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Yoshikawa MH, Rabelo NN, Telles JPM, Pipek LZ, Barbosa GB, Barbato NC, Coelho ACSDS, Teixeira MJ, Figueiredo EG. Role of temporary arterial occlusion in subarachnoid hemorrhage outcomes: a prospective cohort study. Acta Cir Bras 2023; 38:e387923. [PMID: 38055387 DOI: 10.1590/acb387923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 09/25/2023] [Indexed: 12/08/2023] Open
Abstract
PURPOSE Temporary arterial occlusion (TAO) is a widespread practice in the surgical treatment of intracranial aneurysms. This study aimed to investigate TAO's role during ruptured aneurysm clipping as an independent prognostic factor on short- and long-term outcomes. METHODS This prospective cohort included 180 patients with ruptured intracranial aneurysms and an indication of microsurgical treatment. Patients who died in the first 12 hours after admission were excluded. RESULTS TAO was associated with intraoperative rupture (IOR) (odds ratio - OR = 10.54; 95% confidence interval - 95%CI 4.72-23.55; p < 0.001) and surgical complications (OR = 2.14; 95%CI 1.11-4.07; p = 0.01). The group with TAO and IOR had no significant difference in clinical (p = 0.06) and surgical (p = 0.94) complications compared to the group that had TAO, but no IOR. Among the 111 patients followed six months after treatment, IOR, number of occlusions, and total time of occlusion were not associated with Glasgow Outcome Scale (GOS) in the follow-up (respectively, p = 0.18, p = 0.30, and p = 0.73). Among patients who underwent TAO, IOR was also not associated with GOS in the follow-up (p = 0.29). CONCLUSIONS TAO was associated with IOR and surgical complications, being the latter independent of IOR occurrence. In long-term analysis, neither TAO nor IOR were associated with poor clinical outcomes.
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Silva PA, Vaz R. Letter: Commentary: The Importance of the Temporary Clip Removal Phase on Exposure to Hypoxia: On-Line Measurement of Temporal Lobe Oxygen Levels During Surgery for Middle Cerebral Artery Aneurysms. Neurosurgery 2023; 92:e55-e56. [PMID: 36729539 DOI: 10.1227/neu.0000000000002298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 10/17/2022] [Indexed: 02/03/2023] Open
Affiliation(s)
- Pedro Alberto Silva
- Department of Neurosurgery, Academic Hospital Centre São João, Porto, Portugal
- Department of Clinical Neurosciences, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Rui Vaz
- Department of Neurosurgery, Academic Hospital Centre São João, Porto, Portugal
- Department of Clinical Neurosciences, Faculty of Medicine, University of Porto, Porto, Portugal
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Mariappan R, Krothapalli SB, Nair BR, Alexander BF. Can the Processed EEG Be Utilized as a Cerebral Ischemia Monitor during the Temporary Clip Application in Anterior Circulation Aneurysm Surgery? JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2022. [DOI: 10.1055/s-0042-1744396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
AbstractPatients undergoing cerebral aneurysm clipping are at risk for cerebral ischemia. Ischemic tolerance varies among individuals. Hence, multimodal intraoperative neuromonitoring (IONM) is essential. IONM is not available in many centers. This case report highlights the utilization of processed electroencephalography (EEG) as a cerebral ischemia monitor during temporary clip application. Our patient underwent clipping of a ruptured anterior-communicating artery aneurysm. After the temporary clip applications on the right and left, A1 arterial segments led to a transient drop of somatosensory evoked potentials (SSEPs). At the same time, the frontal four-channel processed EEG showed a burst suppression (BS) pattern. Blood pressure augmentation and the removal of temporary clips helped restore the SSEP back to baseline and the disappearance of the BS pattern in processed EEG. During the steady state of anesthesia, the sudden appearance of the BS pattern in processed EEG can be attributed to clip-induced cerebral ischemia after ruling out other potential causes for BS.
