1.6 msec, contralateral 25.1 ± 4.2 msec; (3) TES: contralateral 55.3 ± 10.2 msec, ipsilateral 54.9 ± 12.0 msec; (4) MNS: ipsilateral 37.8 ± 4.7 msec and contralateral 40.3 ± 3.5 msec. CONCLUSION The tongue muscles are a common efferent in brainstem pathways targeted by trigeminal and cervical sensory fibers. DTNS can elicit the "trigemino-hypoglossal-reflex". For the MNS elicited tongue-LLR, we propose the term "somatosensory-evoked tongue-reflex". Although the origin of the TES related tongue-LLR remains unclear, these data will help to interpret intraoperative tongue recordings.
Collapse
Affiliation(s)
- Andrea Szelényi
- Department of Neurosurgery, University Hospital, LMU Munich, Munich, Germany.
| | - Enrica Fava
- Department of Neurosurgery, Great Metropolitan Hospital of Niguarda, University of Milano, Italy
| |
Collapse
|
13
|
Kodama K, Kothbauer KF, Deletis V. Mapping and monitoring of brainstem surgery. HANDBOOK OF CLINICAL NEUROLOGY 2022; 186:151-161. [PMID: 35772884 DOI: 10.1016/b978-0-12-819826-1.00021-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The surgical morbidity of brainstem lesions is higher than in other areas of the central nervous system because the compact brainstem is highly concentrated with neural structures that are often distorted or even unrecognizable under microscopic view. Intraoperative neurophysiologic mapping helps identify critical neural structures to avoid damaging them. With the trans-fourth ventricular floor approach, identifying the facial colliculi and vagal and hypoglossal triangles enables incising and approaching the brainstem through the safe entry zones, the suprafacial or infrafacial triangle, with minimal injury. Corticospinal tract mapping is adopted in the case of brainstem surgery adjacent to the corticospinal tract. Intraoperative neurophysiologic monitoring techniques include motor evoked potentials (MEPs), corticobulbar MEPs, brainstem auditory evoked potentials, and somatosensory evoked potentials. These provide real-time feedback about the functional integrity of neural pathways, and the surgical team can reconsider and correct the surgical strategy accordingly. With multimodal mapping and monitoring, the brainstem is no longer "no man's land," and brainstem lesions can be treated surgically without formidable morbidity and mortality.
Collapse
Affiliation(s)
- Kunihiko Kodama
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan.
| | - Karl F Kothbauer
- Formerly Department of Neurosurgery, University of Basel and Division of Neurosurgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Vedran Deletis
- Department of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia; Albert Einstein College of Medicine, New York, NY, United States
| |
Collapse
|
14
|
Rauschenbach L, Santos AN, Dinger TF, Herten A, Darkwah Oppong M, Schmidt B, Chihi M, Haubold J, Jabbarli R, Wrede KH, Sure U, Dammann P. Predictive Value of Intraoperative Neuromonitoring in Brainstem Cavernous Malformation Surgery. World Neurosurg 2021; 156:e359-e373. [PMID: 34560298 DOI: 10.1016/j.wneu.2021.09.064] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 09/13/2021] [Accepted: 09/14/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To evaluate the predictive value of intraoperative neuromonitoring (IONM) in brainstem cavernous malformation (BSCM) surgery. METHODS Surgically treated patients with BSCM were included. All patients received IONM consisting of motor-evoked potentials (MEPs) and somatosensory-evoked potentials (SSEPs). Neurologic examination was conducted preoperatively and at discharge and follow-up >3 months after BSCM removal. Demographic, radiographic, and clinical features were assessed. Study end points were new motor or somatosensory deficits and functional disability. RESULTS A total of 62 patients were included. MEP decrease was associated with new motor deficits at discharge (P = 0.022), and SSEP decrease was associated with new somatosensory deficits at discharge (P < 0.001) and follow-up (P < 0.001). Sensitivity and specificity values for MEPs (discharge: 31% and 93%; follow-up: 33% and 91%) and SSEPs (discharge: 82% and 80%; follow-up: 85% and 79%) were calculated, respectively. Receiver operating characteristic analyses with area under the curve (AUC) metrics revealed acceptable performance of MEPs (AUC, 0.75; P = 0.022) and SSEPs (AUC, 0.72; P = 0.004) in predicting early deficits. Intraoperative decrease of MEPs (P = 0.047) and SSEPs (P = 0.017) was associated with early functional disability. Surgery-related subdural air accumulation impaired IONM reliability in predicting early (P = 0.048) and long-term (P = 0.013) deficits. CONCLUSIONS Established IONM warning criteria may be valid for BSCM removal. However, surgical approaches in the sitting position significantly limit the predictive value of IONM, to some extent because of intraoperative pneumocephalus.
Collapse
Affiliation(s)
- Laurèl Rauschenbach
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.
| | - Alejandro N Santos
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Thiemo F Dinger
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Annika Herten
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Marvi Darkwah Oppong
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Börge Schmidt
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, Essen, Germany
| | - Mehdi Chihi
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Johannes Haubold
- Institute for Diagnostic and Interventional Radiology, University Hospital Essen, Essen, Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Karsten H Wrede
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Philipp Dammann
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| |
Collapse
|
15
|
Use of intra-operative stimulation of brainstem lesion target sites for frameless stereotactic biopsies. Childs Nerv Syst 2021; 37:1515-1523. [PMID: 33683422 DOI: 10.1007/s00381-021-05101-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 02/24/2021] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Frameless stereotactic navigation is used to direct the trajectory and biopsy site of target lesions. We report on a novel intra-operative stimulating (IOS) probe that is integrated into a commercially available stereotactic biopsy needle with the rationale that stimulation of the intended biopsy site should predict functional tissue thus preventing inadvertent biopsy of eloquent tissue. METHODS Patients undergoing brainstem biopsies for atypical lesions were offered the additional stimulation procedure. The IOS probe was used to deliver stimulation in an attempt to determine the proximity of eloquent tissue. Once the desired location of the biopsy needle was achieved, the IOS probe was inserted down the centre of the biopsy needle and the stimulus applied. If no action potential was recorded, biopsies from four quadrants of the lesion were taken. If however a compound action potential was recorded, a new target was selected. RESULTS Nine patients had the biopsy and stimulation procedure performed. The median age was 36 months. A minimum of 8 samples were obtained from each patient. Biopsy material was adequate to obtain a diagnosis in all 9 patients. In 2 cases use of the device influenced the insertion trajectory or biopsy site. No patients experienced any complications directly attributable to either the biopsy procedure or application of the stimulation. CONCLUSIONS Use of the IOS probe for intra-operative stimulation of the intended brainstem biopsy site was found to be safe and feasible. The addition of stimulation using the IOS probe can be done with minimal change in workflow.
