Intraoperative monitoring of evoked potentials

Recent advances in Otology: Current landscape and future direction

Hearing is an essential sensation, and its deterioration leads to a significant decrease in the quality of life. Thus, great efforts have been made by otologists to preserve and recover hearing. Our knowledge regarding the field of otology has progressed with advances in technology, and otologists have sought to develop novel approaches in the field of otologic surgery to achieve higher hearing recovery or preservation rates. This requires knowledge regarding the anatomy of the temporal bone and the physiology of hearing. Basic research in the field of otology has progressed with advances in molecular biology and genetics. This review summarizes the current views and recent advances in the field of otology and otologic surgery, especially from the viewpoint of young Japanese clinician-scientists, and presents the perspectives and future directions for several topics in the field of otology. This review will aid next-generation researchers in understanding the recent advances and future challenges in the field of otology.

Direct-cortical visual evoked potential monitoring during brain tumor resection

BACKGROUND

Visual evoked potential (VEP) recording is traditionally regarded as an unreliable evoked potential monitoring technique, precluding widespread use in intracranial neurosurgery. However, VEPs can serve as a useful intraoperative adjunct for real-time detection of mechanical damage to optic apparatuses. The low obtainability and prognostic utility of VEPs are associated with transcranial recording, which typically provides non-focal information and poor signal-to-noise ratio. Direct cortical VEP (DC-VEP) recordings may offer a solution.

METHODS

We evaluated the obtainability of DC-VEPs as well as their prognostic utility in predicting postoperative visual function deterioration in a series of brain tumor patients undergoing craniotomies for tumor resection. Patient records were retrospectively reviewed for all consecutive patients undergoing brain tumor resections with DC-VEP monitoring. Pre- and postoperative visual fields were characterized from patient charts and associated with the presence of intraoperative monitoring alerts to determine the sensitivity, specificity, and positive and negative predictive values (PPV, NPV) of DC-VEPs in detecting postoperative visual field deficits.

RESULTS

Twenty-two patients (9 male, 13 female) were included, with a median age of 60 years. DC-VEPs were reliably detected in 19 of 23 included surgeries (82.6%). The reported sensitivity, specificity, PPV, and NPV in detecting postoperative visual field deficits was 60%, 92.9%, 75%, and 86.7%, respectively. There was a statistically significant association between monitoring alerts and the presence of visual field deterioration by Fischer's exact test (p = 0.0374).

CONCLUSIONS

DC-VEPs can be reliably obtained and are useful for detecting mechanical injury to optic areas and tracts during tumor resection.

Monitoring surgery around the cranial nerves

Intraoperative neurophysiologic monitoring (IONM) of cranial nerve (CN) function is an essential component in multimodality monitoring of surgical procedures where CNs are at risk for injury. In most cases, IONM consists of localizing and mapping CNs and their pathways, and monitoring of CN motor function during surgery. However, CN VIII, which has no motor function, and is at risk for injury in many surgical procedures, can be easily and accurately monitored using brainstem auditory evoked potentials. For motor CNs, the literature is clear that function can be safely and adequately performed using basic electromyographic (EMG) techniques, such as recording of continuous EMG activity and electrically evoked compound muscle actions potentials. Newer techniques, such as corticobulbar motor evoked potentials and reflex studies, show good potential for a greater degree of functional assessment but require further study to determine their clinical utility. EMG remains the basic clinical neurophysiologic technique with the greatest clinical research supporting its utility in IONM of motor CN function and should be used as part of a comprehensive multimodality IONM protocol. Understanding the physiologic basis of EMG and the changes associated with altered motor function will allow the practitioner to alter surgical course to prevent injury and improve patient safety.

Understanding the Molecular Mechanism of Vestibular Schwannoma for Hearing Preservation Surgery: Otologists’ Perspective from Bedside to Bench

Vestibular schwannoma is a clinically benign schwannoma that arises from the vestibulocochlear nerve that causes sensorineural hearing loss. This tumor is clinically and oncologically regarded as a benign tumor as it does not metastasize or invade surrounding tissues. Despite being a benign tumor, its management is difficult and controversial due to the potential serious complications, such as irreversible sensorineural hearing loss, of current interventions. Therefore, preventing hearing loss due to the natural course of the disease and complications of surgery is a challenging issue for an otologist. Improvements have been reported recently in the treatment of vestibular schwannomas. These include advances in intraoperative monitoring systems for vestibular schwannoma surgery where the risk of hearing loss as a complication is decreased. Precise genomic analysis of the tumor would be helpful in determining the characteristics of the tumor for each patient, leading to a better hearing prognosis. These procedures are expected to help improve the treatment of vestibular schwannomas. This review summarizes recent advances in vestibular schwannoma management and treatment, especially in hearing preservation. In addition, recent advances in the understanding of the molecular mechanisms underlying vestibular schwannomas and how these advances can be applied in clinical practice are outlined and discussed, respectively. Moreover, the future directions from the bedside to the bench side are presented from the perspective of otologists.

The brainstem and its neurosurgical history

Brainstem is one of the most complex structures of the human body, and has the most complex intracranial anatomy, which makes surgery at this level the most difficult. Due to its hidden position, the brainstem became known later by anatomists, and moreover, brainstem surgery cannot be understood without knowing the evolution of ideas in neuroanatomy, neuropathology, and neuroscience. Starting from the first attempts at identifying brainstem anatomy in prehistory and antiquity, the history of brainstem discoveries and approach may be divided into four periods: macroscopic anatomy, microscopic anatomy and neurophysiology, posterior fossa surgery, and brainstem surgery. From the first trepanning of the posterior fossa and later finger surgery, to the occurrence of safe entry zones, this paper aims to review how neuroanatomy and brainstem surgery were understood historically, and how the surgical technique evolved from Galen of Pergamon up to the twenty-first century.

Intraoperative Flash Visual Evoked Potential Recording and Relationship to Visual Outcome

OBJECTIVE

To determine the relationship between intraoperative flash visual evoked potential (FVEP) monitoring and visual function.

METHODS

Intraoperative FVEPs were recorded from electrodes placed in the scalp overlying the visual cortex (Oz) after flashing red light stimulation delivered by Cadwell LED stimulating goggles in 89 patients. Restrictive filtering (typically 10-100 Hz), optimal reject window settings, mastoid reference site, total intravenous anesthetic (TIVA), and stable retinal stimulation (ensured by concomitant electroretinogram [ERG] recording) were used to enhance FVEP reproducibility.