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Affiliation(s)
- Ramamani Mariappan
- Department of Neuroanaesthesia, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - Bijesh R. Nair
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Benjamin F. Alexander
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
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Yoshikawa MH, Rabelo NN, Telles JPM, Pipek LZ, Barbosa GB, Barbato NC, da Silva Coelho ACS, Teixeira MJ, Figueiredo EG. Temporary arterial occlusion (TAO) as independent prognostic factor in unruptured aneurysm surgery: A cohort study. J Clin Neurosci 2022; 99:78-81. [DOI: 10.1016/j.jocn.2022.02.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 02/09/2022] [Accepted: 02/28/2022] [Indexed: 11/15/2022]
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Silva PA, Dias C, Vilarinho A, Vaz Ferreira A, Cerejo A, Vaz R. The Importance of the Temporary Clip Removal Phase on Exposure to Hypoxia: On-Line Measurement of Temporal Lobe Oxygen Levels During Surgery for Middle Cerebral Artery Aneurysms. Neurosurgery 2022; 90:475-484. [PMID: 35107086 DOI: 10.1227/neu.0000000000001865] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 10/04/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Most studies concerning intraoperative temporary arterial occlusion overlook the period between and after clip placement. OBJECTIVE To analyze the brain tissue oxygen tension through the process by which anterograde arterial blood flow is re-established after temporary clipping (TR). METHODS In this prospective observational study, patients who presented to surgery for middle cerebral artery aneurysms were continuously monitored with ICM+, to obtain temporal (downstream) PbtO2 levels while M1 segment temporary clips were applied and removed. PbtO2 changes were analyzed and compared with the clipping phase, and measures of exposure to hypoxia were defined and assessed during both phases and used in a model to test the impact of extending them. RESULTS Eighty-six TRs (20 patients) were recorded. The mean acquired amount of time per clip release (CR) event was 336.7 seconds. Temporary clip removal produced specifically shaped, highly individual PbtO2 curves that correlated with their corresponding clipping phase events but developing slower and less consistently. The CR phase was responsible for greater cumulative exposure to hypoxia than the clip application phase through the first and second minutes of each. In our model, the duration of the TR phase was mostly responsible for the total exposure to hypoxia, and longer CR phases reduced the mean exposure to hypoxia. CONCLUSION During the clip removal phase, the brain tissue is still exposed to oxygen levels that are significantly below the baseline, reverting through a singular, dynamic process. Therefore, it must be regarded by surgeons with the same degree of attention as its counterpart.
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Affiliation(s)
- Pedro Alberto Silva
- Department of Neurosurgery, Academic Hospital Centre São João, Porto, Portugal.,Department of Clinical Neurosciences, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Celeste Dias
- Department of Intensive Medicine, Academic Hospital Centre São João, Porto, Portugal.,Department of Medicine, Faculty of Medicine, University of Porto, Porto, Portugal
| | - António Vilarinho
- Department of Neurosurgery, Academic Hospital Centre São João, Porto, Portugal.,Department of Clinical Neurosciences, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Ana Vaz Ferreira
- Department of Neurosurgery, Academic Hospital Centre São João, Porto, Portugal.,Department of Clinical Neurosciences, Faculty of Medicine, University of Porto, Porto, Portugal
| | - António Cerejo
- Department of Neurosurgery, Academic Hospital Centre São João, Porto, Portugal.,Department of Clinical Neurosciences, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Rui Vaz
- Department of Neurosurgery, Academic Hospital Centre São João, Porto, Portugal.,Department of Clinical Neurosciences, Faculty of Medicine, University of Porto, Porto, Portugal
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Rabai F, Dorey CM, Fox WC, Fitzgerald KM, Seubert CN, Robicsek SA. Utility of evoked potentials during anterior cerebral artery and anterior communicating artery aneurysm clipping. Clin Neurophysiol Pract 2022; 7:228-238. [PMID: 35935596 PMCID: PMC9352509 DOI: 10.1016/j.cnp.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 06/30/2022] [Accepted: 07/15/2022] [Indexed: 11/28/2022] Open
Abstract
For anterior cerebral artery aneurysm clipping dual SSEPs and tcMEPs enhance detection of lower extremity deficits. Evoked potentials have limited utility in predicting upper extremity deficits related to subcortical ischemia. Four-extremity dual-modality monitoring can also detect pathogenetic mechanisms that are remote from the surgical site.