Collapse
|
16
|
Hiruta R, Sato T, Itakura T, Fujii M, Sakuma J, Bakhit M, Kojima T, Ichikawa M, Iwatate K, Saito K. Intraoperative transcranial facial motor evoked potential monitoring in surgery of cerebellopontine angle tumors predicts early and late postoperative facial nerve function. Clin Neurophysiol 2021; 132:864-871. [PMID: 33636603 DOI: 10.1016/j.clinph.2020.12.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 11/17/2020] [Accepted: 12/11/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVE We propose a novel method that predicts facial nerve function (FNF) calculated from the drop and recovery of facial motor evoked potential (FMEP) amplitude ratio during the surgery of cerebellopontine angle tumors. METHODS We enrolled 73 patients with cerebellopontine angle tumor, and used a biphasic, constant current, and suprathreshold stimulation (BCS) protocol to record FMEP of the orbicularis oris. We measured the intraoperative minimum-to-baseline amplitude ratio (MBR), the final-to-baseline amplitude ratio (FBR), and the recovery value (RV). RV was measured by subtracting MBR from FBR. Using those values, we evaluated FNF both at early postoperative (EP) and late postoperative (LP) periods. RESULTS We successfully obtained 62 FMEP readings. Facial palsies occurred in 22 patients during the EP period, and 14 patients recovered during the LP period. Both MBR and FBR showed a significant correlation with FNF in the EP period. RV showed a good predictive power of FNF recovery during the LP period for the first time. CONCLUSIONS RV is a new and useful predictor of FNF recovery. MBR can be an intraoperative predictor of FNF in the EP period. SIGNIFICANCE FNF outcome in the early and late postoperative periods can be predicted by FMEP.
Collapse
Affiliation(s)
- Ryo Hiruta
- Department of Neurosurgery, Fukushima Medical University, Fukushima, Fukushima, Japan.
| | - Taku Sato
- Department of Neurosurgery, Fukushima Medical University, Fukushima, Fukushima, Japan
| | - Takeshi Itakura
- Department of Neurosurgery, Fukushima Medical University, Fukushima, Fukushima, Japan; Department of Orthopedic Surgery, Kansai Medical University, Hirakata, Osaka, Japan
| | - Masazumi Fujii
- Department of Neurosurgery, Fukushima Medical University, Fukushima, Fukushima, Japan
| | - Jun Sakuma
- Department of Neurosurgery, Fukushima Medical University, Fukushima, Fukushima, Japan
| | - Mudathir Bakhit
- Department of Neurosurgery, Fukushima Medical University, Fukushima, Fukushima, Japan
| | - Takao Kojima
- Department of Neurosurgery, Fukushima Medical University, Fukushima, Fukushima, Japan
| | - Masahiro Ichikawa
- Department of Neurosurgery, Fukushima Medical University, Fukushima, Fukushima, Japan
| | - Kensho Iwatate
- Department of Neurosurgery, Fukushima Medical University, Fukushima, Fukushima, Japan
| | - Kiyoshi Saito
- Department of Neurosurgery, Fukushima Medical University, Fukushima, Fukushima, Japan
| |
Collapse
|
17
|
Wu Y, Zhang F. Exploiting molecular probes to perform near‐infrared fluorescence‐guided surgery. VIEW 2020. [DOI: 10.1002/viw.20200068] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Yifan Wu
- Department of Chemistry State Key Laboratory of Molecular Engineering of Polymers Shanghai Key Laboratory of Molecular Catalysis and Innovative Materials and iChem Fudan University Shanghai China
| | - Fan Zhang
- Department of Chemistry State Key Laboratory of Molecular Engineering of Polymers Shanghai Key Laboratory of Molecular Catalysis and Innovative Materials and iChem Fudan University Shanghai China
| |
Collapse
|
18
|
Spennato P, Chiaramonte C, Russo C, Onorini N, Mirone G, Mazio F, Di Martino G, Parlato RS, Cinalli G. Subtemporal Transtentorial Approach in Mesencephalic and Perimesencephalic Lesions in Children-A Series of 20 Patients. Oper Neurosurg (Hagerstown) 2020; 18:349-362. [PMID: 31504862 DOI: 10.1093/ons/opz254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 06/08/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Midbrain and surrounding areas are among the most difficult regions to surgically approach in neurosurgery. The subtemporal approach is a well-known neurosurgical approach that is rarely described in children. OBJECTIVE To assess the feasibility, advantages, and disadvantages of subtemporal approach in children. METHODS A total of 20 pediatric patients with intra-axial tumors involving the lateral midbrain or superior cerebellar peduncle or with extra-axial tumors in the middle incisural space/Meckel cave underwent subtemporal transtentorial approaches with the aim to remove (16 cases) or biopsy (4 cases) their lesions. These cases were retrospectively reviewed and the surgical approach described. RESULTS Total resection was achieved in 11 patients. In the 4 patients who underwent biopsies, a diagnosis was obtained. A total of 5 patients presented non-neoplastic lesions (dermoid tumors or cavernomas). A total of 9 patients harbored low-grade tumors and 6 high-grade tumors. Patients with low-grade tumors and non-neoplastic lesions are all alive with no evidence of disease or stable residue. Four patients affected by high grade tumors died. No patient suffered permanent neurological deficits related to the surgical approach. Three patients presented temporary neurological deficits following the procedure: one case of strabismus, one case of aphasia and hemiparesis, secondary to delayed, transient thrombosis of the Labbé vein, and 1 case of trigeminal neuralgia. CONCLUSION The subtemporal approach represents a feasible approach for mesencephalic and perimesencephalic lesions in children. It provides an ample and direct access, with excellent outcomes and acceptable postoperative morbidity.
Collapse
Affiliation(s)
- Pietro Spennato
- Department of Pediatric Neurosurgery, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Carmela Chiaramonte
- Department of Pediatric Neurosurgery, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Carmela Russo
- Department of Pediatric Neuroradiology, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Nicola Onorini
- Department of Pediatric Neurosurgery, Santobono-Pausilipon Children's Hospital, Naples, Italy.,Neurosurgery Unit, University of Brescia, Brescia, Italy
| | - Giuseppe Mirone
- Department of Pediatric Neurosurgery, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Federica Mazio
- Department of Pediatric Neuroradiology, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Giuliana Di Martino
- Department of Pediatric Neurosurgery, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | | | - Giuseppe Cinalli
- Department of Pediatric Neurosurgery, Santobono-Pausilipon Children's Hospital, Naples, Italy
| |
Collapse
|
19
|
Hardian RF, Goto T, Fujii Y, Kanaya K, Horiuchi T, Hongo K. Intraoperative facial motor evoked potential monitoring for pontine cavernous malformation resection. J Neurosurg 2020; 132:265-271. [PMID: 30641834 DOI: 10.3171/2018.8.jns181199] [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: 05/07/2018] [Accepted: 08/16/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to predict postoperative facial nerve function during pontine cavernous malformation surgery by monitoring facial motor evoked potentials (FMEPs). METHODS From 2008 to 2017, 10 patients with pontine cavernous malformations underwent total resection via the trans-fourth ventricle floor approach with FMEP monitoring. House-Brackmann grades and Karnofsky Performance Scale (KPS) scores were obtained pre- and postoperatively. The surgeries were performed using one of 2 safe entry zones into the brainstem: the suprafacial triangle and infrafacial triangle approaches. Six patients underwent the suprafacial triangle approach, and 4 patients underwent the infrafacial triangle approach. A cranial peg screw electrode was used to deliver electrical stimulation for FMEP by a train of 4 or 5 pulse anodal constant current stimulation. FMEP was recorded from needle electrodes on the ipsilateral facial muscles and monitored throughout surgery by using a threshold-level stimulation method. RESULTS FMEPs were recorded and analyzed in 8 patients; they were not recorded in 2 patients who had severe preoperative facial palsy and underwent an infrafacial triangle approach. Warning signs appeared in all patients who underwent the suprafacial triangle approach. However, after temporarily stopping the procedures, FMEP findings during surgery showed recovery of the thresholds. FMEPs in patients who underwent the infrafacial triangle approach were stable during the surgery. House-Brackmann grades were unchanged postoperatively in all patients. Postoperative KPS scores improved in 3 patients, decreased in 1, and remained the same in 6 patients. CONCLUSIONS FMEPs can be used to monitor facial nerve function during surgery for pontine cavernous malformations, especially when the suprafacial triangle approach is performed.