RESULTS

The relationship between FVEP amplitude change and visual outcome was determined from 179 eyes. One eye had a permanent intraoperative FVEP loss despite stable ERG, and this eye had new, severe postoperative visual dysfunction. Seven eyes had transient significant FVEP change (>50% amplitude decrease that recovered by the end of surgery), but only one of those had a decrease in postoperative visual acuity. FVEP changes in all eight eyes (one permanent FVEP loss plus seven transient FVEP changes) were related to surgical manipulation. In each case the surgeon was promptly informed of the FVEP deterioration and took remedial action. The other eyes did not have FVEP changes, and none of those eyes had new postoperative visual deficits.

CONCLUSIONS

Our FVEP findings relate to visual outcome with a sensitivity and specificity of 1.0. New methods for rapidly acquiring reproducible FVEP waveforms allowed for timely reporting of significant FVEP change resulting in prompt surgical action. This may have accounted for the low postoperative visual deficit rate (1%) in this series.

Elaborate mapping of the posterior visual pathway in awake craniotomy

OBJECTIVE Resection of intraaxial tumors adjacent to the optic radiation (OR) may be associated with postoperative visual field (VF) deficits. Intraoperative navigation using MRI-based tractography and electrophysiological monitoring of the visual pathways may allow maximal resection while preserving visual function. In this study, the authors evaluated the value of visual pathway mapping in a series of patients undergoing awake craniotomy for tumor resection. METHODS A retrospective analysis of prospectively collected data was conducted in 18 patients who underwent an awake craniotomy for resection of intraaxial tumors involving or adjacent to the OR. Preoperative MRI-based tractography was used for intraoperative navigation, and intraoperative acquisition of 3D ultrasonography images was performed for real-time imaging and correction of brain shift. Goggles with light-emitting diodes were used as a standard visual stimulus. Direct cortical visual evoked potential (VEP) recording, subcortical recordings from the OR, and subcortical stimulation of the OR were used intraoperatively to assess visual function and proximity of the lesion to the OR. VFs were assessed pre- and postoperatively. RESULTS Baseline cortical VEP recordings were available for 14 patients (77.7%). No association was found between preoperative VF status and baseline presence of cortical VEPs (p = 0.27). Five of the 14 patients (35.7%) who underwent subcortical stimulation of the OR reported seeing phosphenes in the corresponding contralateral VF. There was a positive correlation (r = 0.899, p = 0.04) between the subcortical threshold stimulation intensity (3-11.5 mA) and the distance from the OR. Subcortical recordings from the OR demonstrated a typical VEP waveform in 10 of the 13 evaluated patients (76.9%). These waveforms were present only when recordings were obtained within 10 mm of the OR (p = 0.04). Seven patients (38.9%) had postoperative VF deterioration, and it was associated with a length of < 8 mm between the tumor and the OR (p = 0.05). CONCLUSIONS Intraoperative electrophysiological monitoring of the visual pathways is feasible but may be of limited value in preserving the functional integrity of the posterior visual pathways. Subcortical stimulation of the OR may identify the location of the OR when done in proximity to the pathways, but such proximity may be associated with increased risk of postoperative worsening of the VF deficit.

Neurophysiological intraoperative monitoring during an optic nerve schwannoma removal

This paper reports the case of a patient with optic nerve schwannoma and the first use of neurophysiological intraoperative monitoring of visual evoked potentials during the removal of such tumor with no postoperative visual damage. Schwannomas are benign neoplasms of the peripheral nervous system arising from the neural crest-derived Schwann cells, these tumors are rarely located in the optic nerve and the treatment consists on surgical removal leading to high risk of damage to the visual pathway. Case report of a thirty-year-old woman with an optic nerve schwannoma. The patient underwent surgery for tumor removal on the left optic nerve through a left orbitozygomatic approach with intraoperative monitoring of left II and III cranial nerves. We used Nicolet Endeavour CR IOM (Carefusion, Middleton WI, USA) to performed visual evoked potentials stimulating binocularly with LED flash goggles with the patient´s eyes closed and direct epidural optic nerve stimulation delivering rostral to the tumor a rectangular current pulse. At follow up examinations 7 months later, the left eye visual acuity was 20/60; Ishihara score was 8/8 in both eyes; the right eye photomotor reflex was normal and left eye was mydriatic and arreflectic; optokinetic reflex and ocular conjugate movements were normal. In this case, the epidural direct electrical stimulation of optic nerve provided stable waveforms during optic nerve schwannoma resection without visual loss.

Interpretation of the causes of instability of flash visual evoked potentials in intraoperative monitoring and proposal of a recording method for reliable functional monitoring of visual evoked potentials using a light-emitting device

OBJECTIVE Effective monitoring and application of visual evoked potentials (VEPs) during neurosurgery is a major challenge. While many monitoring methods have been effectively used, the use of VEPs as an objective determination method has not been established. The purpose of this report was to present a method for overcoming this limitation according to the use of a specific stimulus. METHODS Data analysis was performed in 26 cases of brain surgery. Observation was carried out for 2 groups of responses: the response derived from the start of light emission, described as the on response, and the response derived from the end of light emission, described as the off response. These reactions were separated by extending the light emission time. The waves from the visual cortex were selected from each reaction following the start and the end of light emission with consideration for the characteristics of the potential distribution. The waves were observed to characterize changes resulting from variations in duration and quantity of light emission. The results of the analysis were used to determine the optimal emission time and amount of light for effective use of wave components during VEP monitoring. RESULTS Stable and recordable waves were observed by monitoring the off response, consisting of the P1-N1-P2 component, with a wave latency of approximately 100 msec. Since the off response was correlated with the input, the stable wave derived from the off response could be adjusted by changing the light emission time and intensity. Individual differences in the latency of the off response were decreased by extending the light emission time and reducing the quantity of light. However, it was difficult to achieve stability by adjusting the light intensity and emission time using the on response. The off response was confirmed to be sufficiently stable for intraoperative monitoring. Moreover, during 1 case in which manipulation of the optic nerve was necessary, reduction in the off response was found to occur when the nerve was manipulated and to reverse when the manipulation stopped. CONCLUSIONS The off response was shown to have the capacity to function as a monitoring tool, providing more stable wave forms than the on response. Recording conditions could be adjusted to achieve a light-emitting time of 500 msec and a light quantity of 8000 Lx. Stable monitoring of VEPs using light-emitting stimuli can contribute toward improving surgical outcomes.