Objective To investigate the optimal combination of somatosensory- and transcranial motor-evoked potential (SSEP/tcMEP) modalities and monitored extremities during clip reconstruction of aneurysms of the anterior cerebral artery (ACA) and its branches. Methods A retrospective review of 104 cases of surgical clipping of ruptured and unruptured aneurysms was performed. SSEP/tcMEP changes and postoperative motor deficits (PMDs) were assessed from upper and lower extremities (UE/LE) to determine the diagnostic accuracy of each modality separately and in combination. Results PMDs were reported in 9 of 104 patients; 7 LE and 8 UE (3.6% of 415 extremities). Evoked potential (EP) monitoring failed to predict a PMD in 8 extremities (1.9%). Seven of 8 false negatives had subarachnoid hemorrhage. Sensitivity and specificity in LE were 50% and 97% for tcMEP, 71% and 98% for SSEP, and 83% and 98% for dual-monitoring of both tcMEP/SSEP. Sensitivity and specificity in UE were 38% and 99% for tcMEP, and 50% and 97% for tcMEP/SSEP, respectively. Conclusions Combined tcMEP/SSEP is more accurate than single-modality monitoring for LE but is relatively insensitive for UE PMDs. Significance During ACA aneurysm clipping, multiple factors may confound the ability of EP monitoring to predict PMDs, especially brachiofacial hemiparesis caused by perforator insufficiency.
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Affiliation(s)
- Ferenc Rabai
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224, USA
- Department of Anesthesiology, College of Medicine, University of Florida, 1600 Archer Road, PO Box 100254, Gainesville, FL 32610, USA
- Corresponding author at: Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
| | - Claire M. Dorey
- Department of Speech, Language and Hearing, University of Florida College of Health and Health Professions, PO Box 100174, Gainesville, FL 32610, USA
| | - W. Christopher Fox
- Department of Neurosurgery, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224, USA
| | - Krista M. Fitzgerald
- Department of Speech, Language and Hearing, University of Florida College of Health and Health Professions, PO Box 100174, Gainesville, FL 32610, USA
| | - Christoph N. Seubert
- Department of Anesthesiology, College of Medicine, University of Florida, 1600 Archer Road, PO Box 100254, Gainesville, FL 32610, USA
| | - Steven A. Robicsek
- Department of Anesthesiology, College of Medicine, University of Florida, 1600 Archer Road, PO Box 100254, Gainesville, FL 32610, USA
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Silva PA, Dias C, Vilarinho A, Cerejo A, Vaz R. Effects of Temporary Clipping as an Expression of Circulatory Individuality: Online Measurement of Temporal Lobe Oxygen Levels During Surgery for Middle Cerebral Artery Aneurysms. World Neurosurg 2021; 152:e765-e775. [PMID: 34175487 DOI: 10.1016/j.wneu.2021.06.082] [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: 05/23/2021] [Accepted: 06/16/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Despite its widespread use, much is left to understand about the repercussions of parent artery temporary clipping in neurosurgery. This study seeks a better comprehension of the subject by aiming at the online measurement of brain tissue oxygen pressure (PbtO2) during such events. METHODS This was a prospective observational study. Patients submitted to surgery for middle cerebral artery aneurysms (both ruptured and unruptured) were continuously monitored under Intensive Care Monitoring+ software, in order to obtain temporal (downstream) PbtO2 levels while temporary clips were applied. Separate PbtO2 curve events were identified, extracted, and processed. These were studied for assessing intraindividual and interindividual variability and the potential impact of repeated clipping and previous aneurysmal rupture. RESULTS Eighty-six temporary clippings (from 20 patients) were recorded with a mean duration of 140.8 (41 - 238) seconds. Temporary arterial occlusion at the M1 segment of the middle cerebral artery produced specifically shaped trajectories, characterized by a preclipping PbtO2 level, rapid downward sigmoid-shaped curve, succession of progressively angled slopes, and lower plateau. The steepest slope of the curve correlated strongly with PbtO2 range (P < 0.001, r = 0.944). These features were highly reproducible only intraindividually and did not vary significantly with repeated clippings. CONCLUSIONS The effects of temporary arterial occlusion on temporal lobe oxygenation demonstrate a high degree of singularity, highlighting the potential benefits of assessing individual available collateral circulation intraoperatively. The "PbtO2 steepest slope" predicted the severity of PbtO2 decrease and was available within the first minute.