Collapse
|
20
|
Roser F, Rigante L, Elhammady MS. Endoscope-assisted resection of a brainstem cavernoma. NEUROSURGICAL FOCUS: VIDEO 2019; 1:V6. [PMID: 36285042 PMCID: PMC9541655 DOI: 10.3171/2019.7.focusvid.19158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 05/07/2019] [Indexed: 11/24/2022]
Abstract
Procedures on cavernous malformations of the brainstem are challenging due to their eloquent location. This accounts especially for recurrent cavernomas as surgical scars, adhesions, and functional shift might have occurred since primary surgery. We report on a 38-year-old female patient with a large recurrent brainstem cavernoma, who underwent previous successful surgery and experienced recurrent bleeding about 2 years later. She harbored a large associated developmental venous anomaly (DVA) traversing the cavernoma through the midline of the brainstem. In order to visualize complete resection and preservation of the DVA at the same time, endoscopic-assisted resection within the brainstem after decompression in the semisitting position was performed. The video can be found here: https://youtu.be/K1p-Sx7jUpA.
Collapse
|
21
|
Ichino T, Tanaka S, Tanaka R, Tanaka N, Ishida T, Sugiyama Y, Kawamata M. Transcranial motor-evoked potentials of laryngeal muscles for intraoperative neuromonitoring of the vagus nerve during thyroid surgery. J Anesth 2019; 33:221-229. [PMID: 30600346 DOI: 10.1007/s00540-018-2601-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 12/19/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE The aim of this study was to elucidate normative features of vagal motor-evoked potentials (MEPs) induced by transcranial electrical stimulation (TES) and to determine the influence of functional decline of the recurrent laryngeal nerve (RLN) on vagal MEPs during thyroid surgery. METHODS A total of 54 patients undergoing elective thyroid surgery under general anesthesia were enrolled in this study. Vagal MEPs induced by TES were measured from the vocal cord using one of two types of electrodes (wire type or wide and flat type) mounted on an endotracheal tube. We investigated the effects of stimulation intensity and train pulse number on vagal MEP amplitude, the time course of vagal MEP amplitude during surgery, and the effects of functional decline of the RLN on vagal MEPs. RESULTS The success rate of vagal MEP monitoring with wide- and flat-type electrodes was significantly higher than that with wire-type electrodes. Reliable vagal MEPs were obtained at a stimulation intensity of approximately 300 V with 3 or more pulses in 91% of the patients without preoperative RLN palsy (RLNP), and the amplitude was augmented with increasing stimulation intensity and train pulse number. Vagal MEP amplitude decreased during thyroid surgery and then partially recovered at the end of surgery. Vagal MEP amplitude recorded from the electrode ipsilateral to preoperative RLNP was significantly lower than that on the contralateral intact side. CONCLUSION Vagal MEPs induced by TES can be obtained with a high success rate during thyroid surgery and would reflect functional status of the RLN.
Collapse
Affiliation(s)
- Takashi Ichino
- Department of Anesthesiology and Resuscitology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Satoshi Tanaka
- Department of Anesthesiology and Resuscitology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan.
| | - Ryusuke Tanaka
- Department of Anesthesiology and Resuscitology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Naruaki Tanaka
- Department of Anesthesiology and Resuscitology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Takashi Ishida
- Department of Anesthesiology and Resuscitology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Yuki Sugiyama
- Department of Anesthesiology and Resuscitology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Mikito Kawamata
- Department of Anesthesiology and Resuscitology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| |
Collapse
|
22
|
Baek JS, Park SK, Kim DJ, Park CW, Lim SH, Lee JH, Cho YK. Facial Motor Evoked Potential Techniques and Functional Prediction during Cerebello-pontine Angle Surgery. KOREAN JOURNAL OF CLINICAL LABORATORY SCIENCE 2018. [DOI: 10.15324/kjcls.2018.50.4.470] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Jae-Seung Baek
- Department of Neurology, Samsung Medical Center, Seoul, Korea
| | - Sang-Ku Park
- Department of Neurology, Samsung Medical Center, Seoul, Korea
| | - Dong-Jun Kim
- Department of Neurology, Samsung Medical Center, Seoul, Korea
| | - Chan-Woo Park
- Department of Neurology, Samsung Medical Center, Seoul, Korea
| | - Sung-Hyuk Lim
- Department of Neurology, Samsung Medical Center, Seoul, Korea
| | - Jang Ho Lee
- Department of Clinical Laboratory Science, Semyung University, Jecheon, Korea
| | - Young-Kuk Cho
- Department of Medical Laboratory Science, Seoyeong University, Gwangju, Korea
| |
Collapse
|
23
|
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
|
24
|
Microsurgical treatment outcomes of brainstem cavernous malformation: Subgroup comparison depending on application of intraoperative neurophysiologic monitoring. INTERDISCIPLINARY NEUROSURGERY 2018. [DOI: 10.1016/j.inat.2018.04.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
|
25
|
Li Z, Wang M, Zhang L, Fan X, Tao X, Qi L, Ling M, Xiao X, Wu Y, Guo D, Qiao H. Neuronavigation-Guided Corticospinal Tract Mapping in Brainstem Tumor Surgery: Better Preservation of Motor Function. World Neurosurg 2018; 116:e291-e297. [PMID: 29733992 DOI: 10.1016/j.wneu.2018.04.189] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 04/24/2018] [Accepted: 04/25/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To evaluate a new technique in brainstem surgery, neuronavigation (NN)-guided corticospinal tract (CST) mapping, in a retrospective study of patients undergoing brainstem tumor surgery. METHODS We studied 40 patients with a brainstem tumor who were enrolled in this study. Patients whose worst preoperative muscle strength of the 4 limbs was greater than 3 levels from normal on the Lovett scale were divided into 2 groups: a treatment group of 21 patients who underwent NN-guided CST mapping and routine intraoperative neurophysiology monitoring (IONM) and a control group of 19 patients who underwent routine NN and IONM. Preoperative muscle strength and postoperative (day 90 postsurgery) muscle strength were assessed and compared between the 2 groups. RESULTS In the NN-guided CST mapping group, 3 patients (14.3%) had a decrease in muscle strength by 1 level postoperatively, and no patient experienced a decrease of >1 level. In the control group, 4 patients (21.1%) had a 1-level decrease in muscle strength, and 5 (26.3%) had a decrease of >1 level. Patients in the NN-guided CST mapping group had significantly better surgical outcomes compared with those in the control group (P = 0.018, Fisher exact test). CONCLUSIONS Brainstem tumor resection using NN-guided CST mapping achieved better preservation of motor function compared with routine NN and IONM. NN-guided CST mapping not only decreased the difficulty of the surgery, but also significantly improved the efficiency of surgery.