Clinical utility and limitations of intraoperative monitoring of visual evoked potentials

Objectives

During surgeries that put the visual pathway at risk of injury, continuous monitoring of the visual function is desirable. However, the intraoperative monitoring of the visual evoked potential (VEP) is not yet widely used. We evaluate here the clinical utility of intraoperative VEP monitoring.

Methods

We analyzed retrospectively 46 consecutive surgeries in 2011-2013. High luminance stimulating devices delivered flash stimuli on the closed eyelid during intravenous anesthesia. We monitored VEP features N75 and P100 and took patients' preoperative and postoperative visual function from patient charts. Postoperative ophthalmologic workup was performed in 25 (54%) patients and preoperatively in 28 (61%) patients.

Results

VEP recordings were feasible in 62 of 85 eyes (73%) in 46 patients. All 23 eyes without VEP had impaired vision. During surgery, VEPs remained stable throughout surgery in 50 eyes. In 44 of these, visual function did not deteriorate and three patients (6 eyes) developed hemianopia. VEP decreased transiently in 10 eyes and visual function of all was preserved. VEPs were lost permanently in 2 eyes in two patients without new postoperative visual impairment.

Conclusions

Satisfactory intraoperative VEP monitoring was feasible in all patients except in those with severe visual impairment. Preservation of VEPs predicted preserved visual function. During resection of lesions in the visual cortex, VEP monitoring could not detect new major visual field defects due to injury in the posterior visual pathway. Intraoperative VEPs were sensitive enough to detect vascular damage during aneurysm clipping and mechanical manipulation of the anterior visual pathway in an early reversible stage. Intraoperative VEP monitoring influenced surgical decisions in selected patients and proved to be a useful supplement to the toolbox of intraoperative neurophysiological monitoring.

Thin-film electroencephalographic electrodes using multi-walled carbon nanotubes are effective for neurosurgery

Background

Intraoperative morphological and functional monitoring is essential for safe neurosurgery. Functional monitoring is based on electroencephalography (EEG), which uses silver electrodes. However, these electrodes generate metal artifacts as silver blocks X-rays, creating white radial lines on computed tomography (CT) images during surgery. Thick electrodes interfere with surgical procedures. Thus, thinner and lighter electrodes are ideal for intraoperative use.

Methods

The authors developed thin brain electrodes using carbon nanotubes that were formed into thin sheets and connected to electrical wires.

Results

The nanotube sheets were soft and fitted the curve of the head very well. When attached to the head using paste, the impedance of the newly developed electrodes was 5 kΩ or lower, which was similar to that of conventional metal electrodes. These electrodes can be used in combination with intraoperative CT, magnetic resonance imaging (MRI), or cerebral angiography. Somatosensory-evoked potentials, auditory brainstem responses, and visually evoked potentials were clearly identified in ten volunteers. The electrodes, without any artifacts that distort images, did not interfere with X-rays, CT, or MR images. They also did not cause skin damage.

Conclusions

Carbon nanotube electrodes may be ideal for neurosurgery.

Sequential episodes of perioperative ischemic optic neuropathy after hip surgery

Perioperative ischemic optic neuropathy (ION) after nonocular surgery is a rare complication leading to permanent and often severe vision loss. Due in part to the low prevalence of this complication, there remains no reliable way to predict which patients will develop ION. We present a patient with sequential episodes of unilateral perioperative ION, both occurring after otherwise uncomplicated hip operations. Patients and physicians should be aware that perioperative ION after one surgery may increase the risk of ION after subsequent surgeries.

Cortical potentials after electrical intraneural stimulation of the optic nerve during orbital enucleation

BACKGROUND

The aim of this study was to present cortical potentials after electrical intraneural stimulation of the optic nerve during orbital enucleation due to malignant melanoma of the choroid or the ciliary body. These cortical potentials were related to cortical potentials after electrical epidural stimulation of the optic nerve, recorded during non-manipulative phases of neurosurgery for central skull base tumors.

METHODS

Cortical potentials were recorded with surface occipital electrode (Oz) in six patients undergoing orbital enucleation under total intravenous anesthesia. Two thin needle stimulating electrodes were inserted inside the intraorbital part of the optic nerve. The electrical stimulus consisted of a rectangular current pulse of varying intensity (0.2-10.0 mA) and duration (0.1-0.3 ms); the stimulation rate was 2 Hz; the bandpass filter was 1-1,000 Hz; the analysis time was 50-300 ms.

RESULTS

Cortical potentials could not be obtained or were inconsistently elicitable in three patients with longstanding history (>3 months) of severe visual deterioration, while they consisted of several positive and negative deflections in a patient with a short history of mild visual impairment. In two other patients, cortical potentials consisted of N20, P30 and N40 waves.

DISCUSSION

Cortical potentials after electrical intraneural stimulation of the optic nerve could be recorded in patients with a short history of visual deterioration and without optic nerve atrophy and appear more heterogeneous than cortical potentials after electrical epidural stimulation of the optic nerve, recorded during non-manipulative phases of neurosurgery for central skull base tumors.

Intraoperative monitoring of the visual function using cortical potentials after electrical epidural stimulation of the optic nerve

BACKGROUND

Central skull base meningiomas commonly present with visual deficit, and their removal often leads to improvement of visual function. However, the incidence of postoperative visual deterioration has been reported to be up to 10%. Intraoperative monitoring using flash visual evoked potential has only recently been used with success. Cortical potentials (CP) after electrical epidural stimulation of the optic nerve (ON) were correlated with ON manipulation due to central skull base tumor removal to contribute to improvement of the intraoperative monitoring of the visual function.

METHODS

Blunt needle stimulating electrodes were attached epidurally alongside ON in an unroofed optic canal and used for delivering a rectangular current pulse (intensity 0.2-5.0 mA; duration 0.1-0.3 ms; rate 2 Hz). CPs after electrical epidural stimulation of ON were recorded with corkscrew electrodes at O(z) with the reference electrode at F(z).