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Affiliation(s)
- Pedro Alberto Silva
- Department of Neurosurgery, Academic Hospital Centre São João, Porto, Portugal; Department of Clinical Neurosciences, University of Porto, Porto, Portugal.
| | - Celeste Dias
- Department of Intensive Medicine, Academic Hospital Centre São João, Porto, Portugal; Department of Medicine, Faculty of Medicine, University of Porto, Porto, Portugal
| | - António Vilarinho
- Department of Neurosurgery, Academic Hospital Centre São João, Porto, Portugal; Department of Clinical Neurosciences, University of Porto, Porto, Portugal
| | - António Cerejo
- Department of Neurosurgery, Academic Hospital Centre São João, Porto, Portugal; Department of Clinical Neurosciences, University of Porto, Porto, Portugal
| | - Rui Vaz
- Department of Neurosurgery, Academic Hospital Centre São João, Porto, Portugal; Department of Clinical Neurosciences, University of Porto, Porto, Portugal
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Kumar S, Sahana D, Menon G. Optimal Use of Temporary Clip Application during Aneurysm Surgery - In Search of the Holy Grail. Asian J Neurosurg 2021; 16:237-242. [PMID: 34268145 PMCID: PMC8244713 DOI: 10.4103/ajns.ajns_465_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 01/29/2021] [Indexed: 11/04/2022] Open
Abstract
Temporary clips are invaluable safety tools during the clipping of an aneurysm. Controversies regarding maximum permissible duration and safety, however, remain unanswered. This descriptive narrative attempts to review the literature to provide valuable insights on controversies clouding the use of temporary clips among neurosurgeons. Popular databases, including Pub Med, Medline/Medscape, Scopus, Cochrane, Embase, Google Scholar, were searched to find available literature on temporary clips. The searched MeSH terms were "Temporary Clip," "Temporary Clipping," "Cerebral Aneurysm," and "Aneurysm." Temporary clips have been in use since 1928 and have undergone considerable structural and technical modifications. A temporary clip's optimal safety limit is not yet defined with literature evidence ranging from immediate to 93 min. It is not yet definite whether temporary clips application aggravates vasospasm, but emergency temporary clips application, especially in poor-grade aneurysmal subarachnoid hemorrhage patients, is associated with poor outcomes. A temporary clip needs to be applied with caution in patients treated earlier by endovascular technique and having indwelling stents. Nitinol Stent is feasible, while a Cobalt-Chromium alloy stent does not get occluded and gets deformed under the closing pressure of a temporary clip. Although a temporary clip application is a fundamental strategy during the clipping of an aneurysm; the exact safe duration remains to be decided in randomized control trials. Their utility for the shorter duration is beneficial under un-conclusive evidence of neuroprotective agents and intraoperative monitoring. Neurosurgeons need to consider all aspects of their pros and cons for optimal use.