Collapse
Affiliation(s)
- Zhibao Li
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Neuroelectrophysiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Mingran Wang
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Neuroelectrophysiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liwei Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xing Fan
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Neuroelectrophysiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaorong Tao
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Neuroelectrophysiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Lei Qi
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Neuroelectrophysiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Miao Ling
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Neuroelectrophysiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiong Xiao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuliang Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dongze Guo
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Neuroelectrophysiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hui Qiao
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Neuroelectrophysiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
| |
Collapse
|
26
|
Tang Y, Sun W, Toga AW, Ringman JM, Shi Y. A probabilistic atlas of human brainstem pathways based on connectome imaging data. Neuroimage 2018; 169:227-239. [PMID: 29253653 PMCID: PMC5856609 DOI: 10.1016/j.neuroimage.2017.12.042] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 12/05/2017] [Accepted: 12/14/2017] [Indexed: 11/26/2022] Open
Abstract
The brainstem is a critical structure that regulates vital autonomic functions, houses the cranial nerves and their nuclei, relays motor and sensory information between the brain and spinal cord, and modulates cognition, mood, and emotions. As a primary relay center, the fiber pathways of the brainstem include efferent and afferent connections among the cerebral cortex, spinal cord, and cerebellum. While diffusion MRI has been successfully applied to map various brain pathways, its application for the in vivo imaging of the brainstem pathways has been limited due to inadequate resolution and large susceptibility-induced distortion artifacts. With the release of high-resolution data from the Human Connectome Project (HCP), there is increasing interest in mapping human brainstem pathways. Previous works relying on HCP data to study brainstem pathways, however, did not consider the prevalence (>80%) of large distortions in the brainstem even after the application of correction procedures from the HCP-Pipeline. They were also limited in the lack of adequate consideration of subject variability in either fiber pathways or region of interests (ROIs) used for bundle reconstruction. To overcome these limitations, we develop in this work a probabilistic atlas of 23 major brainstem bundles using high-quality HCP data passing rigorous quality control. For the large-scale data from the 500-Subject release of HCP, we conducted extensive quality controls to exclude subjects with severe distortions in the brainstem area. After that, we developed a systematic protocol to manually delineate 1300 ROIs on 20 HCP subjects (10 males; 10 females) for the reconstruction of fiber bundles using tractography techniques. Finally, we leveraged our novel connectome modeling techniques including high order fiber orientation distribution (FOD) reconstruction from multi-shell diffusion imaging and topography-preserving tract filtering algorithms to successfully reconstruct the 23 fiber bundles for each subject, which were then used to calculate the probabilistic atlases in the MNI152 space for public release. In our experimental results, we demonstrate that our method yielded anatomically faithful reconstruction of the brainstem pathways and achieved improved performance in comparison with an existing atlas of cerebellar peduncles based on HCP data. These atlases have been publicly released on NITRIC (https://www.nitrc.org/projects/brainstem_atlas/) and can be readily used by brain imaging researchers interested in studying brainstem pathways.
Collapse
Affiliation(s)
- Yuchun Tang
- Laboratory of Neuro Imaging (LONI), USC Stevens Neuroimaging and Informatics Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Research Center for Sectional and Imaging Anatomy, Shandong University Cheeloo College of Medicine, Jinan, Shandong, China
| | - Wei Sun
- Laboratory of Neuro Imaging (LONI), USC Stevens Neuroimaging and Informatics Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Arthur W Toga
- Laboratory of Neuro Imaging (LONI), USC Stevens Neuroimaging and Informatics Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - John M Ringman
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Yonggang Shi
- Laboratory of Neuro Imaging (LONI), USC Stevens Neuroimaging and Informatics Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| |
Collapse
|
27
|
Ling M, Tao X, Ma S, Yang X, Liu L, Fan X, Jia G, Qiao H. Predictive Value of Intraoperative Facial Motor Evoked Potentials in Vestibular Schwannoma Surgery Under 2 Anesthesia Protocols. World Neurosurg 2018; 111:e267-e276. [DOI: 10.1016/j.wneu.2017.12.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 12/05/2017] [Accepted: 12/08/2017] [Indexed: 11/25/2022]
|
28
|
Meola A, Yeh FC, Fellows-Mayle W, Weed J, Fernandez-Miranda JC. Human Connectome-Based Tractographic Atlas of the Brainstem Connections and Surgical Approaches. Neurosurgery 2017; 79:437-55. [PMID: 26914259 DOI: 10.1227/neu.0000000000001224] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The brainstem is one of the most challenging areas for the neurosurgeon because of the limited space between gray matter nuclei and white matter pathways. Diffusion tensor imaging-based tractography has been used to study the brainstem structure, but the angular and spatial resolution could be improved further with advanced diffusion magnetic resonance imaging (MRI). OBJECTIVE To construct a high-angular/spatial resolution, wide-population-based, comprehensive tractography atlas that presents an anatomical review of the surgical approaches to the brainstem. METHODS We applied advanced diffusion MRI fiber tractography to a population-based atlas constructed with data from a total of 488 subjects from the Human Connectome Project-488. Five formalin-fixed brains were studied for surgical landmarks. Luxol Fast Blue-stained histological sections were used to validate the results of tractography. RESULTS We acquired the tractography of the major brainstem pathways and validated them with histological analysis. The pathways included the cerebellar peduncles, corticospinal tract, corticopontine tracts, medial lemniscus, lateral lemniscus, spinothalamic tract, rubrospinal tract, central tegmental tract, medial longitudinal fasciculus, and dorsal longitudinal fasciculus. Then, the reconstructed 3-dimensional brainstem structure was sectioned at the level of classic surgical approaches, namely supracollicular, infracollicular, lateral mesencephalic, perioculomotor, peritrigeminal, anterolateral (to the medulla), and retro-olivary approaches. CONCLUSION The advanced diffusion MRI fiber tracking is a powerful tool to explore the brainstem neuroanatomy and to achieve a better understanding of surgical approaches. ABBREVIATIONS CN, cranial nerveCPT, corticopontine tractCST, corticospinal tractCTT, central tegmental tractDLF, dorsal longitudinal fasciculusHCP, Human Connectome ProjectML, medial lemniscusMLF, medial longitudinal fasciculusRST, rubrospinal tractSTT, spinothalamic tract.
Collapse
Affiliation(s)
- Antonio Meola
- *Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; ‡Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts; §Department of Psychology, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | | | | | | | | |
Collapse
|
29
|
Vasyatkina AG, Levin EA, Orlov KY, Kobozev VV. [An experience of neurophysiological monitoring in neurosurgery]. Zh Nevrol Psikhiatr Im S S Korsakova 2017; 117:21-27. [PMID: 28805756 DOI: 10.17116/jnevro20171177121-27] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To evaluate the efficacy of neuromonitoring methods in prevention of postoperative neurological complications and estimation of predictive power of intraoperative changes in monitored characteristics. MATERIAL AND METHODS Retrospective study examined 240 patients, operated in the years 2014-2015 using intraoperative neurophysiological monitoring. One hundred and seventy-three patients suffered from hemispheric lesions and 67 had lesions located in or near the brainstem. Somatosensory evoked potentials (SSEP) were monitored in 152 cases, visual in 32, brainstem acoustic in 22, transcranial motor in 36; stimulation mapping of motor cortex was performed in 69 surgeries, and cranial nerves identification in 27. EEG was recorded in 7 patients, and 3 of them were woke up during the surgery for speech mapping. RESULTS The sensitivity of the SSEP in motor dysfunction detection was low (33%), while the specificity was relatively high (82%). These characteristics for visual and motor evoked potentials were close to 100% provided that the parameters of anesthesia met the corresponding requirements. The most effective methods in respect of prevention of postoperative dysfunctions were the stimulation mapping of functionally significant areas (motor and speech) and motor pathways mapping. CONCLUSION Intraoperative neuromonitoring reduces a number of neurological complications after neurosurgical operations. The SSEP method is not sensitive enough in surgeries that could affect motor centers and/or pathways, and multimodal monitoring combining SSEP and motor responses recording during transcranial and/or direct electrical brain stimulation. Successful monitoring requires highly coordinated actions between neurophysiologists, neurosurgeons and anesthesiologists.