RESULTS

P20 and N30 amplitudes were significantly lower (p < 0.05) during tumor removal associated with ON manipulation than in other phases of surgery; the amplitude reductions were reversible in all cases. There were no significant changes in P20, N30 and P40 latencies during the surgery. Immediate postoperative visual function was unchanged in all patients.

CONCLUSIONS

P20 and N30 amplitude changes seem to reliably correspond with the manipulation of ON during anterior skull base tumor removal. Reversible reduction of P20 and N30 amplitude was associated with unchanged immediate postoperative visual function. No correlation between intraoperative variation of CP and newly acquired postoperative visual deficit can presently be made.

Value of intraoperative brainstem auditory evoked potential monitoring in reducing the auditory morbidity associated with microvascular decompression of cranial nerves

The present study was performed to determine whether the intraoperative monitoring of brainstem auditory evoked potentials (BAEPs) during microvascular decompression operations is effective in preventing profound hearing loss or deafness in the ipsilateral ear. The authors retrospectively compared the auditory morbidity of posterior fossa microvascular decompression surgery for the treatment of tic douloureux and hemifacial spasm before and after the introduction of routine intraoperative BAEP monitoring in 1984. Each patient underwent a similar procedure performed by the same surgeon. The two patient groups were comparable with regard to age, sex, and indications for surgery, Auditory morbidity did not decline with the increasing experience of the surgeon prior to 1984; 10 (6.6%) of 152 primary operations (151 patients) in which monitoring was not performed were followed by a profound ipsilateral hearing loss or deafness. In the monitored group, none of 109 operations (104 patients) caused profound hearing loss or deafness. This significant decline in auditory morbidity is attributed by the authors to the use of intraoperative BAEP monitoring, which allows the surgeon to alter the operation in response to degradations in the wave patterns. Based on our experience and that of others, we believe that intraoperative BAEP monitoring is of value in reducing the auditory morbidity of posterior fossa microvascular decompression surgery.

Intraoperative monitoring of visual evoked potential: introduction of a clinically useful method

Object

To obtain a clinically useful method of intraoperative monitoring of visual evoked potentials (VEPs), the authors developed a new light-stimulating device and introduced electroretinography (ERG) to ascertain retinal light stimulation after induction of venous anesthesia.

Methods

The new stimulating device consists of 16 red light–emitting diodes embedded in a soft silicone disc to avoid deviation of the light axis after frontal scalp-flap reflection. After induction of venous anesthesia with propofol, the authors performed ERG and VEP recording in 100 patients (200 eyes) who were at intraoperative risk for visual impairment.

Results

Stable ERG and VEP recordings were obtained in 187 eyes. In 12 eyes, stable ERG data were recorded but VEPs could not be obtained, probably because all 12 eyes manifested severe preoperative visual dysfunction. The disappearance of ERG data and VEPs in the 13th eye after frontal scalp-flap reflection suggested technical failure attributable to deviation of the light axis. The criterion for amplitude changes was defined as a 50% increase or decrease in amplitude compared with the control level. In 1 of 187 eyes the authors observed an increase in intraoperative amplitude and postoperative visual function improvement. Of 169 eyes without amplitude changes, 17 manifested improved visual function postoperatively, 150 showed no change, and 2 worsened (1 patient with a temporal tumor developed a slight visual field defect in both eyes). Of 3 eyes with intraoperative VEP deterioration and subsequent recovery upon changing the operative maneuver, 1 improved and 2 exhibited no change. The VEP amplitude decreased without subsequent recovery to 50% of the control level in 14 eyes, and all of these developed various degrees of postoperative deterioration of visual function.

Conclusions

With the strategy introduced here it is possible to record intraoperative VEPs in almost all patients except in those with severe visual dysfunction. In some patients, postoperative visual deterioration can be avoided or minimized by intraoperative VEP recording. All patients without an intraoperative decrease in the VEP amplitude were without severe postoperative deterioration in visual function, suggesting that intraoperative VEP monitoring may contribute to prevent postoperative visual dysfunction.

Intraoperative monitoring of cortically recorded visual response for posterior visual pathway

Object

Intraoperative monitoring of visual evoked potentials (VEPs) has been regarded as having limited significance for the preservation of visual function during neurosurgical procedures, mainly due to its poor spatial resolution and signal-to-noise ratio. The authors evaluated the usefulness of cortically recorded VEPs, instead of the usual scalp VEPs, as intraoperative monitoring focusing on the posterior visual pathway.

Methods

In 17 consecutive patients who underwent microsurgical procedures for lesions near the posterior visual pathway, cortical responses were recorded using 1-Hz flashing light-emitting diodes and subdural strip electrodes after induction of general anesthesia with sevoflurane or propofol. The detectability and waveform of the initial response, stability, and changes during microsurgical manipulations were analyzed in association with the position of electrodes and postoperative changes in visual function.

Results

Initial VEPs were detected in 82% of all patients. The VEPs were detected in 94% of patients without total hemianopia in whom electrodes were placed sufficiently near the occipital pole; in these cases the recordings were not significantly affected by anesthesia. The detectability rates of the negative peak before 100 msec (N1), positive peak ~ 100 msec (P100), and negative peak after 100 msec (N2) were 36, 50, and 100%, respectively. The mean latencies and amplitudes of N1, P100, and N2 were 90.0 ± 15.9 msec and 61.0 ± 64.0 μV, 103.9 ± 13.5 msec and 34.3 ± 38.6 μV, and 125.7 ± 12.2 msec and 44.9 ± 48.9 μV, respectively, showing great variability. In 11 patients, the initial waveforms of VEP remained stable during microsurgical procedures, and the visual status did not change postoperatively, while it disappeared in 2 patients who presented with postoperative hemianopia.

Conclusions

Direct recording from the visual cortices under general anesthesia achieved satisfactory detectability of the visual response to a light-emitting diode flashing light. Although the initial waveforms varied greatly among patients, they were stable during microsurgical procedures, and the changes were consistent with postoperative visual function. Intraoperative cortical VEP monitoring is a potentially useful procedure to monitor the functional integrity of the posterior visual pathway.

Ischemic orbital compartment syndrome after posterior spinal surgery

STUDY DESIGN

Case report.