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Affiliation(s)
- Sanjeev Kumar
- Department of Neurosurgery, DKS Postgraduate Institute and Research Center, Raipur, Chhattisgarh, India
| | - Debabrata Sahana
- Department of Neurosurgery, DKS Postgraduate Institute and Research Center, Raipur, Chhattisgarh, India
| | - Girish Menon
- Department of Neurosurgery, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Rajappa D, Masapu D, Gopal S, Rudrappa S. Somatosensory Evoked Potentials as a Useful Tool to Limit the Temporary Clipping Time during Aneurysm Clipping. JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2020. [DOI: 10.1055/s-0040-1716946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Affiliation(s)
- Deepak Rajappa
- Division of Neuroanaesthesia, Department of Anaesthesia, Sakra World Hospital, Bengaluru, Karnataka, India
| | - Dheeraj Masapu
- Division of Neuroanaesthesia, Department of Anaesthesia, Sakra World Hospital, Bengaluru, Karnataka, India
| | - Swaroop Gopal
- Department of Neurosurgery, Sakra World Hospital, Bengaluru, Karnataka, India
| | - Satish Rudrappa
- Department of Neurosurgery, Sakra World Hospital, Bengaluru, Karnataka, India
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Microsurgical clipping of ruptured anterior choroidal artery aneurysms: Incidence of and risk factors for ischemic complications. Clin Neurol Neurosurg 2020; 195:105884. [DOI: 10.1016/j.clineuro.2020.105884] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 04/29/2020] [Accepted: 04/29/2020] [Indexed: 11/19/2022]
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Kashkoush AI, Nguyen C, Balzer J, Habeych M, Crammond DJ, Thirumala PD. Diagnostic accuracy of somatosensory evoked potentials during intracranial aneurysm clipping for perioperative stroke. J Clin Monit Comput 2019; 34:811-819. [PMID: 31399827 DOI: 10.1007/s10877-019-00369-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 07/29/2019] [Indexed: 11/24/2022]
Abstract
Somatosensory evoked potentials (SSEPs) are utilized during aneurysm clipping to detect intraoperative ischemia. We assess the diagnostic accuracy of SSEPs in predicting perioperative stroke during aneurysm clipping. A retrospective review was conducted of 429 consecutive patients who underwent surgical clipping for ruptured and unruptured cerebral aneurysms with intraoperative SSEP monitoring from 2006 to 2013. The relationship between perioperative stroke and SSEP changes was analyzed by calculating the sensitivity, specificity, and area under a Receiving Operating Characteristic curve. Sensitivity and specificity were 42% and 90%, respectively. Area under the curve was 0.66 (95% confidence interval, 0.53-0.79). Reclassification of reversible temporary clip changes to correct for paradoxical classification of SSEP false positives raised the sensitivity from 42 to 65% (p = 0.041, Chi squared test). EEG (electroencephalography) changes increased the specificity (98% vs. 90%, p < 0.001, McNemar's test), but not sensitivity (48% vs. 42%, p = 0.621, McNemar's test) of SSEPs for perioperative stroke. A stepwise logistic regression model selected SSEP amplitude loss (p = 0.006, OR = 3.7 [95% CI 1.5-9.2]) and the SSEP change duration (p = 0.034, OR = 1.8 [95% CI 1.1-3.1]) as independent predictors of perioperative stroke. SSEP changes induced by temporary clipping were highly reversible compared to other SSEP changes (94% vs. 60%, p = 0.003, Fisher exact test), and typically responded to clip removal or readjustment. SSEP changes have high specificity and modest sensitivity for perioperative stroke. Stroke risk is a function of both the magnitude of SSEP amplitude loss and the duration of its loss. Given the modest sensitivity, patients may benefit from multimodal monitoring including motor-evoked potentials during cerebral aneurysm surgery.
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Affiliation(s)
- Ahmed I Kashkoush
- Department of Neurological Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | - Jeffrey Balzer
- Department of Neurological Surgery, University of Pittsburgh Medical Center, UPMC, Pittsburgh, PA, USA
- Department of Neuroscience, University of Pittsburgh, Pittsburgh, PA, USA
| | - Miguel Habeych
- Department of Neurological Surgery, University of Pittsburgh Medical Center, UPMC, Pittsburgh, PA, USA
| | - Donald J Crammond
- Department of Neurological Surgery, University of Pittsburgh Medical Center, UPMC, Pittsburgh, PA, USA
| | - Parthasarathy D Thirumala
- Department of Neurological Surgery, University of Pittsburgh Medical Center, UPMC, Pittsburgh, PA, USA.