Collapse
Affiliation(s)
- A G Vasyatkina
- Center of Angioneurology and Neurosurgery, Novosibirsk Research Institute of Circulation Pathology, Ministry of Health Care of Russian Federation, Novosibirsk, Russia
| | - E A Levin
- Center of Angioneurology and Neurosurgery, Novosibirsk Research Institute of Circulation Pathology, Ministry of Health Care of Russian Federation, Novosibirsk, Russia
| | - K Yu Orlov
- Center of Angioneurology and Neurosurgery, Novosibirsk Research Institute of Circulation Pathology, Ministry of Health Care of Russian Federation, Novosibirsk, Russia
| | - V V Kobozev
- Center of Angioneurology and Neurosurgery, Novosibirsk Research Institute of Circulation Pathology, Ministry of Health Care of Russian Federation, Novosibirsk, Russia
| |
Collapse
|
30
|
Sala F. A spotlight on intraoperative neurophysiological monitoring of the lower brainstem. Clin Neurophysiol 2017; 128:1369-1371. [PMID: 28571911 DOI: 10.1016/j.clinph.2017.04.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 04/29/2017] [Indexed: 11/19/2022]
Affiliation(s)
- Francesco Sala
- Institute of Neurosurgery, University Hospital, Piazzale Stefani 1, 37124 Verona, Italy.
| |
Collapse
|
31
|
|
32
|
Czernicki T, Maj E, Podgórska A, Kunert P, Prokopienko M, Nowak A, Cieszanowski A, Marchel A. Diffusion tensor tractography of pyramidal tracts in patients with brainstem and intramedullary spinal cord tumors: Relationship with motor deficits and intraoperative MEP changes. J Magn Reson Imaging 2017; 46:715-723. [DOI: 10.1002/jmri.25578] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Accepted: 11/21/2016] [Indexed: 11/11/2022] Open
Affiliation(s)
- Tomasz Czernicki
- Department of Neurosurgery; Medical University of Warsaw; Warsaw Poland
| | - Edyta Maj
- 2nd Department of Clinical Radiology; Medical University of Warsaw; Warsaw Poland
| | - Anna Podgórska
- Department of Neurosurgery; Medical University of Warsaw; Warsaw Poland
| | - Przemysław Kunert
- Department of Neurosurgery; Medical University of Warsaw; Warsaw Poland
| | - Marek Prokopienko
- Department of Neurosurgery; Medical University of Warsaw; Warsaw Poland
| | - Arkadiusz Nowak
- Department of Neurosurgery; Medical University of Warsaw; Warsaw Poland
| | - Andrzej Cieszanowski
- 2nd Department of Clinical Radiology; Medical University of Warsaw; Warsaw Poland
| | - Andrzej Marchel
- Department of Neurosurgery; Medical University of Warsaw; Warsaw Poland
| |
Collapse
|
33
|
Kullmann M, Tatagiba M, Liebsch M, Feigl GC. Evaluation of the Predictive Value of Intraoperative Changes in Motor-Evoked Potentials of Caudal Cranial Nerves for the Postoperative Functional Outcome. World Neurosurg 2016; 95:329-334. [DOI: 10.1016/j.wneu.2016.07.078] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Revised: 07/20/2016] [Accepted: 07/21/2016] [Indexed: 10/21/2022]
|
34
|
Singh H, Vogel RW, Lober RM, Doan AT, Matsumoto CI, Kenning TJ, Evans JJ. Intraoperative Neurophysiological Monitoring for Endoscopic Endonasal Approaches to the Skull Base: A Technical Guide. SCIENTIFICA 2016; 2016:1751245. [PMID: 27293965 PMCID: PMC4886091 DOI: 10.1155/2016/1751245] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 04/04/2016] [Accepted: 04/11/2016] [Indexed: 06/06/2023]
Abstract
Intraoperative neurophysiological monitoring during endoscopic, endonasal approaches to the skull base is both feasible and safe. Numerous reports have recently emerged from the literature evaluating the efficacy of different neuromonitoring tests during endonasal procedures, making them relatively well-studied. The authors report on a comprehensive, multimodality approach to monitoring the functional integrity of at risk nervous system structures, including the cerebral cortex, brainstem, cranial nerves, corticospinal tract, corticobulbar tract, and the thalamocortical somatosensory system during endonasal surgery of the skull base. The modalities employed include electroencephalography, somatosensory evoked potentials, free-running and electrically triggered electromyography, transcranial electric motor evoked potentials, and auditory evoked potentials. Methodological considerations as well as benefits and limitations are discussed. The authors argue that, while individual modalities have their limitations, multimodality neuromonitoring provides a real-time, comprehensive assessment of nervous system function and allows for safer, more aggressive management of skull base tumors via the endonasal route.
Collapse
Affiliation(s)
- Harminder Singh
- Stanford Hospitals and Clinics, Department of Neurosurgery, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Richard W. Vogel
- Safe Passage Neuromonitoring, 915 Broadway, Suite 1200, New York, NY 10010, USA
| | - Robert M. Lober
- Stanford Hospitals and Clinics, Department of Neurosurgery, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Adam T. Doan
- Safe Passage Neuromonitoring, 915 Broadway, Suite 1200, New York, NY 10010, USA
| | - Craig I. Matsumoto
- Sentient Medical Systems, 11011 McCormick Road, Suite 200, Hunt Valley, MD 21031, USA
| | - Tyler J. Kenning
- Department of Neurosurgery, Albany Medical Center, Physicians Pavilion, First Floor, 47 New Scotland Avenue, MC 10, Albany, NY 12208, USA
| | - James J. Evans
- Thomas Jefferson University Hospital, Department of Neurosurgery, 909 Walnut Street, Third Floor, Philadelphia, PA 19107, USA
| |
Collapse
|
35
|
Cavalcanti DD, Preul MC, Kalani MYS, Spetzler RF. Microsurgical anatomy of safe entry zones to the brainstem. J Neurosurg 2016; 124:1359-76. [DOI: 10.3171/2015.4.jns141945] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECT
The aim of this study was to enhance the planning and use of microsurgical resection techniques for intrinsic brainstem lesions by better defining anatomical safe entry zones.
METHODS
Five cadaveric heads were dissected using 10 surgical approaches per head. Stepwise dissections focused on the actual areas of brainstem surface that were exposed through each approach and an analysis of the structures found, as well as which safe entry zones were accessible via each of the 10 surgical windows.
RESULTS
Thirteen safe entry zones have been reported and validated for approaching lesions in the brainstem, including the anterior mesencephalic zone, lateral mesencephalic sulcus, intercollicular region, peritrigeminal zone, supratrigeminal zone, lateral pontine zone, supracollicularzone, infracollicularzone, median sulcus of the fourth ventricle, anterolateral and posterior median sulci of the medulla, olivary zone, and lateral medullary zone. A discussion of the approaches, anatomy, and limitations of these entry zones is included.
CONCLUSIONS
A detailed understanding of the anatomy, area of exposure, and safe entry zones for each major approach allows for improved surgical planning and dissemination of the techniques required to successfully resect intrinsic brainstem lesions.