OBJECTIVE

To describe a patient with ischemic orbital compartment syndrome after undergoing spinal surgery in a prone position.

SUMMARY OF BACKGROUND DATA

Ocular complications after nonocular surgery are devastating. The most common etiology is ischemic optic neuropathy. Orbital compartment syndrome with ischemic change is quite rare and urgent management is necessary.

METHODS

Early diagnosis and surgical intervention was performed for ischemic compartment syndrome after posterior spinal surgery was done.

RESULTS

Despite immediate management, the patient remained blind and ptotic 3 months after the injury.

CONCLUSION

Understanding ocular complications after spinal surgery is vital. Although rare, but the most troublesome complication is ischemic orbital compartment syndrome.

Experience of 500 cases of neurophysiological monitoring in carotid endarterectomy

BACKGROUND

Experience with Intraoperative monitoring using neurophysiological and haemodynamic indices in 500 operations for carotid endarterectomy is reported.

METHODS

Transcranial Doppler technique (TCD), electroencephalogram (EEG) and bilateral median somatosensory evoked potentials (SEP) were performed. Latency and amplitude of SEP, spectral analysis of EEG signal and blood flow velocity in the medial cerebral artery (MCA) were continuously measured.

FINDINGS

After two consecutive drops of N20/P25 complex of more than 50%, a warning was given, and when the decrease continued, an the alarm raised. Abnormal EEG changes, if any, appeared after a significant decrease in the N20/P25 amplitude. A mean blood flow velocity drop below 40% of the reference value after cross clamping was rated as a significant warning event.A warning as a result of a decrease in N20/P25 amplitude occurred in 80 operations (16.0%), after an spectral edge frequency decrease in 2 cases (0.4%) and after a V(mean) decrease in 21 cases (4.2%). False negative results were experienced in 2 patients (0.4%). A shunt was inserted in 2.8% of the operations. The overall mortality/morbidity rate was 2.4%.

CONCLUSION

A decrease of more than 50% in the amplitude of the thalamocortical somatosensory evoked potential complex N20/P25 proved to be the most reliable warning of danger of ischaemia during carotid endarterectomy.

Cerebral Monitoring in the Operating Room and the Intensive Care Unit – An Introductory for the Clinician and a Guide for the Novice Wanting to Open a Window to the Brain

An evoked potential differs from the EEG mainly in two ways: 1. The EEG is a random, continuous signal, which arises from the ongoing activity of the outer layers of the cortex. An evoked potential is the brain's response to a repetitive stimulus along a specific nerve pathway. 2.EEG signals range from 10-200 milliVolt (mV). Evoked potentials are smaller in amplitude (1-5-20 microVolt requiring precise electrode positioning and special techniques (signal averaging) to extract the specific response from the underlying EEG "noise". The technique of signal averaging, as originally described by Dawson in 1954 [69J, has been further developed in computer processing. The technique is now used by applying a stimulus repeatedly--preferably at randomized intervals--and to record the evoked response over the corresponding area of the brain, averaging out mathematically the change over the number of stimuli. Rationale for the use of EPs in the OR and the ICU. Evoked potentials (EPs) serve the following major purposes: 1. Monitoring of the functional integrity of neural structures that may be at risk during, for instance, ECC (extracorporeal circulation) or endarterectomy indicating cerebral hypoxia. 2. Monitoring of the effects of anesthetic agents and other centrally active drugs, which, besides the cortex, affect deeper neuronal structures. 3. Orthopedic cases where the spinal cord is at risk such as Harrington rod insertion and removal. 4. Clamping of the abdominal aortic artery during aneurysmectomy resulting in a potential damage of the lower parts of the spinal cord. 5. Clipping of an intracerebral aneurysm, which may be impeding blood flow to vital cerebral textures. 6. An indicator of cerebral hypoxia when the blood pressure is deliberately lowered. 7. Operation on peripheral nerves and nerve roots to identify early trauma. 8. Monitoring the cerebral function during controlled hypothermia when the EEG becomes flat. 9. Monitoring of the pathophysiological conditions after severe head trauma and the effects of therapy. 10. An intraoperative warning device of unsuspected awareness during light anesthesia when movement is abolished by muscle relaxants and cardiovascular responses are modified by vasoactive drugs. In case of the latter the stimulus is a small electrical potential applied to the skin of the hand. Thereafter, the stimulus travels along the specific nervous pathways inducing (= generating) potential activation at various sites. The generation of potential changes at various sites along the pathway is an index for the integrity of the nerve. Thus, the evoked potential can be considered a neurophysiological response (usually of the cortex) to impulses originating from some externally stimulated sensory nerve. They provide a physiological measure of the functional integrity of the sensory nerve pathway, which can be used as a clinical diagnostic tool as well as for intraoperative monitoring. The evoked potential usually is recorded from the specific cortical area corresponding to the stimulus input. The classification of evoked potentials. Stimulating a sensory nervous pathway induces evoked potentials. If the auditory nerve is stimulated by "clicks" from headphones, it is called the auditory evoked potential (AEP). The early part of the AEP waveform (less than 10 msec) is called the Brainstem Auditory Evoked Potential (BAEP) since it reflects the passing of the impulse through the brainstem. If a nerve on the arm or the leg is stimulated by a small electrical current applied to the overlying skin, it is called the Somatosensory Evoked Potential (SSEP). If, however, the retina is stimulated by means of flicker light or a sudden change in a checkerboard pattern, the evoked potential thus recorded over the corresponding cortical area is called the Visual Evoked Potential (VEP). Evoked potentials are used both as a diagnostic tool and as a monitoring technique. As diagnostic tests, evoked potentials are useful to evaluate neurologic disorders such as: a) multiple sclerosis, b) acoustic nerve tumors, and c) optic neuritis. As a monitoring modality, evoked potentials are used during all surgical procedures, which might compromise part of the brain or the spinal cord.