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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Multimodal Monitoring Strategy Is Decisive in Elective Middle Cerebral Artery Aneurysm Clipping: A Case Report. World Neurosurg 2019; 122:43-47. [PMID: 31108065 DOI: 10.1016/j.wneu.2018.10.096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 10/14/2018] [Accepted: 10/16/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND The intraoperative use of neurophysiological monitoring (IONM) and indocyanine green video angiography (ICGVA) for aneurysm clipping have evolved during the last years. Both modalities are useful and safe by allowing greater rates of complete aneurysm occlusion with less intraoperative complications and postoperative neurologic deficits. We report a case of attempted aneurysm clipping in which the combined use of ICGVA and IONM was crucial for intraoperative decision-making. CASE DESCRIPTION A 62-year-old woman was operated for an incidental 6-mm aneurysm at the origin of the right fronto-opercular branch. During aneurysm clipping, IONM amplitudes dropped drastically, despite patency of the parent artery and perforators in ICGVA. Several attempts for clipping were made with recurring drops in IONM amplitudes, which forced us to leave the aneurysm untreated. The patient had a postoperative left-sided hemiparesis that improved on follow-up. Thereafter, the aneurysm was treated with stent-assisted coiling. CONCLUSIONS The combination of IONM and ICGVA during aneurysm surgery allows for a better assessment of vascular integrity and patient's postoperative outcome than ICGVA alone. Simultaneous evaluation of vessel patency and integrity of the somatosensory and motor pathways illustrates the complementarity of testing different modalities for intraoperative decision-making and for maximizing safeness in aneurysm clipping.
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Zhu F, Chui J, Herrick I, Martin J. Intraoperative evoked potential monitoring for detecting cerebral injury during adult aneurysm clipping surgery: a systematic review and meta-analysis of diagnostic test accuracy. BMJ Open 2019; 9:e022810. [PMID: 30760514 PMCID: PMC6377512 DOI: 10.1136/bmjopen-2018-022810] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES We aim to evaluate the diagnostic test accuracy (DTA) of intraoperative evoked potential (EP) monitoring to detect cerebral injury during clipping of cerebral aneurysms. DESIGN Systematic review. DATA SOURCES Major electronic databases including MEDLINE, EMBASE, LILACS. ELIGIBILITY CRITERIA We included studies that reported the DTA of intraoperative EP monitoring during intracranial aneurysm clipping procedures in adult patients. DATA EXTRACTION AND SYNTHESIS After quality assessment, we performed a meta-analysis using the bivariate random effects model, and calculated the possible range of DTA point estimates using a new best-case/worst-case scenario approach to quantify the impact of rescue intervention on DTA. RESULTS A total of 35 studies involving 4011 patients were included. The quality of the primary studies was modest and the heterogeneity across studies was high. The pooled sensitivity and specificity for predicting postoperative neurological deficits for the somatosensory evoked potential (SSEP) monitoring was 59% (95% CI: 39% to 76%; I2: 76%) and 86% (95% CI: 77% to 92%; I2: 94%), for motor evoked potential (MEP) monitoring was 81% (95% CI: 58% to 93%; I2: 54%) and 90% (95% CI: 86% to 93%; I2: 81%), and for combined SSEP and MEP monitoring was 92% (95% CI: 62% to 100%) and 88% (95% CI: 83% to 93%). The best-case/worst-case range for the pooled point estimates for sensitivity and specificity for SSEP was 50%-63% and 81%-100%, and for MEP was 59%-74% and 93%-100%, and for combined SSEP and MEP was 89%-94% and 83%-100%. CONCLUSIONS Due to the modest quality and high heterogeneity of the existing primary studies, it is not possible to confidently support or refute the diagnostic value of EP monitoring in cerebral aneurysm clipping surgery. However, combined SSEP and MEP appears to provide the best DTA for predicting postoperative stroke. Contrary to popular assertion, the modest sensitivity of SSEP monitoring is not explained by the use of rescue intervention. PROSPERO REGISTRATION NUMBER CRD42015016884.
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Affiliation(s)
- Fang Zhu
- Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Centre for Medical Evidence Decision Integrity and Clinical Impact (MEDICI), Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Jason Chui
- Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Ian Herrick
- Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Janet Martin
- Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Centre for Medical Evidence Decision Integrity and Clinical Impact (MEDICI), Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
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