Collapse
Affiliation(s)
- Daniel D. Cavalcanti
- 1Department of Neurosurgery, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil; and
| | - Mark C. Preul
- 2Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - M. Yashar S. Kalani
- 2Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Robert F. Spetzler
- 2Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| |
Collapse
|
36
|
Shiban E, Zerr M, Huber T, Boeck-Behrends T, Wostrack M, Ringel F, Meyer B, Lehmberg J. Poor diagnostic accuracy of transcranial motor and somatosensory evoked potential monitoring during brainstem cavernoma resection. Acta Neurochir (Wien) 2015; 157:1963-9; discussion 1969. [PMID: 26347046 DOI: 10.1007/s00701-015-2573-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 08/27/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Microsurgical resection of brainstem cavernomas carries a high risk of new postoperative morbidity such as cranial nerve, motor and sensory deficits as well as functional deterioration. Intraoperative monitoring is used to avoid impending damage to these highly eloquent tracts. However, data on neurophysiological monitoring during resection of brainstem cavernomas are lacking. METHODS Consecutive patients with brainstem cavernomas who underwent surgical removal from June 2007 to December 2014 were retrospectively analysed. Transcranial motor-evoked potential (MEP) and somatosensory-evoked potential (SSEP) monitorings were performed in all cases. The evoked potential (EP) monitoring data were reviewed and related to new postoperative motor and sensory deficits and postoperative imaging. Clinical outcomes were assessed during follow-up. RESULTS Twenty-six consecutive patients with brainstem cavernoma underwent 27 surgical resections within this study. MEP and SSEP monitoring was technically feasible in 26 and 27 cases, respectively. MEP sensitivity and specificity were 33 and 88 %, respectively. MEP positive and negative predictive values were 28 and 78 %, respectively. SSEP sensitivity and specificity were 20 and 81 %, respectively. SSEP positive and negative predictive values were 20 and 81 %, respectively. CONCLUSION In continuous MEP and SSEP monitoring during brainstem cavernoma microsurgery, high rates of false-positive and -negative results are encountered, resulting in low positive and relatively high negative predictive values. Careful interpretation of the intraoperative monitoring results is essential in order to avoid potentially unjustified termination of brainstem cavernoma resection.
Collapse
Affiliation(s)
- Ehab Shiban
- Department of Neurosurgery, Technische Universität München, Munich, Germany.
| | - Marina Zerr
- Department of Neurosurgery, Technische Universität München, Munich, Germany.
| | - Thomas Huber
- Department of Radiology, Division of Neuroradiology, Technische Universität München, Munich, Germany.
| | - Tobias Boeck-Behrends
- Department of Radiology, Division of Neuroradiology, Technische Universität München, Munich, Germany.
| | - Maria Wostrack
- Department of Neurosurgery, Technische Universität München, Munich, Germany.
| | - Florian Ringel
- Department of Neurosurgery, Technische Universität München, Munich, Germany.
| | - Bernhard Meyer
- Department of Neurosurgery, Technische Universität München, Munich, Germany.
| | - Jens Lehmberg
- Department of Neurosurgery, Technische Universität München, Munich, Germany.
| |
Collapse
|
37
|
Párraga RG, Possatti LL, Alves RV, Ribas GC, Türe U, de Oliveira E. Microsurgical anatomy and internal architecture of the brainstem in 3D images: surgical considerations. J Neurosurg 2015; 124:1377-95. [PMID: 26517774 DOI: 10.3171/2015.4.jns132778] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Brainstem surgery remains a challenge for the neurosurgeon despite recent improvements in neuroimaging, microsurgical techniques, and electrophysiological monitoring. A detailed knowledge of the microsurgical anatomy of the brainstem surface and its internal architecture is mandatory to plan appropriate approaches to the brainstem, to choose the safest point of entry, and to avoid potential surgical complications. METHODS An extensive review of the literature was performed regarding the brainstem surgical approaches, and their correlations with the pertinent anatomy were studied and illustrated through dissection of human brainstems properly fixed with 10% formalin. The specimens were dissected using the fiber dissection technique, under ×6 to ×40 magnification. 3D stereoscopic photographs were obtained (anaglyphic 3D) for better illustration of this study. RESULTS The main surgical landmarks and their relationship with the cerebellum and vascular structures were identified on the surface of the brainstem. The arrangements of the white matter (ascending and descending pathways as well as the cerebellar peduncles) were demonstrated on each part of the brainstem (midbrain, pons, and medulla oblongata), with emphasis on their relationships with the surface. The gray matter, constituted mainly by nuclei of the cranial nerves, was also studied and illustrated. CONCLUSIONS The objective of this article is to review the microsurgical anatomy and the surgical approaches pertinent to the brainstem, providing a framework of its external and internal architecture to guide the neurosurgeon during its related surgical procedures.
Collapse
Affiliation(s)
- Richard Gonzalo Párraga
- Institute of Neurological Sciences (ICNE), São Paulo;,Microneurosurgery Laboratory, Beneficência Portuguesa Hospital, São Paulo;,Department of Neurological Surgery, Hospital UNIVALLE, Cochabamba-Cercado, Bolivia; and
| | - Lucas Loss Possatti
- Institute of Neurological Sciences (ICNE), São Paulo;,Microneurosurgery Laboratory, Beneficência Portuguesa Hospital, São Paulo
| | - Raphael Vicente Alves
- Institute of Neurological Sciences (ICNE), São Paulo;,Microneurosurgery Laboratory, Beneficência Portuguesa Hospital, São Paulo
| | | | - Uğur Türe
- Department of Neurosurgery, Yeditepe University School of Medicine, Istanbul, Turkey
| | - Evandro de Oliveira
- Institute of Neurological Sciences (ICNE), São Paulo;,Microneurosurgery Laboratory, Beneficência Portuguesa Hospital, São Paulo;,Department of Neurosurgery, State University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| |
Collapse
|
38
|
Acioly MA, Liebsch M, de Aguiar PHP, Tatagiba M. Facial Nerve Monitoring During Cerebellopontine Angle and Skull Base Tumor Surgery: A Systematic Review from Description to Current Success on Function Prediction. World Neurosurg 2013; 80:e271-300. [DOI: 10.1016/j.wneu.2011.09.026] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2011] [Accepted: 09/06/2011] [Indexed: 11/17/2022]
|
39
|
Cosetti MK, Xu M, Rivera A, Jethanamest D, Kuhn MA, Beric A, Golfinos JG, Roland JT. Intraoperative Transcranial Motor-Evoked Potential Monitoring of the Facial Nerve during Cerebellopontine Angle Tumor Resection. J Neurol Surg B Skull Base 2013; 73:308-15. [PMID: 24083121 DOI: 10.1055/s-0032-1321507] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2011] [Accepted: 03/28/2012] [Indexed: 10/28/2022] Open
Abstract
Objective To determine whether transcranial motor-evoked potential (TCMEP) monitoring of the facial nerve (FN) during cerebellopontine angle (CPA) tumor resection can predict both immediate and long-term postoperative FN function. Design Retrospective review. Setting Tertiary referral center. Main Outcome Measures DeltaTCMEP (final-initial) and immediate and long-term facial nerve function using House Brackmann (HB) rating scale. Results Intraoperative TCMEP data and immediate and follow-up FN outcome are reported for 52 patients undergoing CPA tumor resection. Patients with unsatisfactory facial outcome (HB >2) at follow-up had an average deltaTCMEP of 57 V, whereas those with HB I or II had a mean deltaTCMEP of 0.04 V (t = -2.6, p < 0.05.) Intraoperative deltaTCMEP did not differ significantly between groups with satisfactory (HB I, II) and unsatisfactory (HB > 2) facial function in the immediate postoperative period. Conclusion Intraoperative TCMEP of the facial nerve can be a valuable adjunct to conventional facial nerve electromyography during resection of tumors at the CPA. Intraoperative deltaTCMEP >57 V may be worrisome for long-term recovery of satisfactory facial nerve function.