Optic Nerve Evoked Potentials Elicited by Electrical Stimulation-Experimental and Clinical Studies-

This study investigated whether the optic nerve evoked potential (ONEP) elicited by electrical stimulation of the optic nerve can serve as a reliable intraoperative indicator of visual function. In the experimental study, two silver-ball stimulating electrodes were placed on the dog optic nerve adjacent to the apex of the orbit and one recording electrode was placed on the optic nerve near the chiasm. The nerve was stimulated with 0.1 to 10 mA rectangular pulses. Stable and reproducible ONEPs were obtained. The ONEPs were not influenced by electromyographic potentials and were recorded more clearly on the optic nerve than on the surrounding tissue. Stepwise incremental transection of the thickness of the nerve resulted in incremental amplitude reduction proportional to the transected area. No response was recorded after complete sectioning of the nerve. In the clinical study, recordings were obtained from 15 patients after craniotomy to treat parasellar tumors or cerebral aneurysms. Reproducible ONEPs were recorded intraoperatively from the electrode placed on the optic nerve near the chiasm in 14 of 15 patients. In the remaining patient, the ONEP, recorded only after tumor removal because the optic nerve was stretched and extremely thin, was remarkably small and the patient developed unilateral blindness postoperatively. These experimental and clinical results suggest the possibility of intraoperative monitoring of visual function in patients undergoing craniotomy for the treatment of lesions near the optic nerve.

Visual evoked potentials for intraoperative neurophysiologic monitoring using total intravenous anesthesia

Conflicting reports on the usefulness of intraoperative monitoring of visual function by means of visual evoked potentials (VEPs) initiated this study. In 32 patients without visual problems, VEPs were recorded to evaluate the reliability for intraoperative monitoring with total intravenous anesthesia. All patients underwent noncranial surgery. Using a standard technique, VEPs were recorded preoperatively in the awake patients and after induction of anesthesia during surgery. A total of 1436 intraoperative traces were recorded and analyzed. A minor prolongation of the P100 latency of 8% and a more pronounced attenuation of the P100-N145 amplitude of 60% were observed in the anesthetized patients. In most of the anesthetized patients, a stable recording of VEPs was not obtainable. In 4 patients (12.5%), clearly identifiable VEP peaks were detected in more than 90% of the traces recorded intraoperatively. In 88% of the patients, reproducible VEPs were obtained in less than 75% of the intraoperative traces only. We concluded that with standard recording techniques and total intravenous anesthesia, intraoperative VEP monitoring in surgically anesthetized patients is not reliable.

Evoked potential monitoring in anaesthesia and analgesia

Electrophysiological monitoring of selected neural pathways of the brain, brainstem, spinal cord and peripheral nervous system has become mandatory in some surgery of the nervous system where preventable neural injury can occur. Evoked potentials are relatively simple methods of testing the integrity of various aspects of the nervous system. This review covers the variety of evoked potentials that can be monitored and outlines the principles of their measurement. Their use in specific situations and how factors such as anaesthesia might affect them is presented.

Hearing preservation in microvascular decompression for trigeminal neuralgia

OBJECTIVE/HYPOTHESIS

Sensorineural hearing loss is a disturbing complication of microvascular decompression (MVD) for trigeminal neuralgia with an incidence of 1% to 23.8%. Cerebellar retraction with increasing I-V interpeak latency (IPL) during intraoperative brainstem auditory evoked potentials (BAEP) has been identified as the chief cause of acoustic injury. This study was designed to eliminate cerebellar retraction by a modification of the standard suboccipital craniectomy.

STUDY DESIGN

Nine consecutive patients undergoing surgery for trigeminal neuralgia were prospectively selected for this study between 1994 and 1995.

METHODS

Preoperative and postoperative audiograms were obtained. Preoperative and intraoperative BAEPs were performed. The surgical modification describes initiating a partial mastoidectomy to enhance early recognition and delineation of the sigmoid and transverse sinuses crucial to maximizing the lateral extent of the craniectomy. The additional exposure gained by this technique allows for improved visualization of the brainstem without cerebellar retraction.

RESULTS

All patients were relieved of neuralgic pain. Postoperative IPL values were not significantly different from preoperative values (4.9+/-0.6 vs. 4.7+/-0.3 ms). Maintaining IPL of less than 1.5 ms is considered critical for preventing injury to the auditory nerve. In this study the average increase in postoperative IPL was 0.25 ms for the ipsilateral ear and 0.1 ms for the contralateral ear.

CONCLUSIONS

The authors offer a surgical modification of the standard suboccipital craniectomy and furnish intraoperative neurophysiologic data to demonstrate how cerebellar compression can be eliminated and hearing preserved in MVD for trigeminal neuralgia.

Vector analysis of visual evoked potentials elicited by pattern reversal and photic stimuli

OBJECTIVE

The 2D VEPs to pattern reversal (PR) and LED goggle were studied in order to obtain a stable parameter for the functional assessing of posterior visual pathways regardless of the stimulus type used.

DESIGN AND METHODS

Apex c latency, bc segment amplitude (V), and bc vector orientation angle (theta) in voltage space were computed from VEPs recorded in 50 normal human beings and two patients with left posterior brain lesions, in an orthogonal Fpz-Oz and T3-T4 montage and displayed as a two channel Lissajous' trajectory. The effects of stimulus type and stimulated eye were analyzed in the normal group by a two-way ANOVA.

RESULTS

The stimulated eye had no effect on any parameter. Apex c latency was slightly longer, and V was greater and more variable in the responses to goggle stimuli, but there was no significant difference in theta, oriented to mid-occipital scalp with very low variability for both stimulus types. The patients showed significant deviations of theta towards the affected hemisphere.

CONCLUSIONS

The bc vector orientation (theta) is a stable parameter for the evaluation of the posterior visual pathways using both pattern reversal and LED stimuli, specially the latter, useful in unconscious or uncooperative patients.

Interpretation of the dilated pupil during endoscopic sinus surgery

This article describes the anatomy of the visual pathways and how they should be assessed under anaesthesia. The differential diagnosis of asymmetrical pupils is illustrated with clinical examples and a strategy as to how they should be examined.

Electroretinographic alterations during vitrectomy in human eyes

BACKGROUND

We previously reported a new system of electroretinographic monitoring of the retinal function during vitrectomy in human eyes, and found that lowering the intravitreal temperature by applying an infusion solution kept at room temperature (used routinely for vitrectomy throughout the world) can alter the electroretinogram (ERG). This time we attempted to study the effect upon the ERG of replacing the intraocular medium and acutely elevating the intraocular pressure during vitrectomy.

METHODS

Using a special contact lens with a built-in light-emitting diode light source, 30-Hz flicker ERG was quickly recorded under aseptic conditions.