Collapse
Affiliation(s)
- Maura K Cosetti
- Departments of Otolaryngology, New York University School of Medicine, New York, New York, United States
| | | | | | | | | | | | | | | |
Collapse
|
40
|
Ito E, Ichikawa M, Itakura T, Ando H, Matsumoto Y, Oda K, Sato T, Watanabe T, Sakuma J, Saito K. Motor evoked potential monitoring of the vagus nerve with transcranial electrical stimulation during skull base surgeries. J Neurosurg 2013; 118:195-201. [DOI: 10.3171/2012.10.jns12383] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Dysphasia is one of the most serious complications of skull base surgeries and results from damage to the brainstem and/or cranial nerves involved in swallowing. Here, the authors propose a method to monitor the function of the vagus nerve using endotracheal tube surface electrodes and transcranial electrical stimulation during skull base surgeries.
Methods
Fifteen patients with skull base or brainstem tumors were enrolled. The authors used surface electrodes of an endotracheal tube to record compound electromyographic responses from the vocalis muscle. Motor neurons were stimulated using corkscrew electrodes placed subdermally on the scalp at C3 and C4. During surgery, the operator received a warning when the amplitude of the vagal motor evoked potential (MEP) decreased to less than 50% of the control level. After surgery, swallowing function was assessed clinically using grading criteria.
Results
In 5 patients, vagal MEP amplitude permanently deteriorated to less than 50% of the control level on the right side when meningiomas were dissected from the pons or basilar artery, or when a schwannoma was dissected from the vagal rootlets. These 5 patients had postoperative dysphagia. At 4 weeks after surgery, 2 patients still had dysphagia. In 2 patients, vagal MEPs of one side transiently disappeared when the tumors were dissected from the brainstem or the vagal rootlets. After surgery, both patients had dysphagia, which recovered in 4 weeks. In 7 patients, MEP amplitude was consistent, maintaining more than 50% of the control level throughout the operative procedures. After surgery all 7 patients were neurologically intact with normal swallowing function.
Conclusions
Vagal MEP monitoring with transcranial electrical stimulation and endotracheal tube electrode recording was a safe and effective method to provide continuous real-time information on the integrity of both the supranuclear and infranuclear vagal pathway. This method is useful to prevent intraoperative injury of the brainstem corticobulbar tract or the vagal rootlets and to avoid the postoperative dysphagia that is often associated with brainstem or skull base surgeries.
Collapse
Affiliation(s)
- Eiji Ito
- 1Department of Neurosurgery, Chubu Rosai Hospital
| | - Masahiro Ichikawa
- 2Department of Neurosurgery, Fukushima Medical University, Fukushima, Japan
| | - Takeshi Itakura
- 2Department of Neurosurgery, Fukushima Medical University, Fukushima, Japan
| | - Hitoshi Ando
- 2Department of Neurosurgery, Fukushima Medical University, Fukushima, Japan
| | - Yuka Matsumoto
- 2Department of Neurosurgery, Fukushima Medical University, Fukushima, Japan
| | - Keiko Oda
- 2Department of Neurosurgery, Fukushima Medical University, Fukushima, Japan
| | - Taku Sato
- 2Department of Neurosurgery, Fukushima Medical University, Fukushima, Japan
| | - Tadashi Watanabe
- 3Department of Neurosurgery, Nagoya Daini Red Cross Hospital, Nagoya; and
| | - Jun Sakuma
- 2Department of Neurosurgery, Fukushima Medical University, Fukushima, Japan
| | - Kiyoshi Saito
- 2Department of Neurosurgery, Fukushima Medical University, Fukushima, Japan
| |
Collapse
|
41
|
Comparison between the C5 or C6-Cz electrode assembly and C3 or C4-Cz assembly for transcranial electric motor activation of muscular response of the contralateral facial nerve. Acta Neurochir (Wien) 2012; 154:2229-35. [PMID: 23053280 DOI: 10.1007/s00701-012-1505-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Accepted: 09/13/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE We used an assembly of electrodes C3 and C4-Cz in order to activate the motor cortical area of the corticobulbar tract to elucidate the motor-evoked potential of the contralateral mentalis muscle. METHOD We compared this setup to that of an assembly with electrodes C5 or C6-Cz using a train of electrical pulses and a single electrical pulse. This analysis was made in 23 consecutive patients who underwent several varied surgeries and were prospectively operated on at Santa Paula Hospital between January and June 2011. RESULTS The results showed that the assembly with C5 or C6-Cz produced a multisynaptic motor-evoked potential in the contralateral mentalis muscle in 86.9 % of the patients, whereas 82.6 % of patients stimulated at points C3 or C4-Cz presented the same response. However, both assemblies showed similar behavior with the use of a single electrical pulse for peripheral contralateral nerve stimulation. CONCLUSION We concluded that the C5 or C6-Cz assembly was similar to C3 or C4-Cz in obtaining a multisynaptic response in the contralateral mentalis muscle, although it required less intensive stimulation than the C3 or C4- Cz assembly.
Collapse
|
42
|
Surgical treatment of symptomatic cerebral cavernous malformations in eloquent brain regions. Acta Neurochir (Wien) 2012; 154:1419-30. [PMID: 22739772 DOI: 10.1007/s00701-012-1411-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Accepted: 05/29/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND Despite the increased risk of hemorrhage and deteriorating neurological function of once-bled cerebral cavernous malformations (CM), the management of eloquently located CMs remains controversial. METHODS All eloquently located CMs (n = 45) surgically treated between 03/2006 and 04/2011 in our department were consecutively evaluated. Eloquence was characterized according to Spetzler and Martin's definition. The following locations were approached: brainstem, n = 16; sensorimotor, n = 8; visual pathway, n = 7; cerebellum (deep nuclei and peduncles), n = 7; basal ganglia, n = 4, and language, n = 3. Follow-up data was available for 41 patients (91 %) with a median interval of 14 months. Outcomes were evaluated according to the Glasgow outcome and the modified Rankin scale. RESULTS Immediately after surgery, 47 % (n = 21) had a new deficit. At follow-up, 80 % (n = 36) recovered to at least preoperative status or were better than before surgery, 9 % (n = 4) exhibited a slight, and 7 % (n = 3) had a moderate neurological impairment. Only two cases (4 %) with a new permanent severe deficit were observed, both related to dorsal brainstem surgery. The outcome after the surgery of otherwise located brainstem CMs was as beneficial as that for non-brainstem CMs. Patients with initially poor neurological performance fared worse than oligosymptomatic patients. CONCLUSIONS Despite the high postoperative transient morbidity, the majority improved profoundly during follow-ups. Compared with natural history, surgical treatment should be considered for all eloquent symptomatic CMs. Dorsal brainstem location and poor preoperative neurological status are associated with an increased postoperative morbidity.