RESULTS

Acute, reversible reduction in amplitude was observed upon replacing the intraocular medium with air or silicon oil and during periods of acutely elevated intraocular pressure. Infusions of gentamicin or miconazole did not affect the ERG when intravitreal temperature and intraocular pressure were constant.

CONCLUSION

The ERG monitor can reveal changes of the retinal function during vitrectomy, particularly when the infusion temperature, intraocular medium and intraocular pressure are kept constant.

Visual evoked potentials in endoscopic and anterior skull base surgery: a review

The anterior visual pathway can be damaged during surgery of the anterior skull base, the sellar and parasellar area, the orbit, or the paranasal sinuses. Clinical per-operative monitoring of the visual pathway is difficult and damage to the optic nerve is often only determined late. Visual evoked potentials may provide an early indication of reversible change to the visual system and various per-operative monitoring techniques have been used. These techniques show promise but at present they are too cumbersome and give results which are too variable to be reliable in per-operative monitoring.

Flash visual evoked potential monitoring of optic tract function during macroelectrode-based pallidotomy

Posteroventral pallidotomy (PVP) has received renewed interest as an ablative procedure for the symptomatic treatment of Parkinson's disease. In previous reports, the proximity of the optic tract to the lesion target in the globus pallidus internus has resulted in the occurrence of visual field deficits in as much as 14% of patients. The authors have used intraoperative visual evoked potentials (VEPs) during PVP to reduce this risk. All procedures were performed in awake patients. Flash stimuli were delivered to each eye via fiberoptic sources. Baseline flash VEPs were recorded at O1/Cz (left visual cortex to vertex), Oz/Cz (midline visual cortex to vertex), and O2/Cz (right visual cortex to vertex) for OS, OU, and OD stimulation. Epochs were acquired before and after localization, after macroelectrode stimulation, after temporary thermal lesioning, and after permanent thermal lesioning. Forty-seven patients underwent a total of 59 procedures. Visual evoked potentials were recorded reproducibly in all patients. In 11 procedures, VEP changes were reported, including six amplitude changes (10-80%), six latency shifts (3-10 msec), and one report of “variability.” In four procedures, VEP changes prompted a change in target coordinates. One false-positive and one false-negative VEP change were encountered. The only confirmed visual deficit was a superior quadrantanopsia, present on formal fields, but clinically asymptomatic. The authors conclude that VEPs may be useful for procedures performed in the awake patient because of the lack of anesthetic-induced variability. The 1.7% visual morbidity reported here (one in 59 patients) compares favorably with other series using microelectrodes. Visual evoked potentials may be a useful monitoring technique to reduce the incidence of clinically significant visual morbidity during pallidotomy, especially during formal lesioning of the ventral pallidum adjacent to the optic tract.

Behavior of the H-reflex in humans following mechanical perturbation or injury to rostral spinal cord

In humans H-reflexes are suppressed during early spinal shock. In animals rostral cord injury results in loss of segmental reflexes within seconds. If H-reflexes persist under general anesthesia, can they be used to monitor the integrity of the rostral cord? In part I of this study, we recorded H-reflexes intraoperatively in 25 patients to elucidate general anesthesia effect. In 23 subjects, H-reflexes were consistently elicited, and within +/- 13% of the normalized group mean amplitude. In part II, we recorded H-reflexes in 31 patients during spinal cord surgery to elucidate H-reflex behavior immediately following rostral spinal cord injury. In 6, abrupt suppression of the H-reflex coincided with cord injury. In 4 of 6, suppression was transient and less than 50% of baseline; none of these patients developed neurological deficits. In 2, suppression exceeded 90% and persisted throughout surgery; both patients developed profound deficits. We conclude that (1) the H-reflex can be consistently elicited under general anesthesia in most patients, (2) rostral cord injury rapidly suppresses the H-reflex, and (3) the degree and duration of H-reflex suppression reflects the severity of the injury.

Differences in sensitivity between magnetic motor-evoked potentials and somatosensory-evoked potentials in experimental spinal cord lesions

STUDY DESIGN

Graded posterior spinal cord compression and partial sectioning of the spinal cord were performed, and magnetically induced descending spinal cord potentials were recorded.

OBJECTIVES

To compare the sensitivity of transcranial magnetic motor-evoked potentials in the spinal cord and other spinal cord evoked potentials to spinal cord lesions.

SUMMARY OF BACKGROUND DATA

Somatosensory-evoked potentials have been the standard technique for monitoring spinal cord function during spinal surgery. These potentials, however, do not necessarily reflect descending motor tract function. Transcranial electric or magnetic stimulation for motor-evoked potentials is a more direct measure of motor tract function. However, more research on magnetic motor-evoked potentials is needed.

METHODS

Fifteen adult cats were used. Graded posterior spinal cord compression was performed at L2 in 10 cats, and partial sectioning of the spinal cord was performed at L2 in five cats. The location sequence of lesioning was dorsal column section, dorsal 1/2 section, dorsal 2/3 section, and total spinal cord section. Magnetic motor-evoked potentials were recorded by epidural catheter electrodes placed above at, and below the lesion. Electric motor evoked potentials and spinal and cortical somatosensory-evoked potentials were recorded serially for a comparison of their sensitivity to spinal cord dysfunction.

RESULTS

In posterior spinal cord compression, N1 amplitude of magnetic motor-evoked potentials at and below the lesion decreased after 1 minute of compression with a 70 g weight, and N1 and N2 amplitude disappeared after 1 minute of compression with a 100 to 120-g weight. Electric motor-evoked potentials changed at amplitudes comparable with those shown by magnetic motor-evoked potentials. Spinal somatosensory-evoked potentials showed the most sensitive changes to spinal cord posterior compression and disappeared after 1 minute of compression with 80 g Cortical somatosensory-evoked potentials in five cats were not sensitive enough for spinal cord posterior compression injury and did not disappear even after 1 minute of compression with 120 g. In magnetic motor-evoked potentials, after dorsal hemisectioning of the spinal cord only N3 disappeared; N1 and N2 disappeared after ventral spinal cord sectioning in spinal somatosensory-evoked potentials, amplitudes decreased after dorsal column sectioning, and all negative peaks disappeared after dorsal hemisectioning of the spinal cord.

CONCLUSIONS

Posterior compression injuries are diagnosed more easily with spinal somatosensory-evoked potentials. Motor-evoked potentials were slightly less sensitive, but they were significantly more useful in diagnosing posterior compression injuries than were cortical somatosensory-evoked potentials.

Intraoperative SEP monitoring in neurosurgery around the brain stem and cervical spinal cord: differential recording of subcortical components

The results of intraoperative monitoring of median nerve somatosensory evoked potentials (SEP's) were evaluated in 75 neurosurgical patients in order to assess the role of differential derivation of brain stem (P14) and spinal cord (N13) wave activity. These components were compared with the conventionally recorded neck potential ("N13") that reflects overlap of P14 and N13. The spinal cord N13 wave was recorded from the posterior to anterior lower aspect of the neck and the brain stem P14 wave from the midfrontal scalp to the nasopharynx; both derivations enabled isolated low-artifact recording of these components. In 18.7% of patients, moderate to major latency and/or amplitude shifts of N13 or P14 were found that were masked in conventional neck-scalp recordings of "N13". There was a 6.7% false-negative rate in this series. Using a neck-scalp derivation alone, a 14.7% false-negative rate would have resulted and an isolated worsening of the P14 component (with stable neck potential) in six cases would have been overlooked. It is concluded that the proposed SEP recording technique allows independent assessment of spinal cord and brain stem activity. It is, therefore, superior to the conventional neck-scalp derivation technique, in which important information may be concealed or even lost due to the overlap of the brain stem P14 and spinal cord N13 potentials.

Loss of somatosensory evoked potentials during intramedullary spinal cord surgery predicts postoperative neurologic deficits in motor function [corrected]

STUDY OBJECTIVES

To estimate the sensitivity and specificity of somatosensory evoked potentials (SSEPs) for predicting new postoperative motor neurologic deficits during intramedullary spinal cord surgery; to establish whether SSEPs more accurately predicted postoperative deficits in position and vibration sense than in strength.

DESIGN

Prospective open and retrospective study.

SETTING

University-affiliated hospital.

PATIENTS

20 patients with intramedullary spinal cord tumors scheduled for surgery with intraoperative SSEPs.

INTERVENTIONS

Median, ulnar, and tibial nerve cortical and subcortical SSEPs were recorded continuously.

MEASUREMENTS AND MAIN RESULTS

Conventional intraoperative SSEP criteria considered indicative of neurologic injury were modified and defined as either the complete and permanent loss of the SSEP or the simultaneous amplitude reduction of 50% or greater in the nearest recording electrode rostral to the surgical site and 0.5 millisecond increase in the central latency. Our definition required confirmation of both amplitude and latency changes on a repeated average. All patients had 1 or more SSEPs, which were reproducible and sufficiently stable for analysis throughout the operation. Six patients developed new postoperative neurologic deficits. One had new motor deficits in an extremity from which no baseline SSEPs could be elicited. In each of the other 5 patients, significant SSEP changes preceded the postoperative motor deficits in the extremity or extremities monitored. In no patient without a new postoperative motor deficit was there a significant change in the SSEP. In only 2 of these 5 patients was there a documented postoperative loss or diminution in vibration or position sense.

CONCLUSIONS

Intraoperative SSEP changes during intramedullary spinal cord surgery are a sensitive predictor of new postoperative motor deficits, but such changes may not correlate reliably with postoperative deficits in position or vibration sense. In this setting SSEP monitoring serves primarily to reassure the operating team that, when the SSEPs remain constant, the surgery has not caused additional injury.

[Somatosensory evoked potentials during spinal orthopedic surgery in adult patients]

Somatosensory evoked potentials (SEPs) were recorded in 165 patients from 185 operations for scoliosis and major spinal distortions, lumbar or cervical stenosis, post-traumatic malunions, or tumors. They were obtained by percutaneous stimulation of right and left median and tibial posterior nerves, and recorded on the scalp as recently, motor potentials (MPs) have also been obtained, by a trans-spinous stimulation rostral to the level of intervention. The protocol consists of pre- and post-operative recordings, as well as a continuous intra-operative monitoring. Neuromonitoring is justified in operations implying neurological risks, particularly scoliosis. A durable disappearance of SEPs and MPs was always associated with post-operative neurological disorders. Transient disappearances, not associated with neurological disorders, have been observed during certain manoeuvres such as vertebral traction, osteosynthesis, placing trans-pedicular screws or hooks, leading the surgeon to modify the operation. The role of medullary ischemia on the degradation of electrophysiological signals, obvious in cardiovascular decompensations, seems predominant in the post-operative occurrence of neurological impairment. During the post-operative period, SEPs allow one to discriminate between organic disorders and subjective complaints; they help in diagnosing hematomas, and distinguish between radicular and spinal cord injuries.

Contralateral effects of cerebello-pontine angle exposure on human auditory brain-stem evoked potentials

Auditory brain-stem evoked potentials (ABEPs) were recorded during surgical procedures which exposed the cerebello-pontine angle (CPA) in humans. Recordings made with the CPA contralateral to stimulus exposed were compared with those obtained with the skin sutured at the end of surgery. Single-channel as well as 3-channel Lissajous' trajectory (3-CLT) analyses were used to evaluate the effect of the surgical exposure on ABEP. The results suggest that exposure of the CPA contralateral to the stimulated ear did not affect dipole equivalent orientation nor magnitude, but did affect timing of the recorded activity being more pronounced for segments 'd'-'e' (corresponding to waves IV-V) than for 'a'-'b' (waves I-II). The results imply that the effects of disrupting the volume conductor may have been overwhelmed by other effects, such as local temperature changes. These changes, although not associated with clinical sequella, should be accounted for when analyzing subtle quantitative changes involving surgical exposures.

Inconsistencies in the correlation between loss of brain stem auditory evoked response waves and postoperative deafness

This case underscores the difficulty of predicting postoperative hearing status from brain stem auditory evoked response (BAER) monitoring when wave I is preserved and all later waves are lost. During an operation involving the base of the skull, sudden and irreversible loss of all BAER waves beyond wave I occurred unilaterally. Wave I was preserved, with reduced amplitude and minimal latency shift. There was no permanent postoperative hearing sensitivity loss or speech discrimination loss.