Collapse
|
43
|
Maruta Y, Fujii M, Imoto H, Nomura S, Oka F, Goto H, Shirao S, Yoshikawa K, Yoneda H, Ideguchi M, Suehiro E, Koizumi H, Ishihara H, Kato S, Kajiwara K, Suzuki M. Intra-operative monitoring of lower extremity motor-evoked potentials by direct cortical stimulation. Clin Neurophysiol 2012; 123:1248-54. [PMID: 22104472 DOI: 10.1016/j.clinph.2011.09.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2011] [Revised: 09/09/2011] [Accepted: 09/30/2011] [Indexed: 10/15/2022]
|
44
|
Abstract
During the last 30 years intraoperative electrophysiological monitoring (IOEM) has gained increasing importance in monitoring the function of neuronal structures and the intraoperative detection of impending new neurological deficits. The use of IOEM could reduce the incidence of postoperative neurological deficits after various surgical procedures. Motor evoked potentials (MEP) seem to be superior to other methods for many indications regarding monitoring of the central nervous system. During the application of IOEM general anesthesia should be provided by total intravenous anesthesia with propofol with an emphasis on a continuous high opioid dosage. When intraoperative MEP or electromyography guidance is planned, muscle relaxation must be either completely omitted or maintained in a titrated dose range in a steady state. The IOEM can be performed by surgeons, neurologists and neurophysiologists or increasingly more by anesthesiologists. However, to guarantee a safe application and interpretation, sufficient knowledge of the effects of the surgical procedure and pharmacological and physiological influences on the neurophysiological findings are indispensable.
Collapse
|
45
|
|
46
|
Matthies C, Raslan F, Schweitzer T, Hagen R, Roosen K, Reiners K. Facial motor evoked potentials in cerebellopontine angle surgery: Technique, pitfalls and predictive value. Clin Neurol Neurosurg 2011; 113:872-9. [DOI: 10.1016/j.clineuro.2011.06.011] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2010] [Revised: 06/02/2011] [Accepted: 06/27/2011] [Indexed: 11/25/2022]
|
47
|
Steňo J, Bízik I, Steňová J, Timárová G. Subtemporal transtentorial resection of cavernous malformations involving the pyramidal tract in the upper pons and mesencephalon. Acta Neurochir (Wien) 2011; 153:1955-62; discussion 1962. [PMID: 21845370 DOI: 10.1007/s00701-011-1123-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Accepted: 07/27/2011] [Indexed: 11/27/2022]
Abstract
BACKGROUND Lateral approaches to the brain stem for the resection of the cavernous malformations are preferred in order to avoid the structures within the floor of the fourth ventricle. The entry behind the pyramidal tract (PT) is usually carried out through the posterolateral surface of the brain stem. The more straightforward lateral approach below the temporal lobe is used rarely because of potential risks. METHODS The outcome after resection of the cavernomas involving the PT in the mesencephalon and the upper pons via the subtemporal transtentorial approach in nine patients was analysed. Mapping of the PT by direct electrical stimulation was used in the last four patients. RESULTS The subtemporal transtentorial approach enabled adequate exposure of the lateral and anterolateral surface of the midbrain and the upper pons. No adverse events from the elevation of the temporal lobe were encountered. Direct electrical stimulation using a bipolar electrode with the parameters of 100 Hz, 1 ms, and 3-9 mA evoked motor responses in three of four patients. It allowed placing the incision in the lateral surface of the midbrain behind the PT or between the fibres of the upper and the lower extremity. No worsening of the PT functions was observed in the series. CONCLUSIONS The subtemporal transtentorial approach enables adequate exposure of the lateral and the anterolateral surface of the mesencephalon and upper pons, allowing neurophysiological mapping of the PT and thus avoiding its damage during removal of the cavernoma.
Collapse
Affiliation(s)
- Juraj Steňo
- Department of Neurosurgery, Comenius University, Derer's Faculty Hospital, Limbová 5, 811 04, Bratislava, Slovakia.
| | | | | | | |
Collapse
|
48
|
Awake far lateral craniotomy for resection of foramen magnum meningioma in a patient with tenuous motor and somatosensory evoked potentials. J Clin Neurosci 2011; 18:1254-6. [DOI: 10.1016/j.jocn.2010.12.046] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2010] [Revised: 12/14/2010] [Accepted: 12/19/2010] [Indexed: 11/20/2022]
|
49
|
Bertalanffy H, Tissira N, Krayenbühl N, Bozinov O, Sarnthein J. Inter- and intrapatient variability of facial nerve response areas in the floor of the fourth ventricle. Neurosurgery 2011; 68:23-31; discussion 31. [PMID: 21206320 DOI: 10.1227/neu.0b013e31820781fb] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Surgical exposure of intrinsic brainstem lesions through the floor of the 4th ventricle requires precise identification of facial nerve (CN VII) fibers to avoid damage. OBJECTIVE To assess the shape, size, and variability of the area where the facial nerve can be stimulated electrophysiologically on the surface of the rhomboid fossa. METHODS Over a period of 18 months, 20 patients were operated on for various brainstem and/or cerebellar lesions. Facial nerve fibers were stimulated to yield compound muscle action potentials (CMAP) in the target muscles. Using the sites of CMAP yield, a detailed functional map of the rhomboid fossa was constructed for each patient. RESULTS Lesions resected included 14 gliomas, 5 cavernomas, and 1 epidermoid cyst. Of 40 response areas mapped, 19 reached the median sulcus. The distance from the obex to the caudal border of the response area ranged from 8 to 27 mm (median, 17 mm). The rostrocaudal length of the response area ranged from 2 to 15 mm (median, 5 mm). CONCLUSION Facial nerve response areas showed large variability in size and position, even in patients with significant distance between the facial colliculus and underlying pathological lesion. Lesions located close to the facial colliculus markedly distorted the response area. This is the first documentation of variability in the CN VII response area in the rhomboid fossa. Knowledge of this remarkable variability may facilitate the assessment of safe entry zones to the brainstem and may contribute to improved outcome following neurosurgical interventions within this sensitive area of the brain.
Collapse
Affiliation(s)
- Helmut Bertalanffy
- Klinik für Neurochirurgie, Universitäts-Spital Zürich, Zürich, Switzerland.
| | | | | | | | | |
Collapse
|
50
|
Quantitative parameters of facial motor evoked potential during vestibular schwannoma surgery predict postoperative facial nerve function. Acta Neurochir (Wien) 2011; 153:1169-79. [PMID: 21455744 DOI: 10.1007/s00701-011-0995-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2010] [Accepted: 03/09/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Facial motor evoked potential (FMEP) amplitude ratio reduction at the end of the surgery has been identified as a good predictor for postoperative facial nerve outcome. We sought to investigate variations in FMEP amplitude and waveform morphology during vestibular schwannoma (VS) resection and to correlate these measures with postoperative facial function immediately after surgery and at the last follow-up. METHODS Intraoperative orbicularis oculi and oris muscles FMEP data from 35 patients undergoing surgery for VS resection were collected, then analysed by surgical stage: initial, dural opening, tumour dissection (TuDis), tumour resection (TuRes) and final. FINDINGS Immediately after surgery, postoperative facial function correlated significantly with the FMEP amplitude ratio during TuDis, TuRes and final stages in both the orbicularis oculi (p = 0.003, 0.055 and 0.028, respectively) and oris muscles (p = 0.002, 0.104 and 0.014, respectively). At the last follow-up, however, facial function correlated significantly with the FMEP amplitude ratio only during the TuDis (p = 0.005) and final (p = 0.102) stages for the orbicularis oris muscle. At both time points, postoperative facial paresis correlated significantly with FMEP waveform deterioration in orbicularis oculi during the final stage (immediate, p = 0.023; follow-up, p = 0.116) and in orbicularis oris during the TuDis, TuRes and final stages (immediate, p = 0.071, 0.000 and 0.001, respectively; follow-up, p = 0.015, 0.001 and 0.01, respectively). CONCLUSIONS FMEP amplitude ratio and waveform morphology during VS resection seem to represent independent quantitative parameters that can be used to predict postoperative facial function. Event-to-baseline FMEP monitoring is quite useful to dictate when intraoperative changes in surgical strategy are warranted to reduce the chances of facial nerve injury.
Collapse
|