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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.
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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
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Predictors of Clamp-Induced Electroencephalographic Changes During Carotid Endarterectomies. J Clin Neurophysiol 2012; 29:462-7. [DOI: 10.1097/wnp.0b013e31826bde88] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Peroperative Neuromonitoring during Carotid Endarterectomy in Relation to Preoperative Positron Emission Tomography Findings. Eur J Vasc Endovasc Surg 2008; 35:652-60. [DOI: 10.1016/j.ejvs.2008.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2007] [Accepted: 01/08/2008] [Indexed: 11/19/2022]
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Deogaonkar A, Vivar R, Bullock RE, Price K, Chambers I, Mendelow AD. Bispectral index monitoring may not reliably indicate cerebral ischaemia during awake carotid endarterectomy † †This study was conducted in the Department of Neurosurgery, Newcastle General Hospital, Newcastle Upon Tyne NE4 6BE, UK. Preliminary results were presented at the British Neurosurgery Research Group Meeting, Sheffield, March 29–30, 2001. Br J Anaesth 2005; 94:800-4. [PMID: 15778269 DOI: 10.1093/bja/aei115] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Intraoperative ischaemia during carotid cross-clamping in patients undergoing carotid endarterectomy (CEA) is a major complication and prompt recognition of insufficient collateral blood supply is crucial. Electroencephalogram (EEG) is believed to be one of the useful forms of monitoring cerebrovascular insufficiency during CEA. The aim of this study was to evaluate the utility of bispectral index (BIS) monitoring, a processed EEG parameter, for the reliable detection of intraoperative cerebral ischaemia during awake CEA. METHODS We monitored 52 patients continuously with the BIS monitor together with assessment of neurological function (contralateral upper and lower limb strength and the verbal component of the Glasgow Coma Scale for speech) in patients undergoing awake CEA. RESULTS Overall mean BIS value in all patients was 96 (SD 2.9). In five patients who showed clinical evidence of cortical ischaemia during carotid cross-clamping, there was no change in the original range of BIS values throughout the procedure (96.7 [3.2]). In one patient BIS values decreased to 38 about 5 min after the incision and recovered within the next 10 min. The mean BIS value in the remaining 46 patients who did not develop clinical signs of ischaemia was 95.4 (2.6). Three cases are presented which demonstrate the inability of the BIS monitor to detect cerebral ischaemia. CONCLUSIONS Lack of correlation of BIS with the signs of cerebral ischaemia during CEA makes it unreliable for detection of cerebrovascular insufficiency. We conclude that awake neurological testing is the preferred method of monitoring in these patients.
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Affiliation(s)
- A Deogaonkar
- Department of General Anesthesiology, Cleveland Clinic Foundation, Cleveland, OH, USA
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Visser GH, Wieneke GH, van Huffelen AC, Eikelboom BC. The use of preoperative transcranial Doppler variables to predict which patients do not need a shunt during carotid endarterectomy. Eur J Vasc Endovasc Surg 2000; 19:226-32. [PMID: 10753684 DOI: 10.1053/ejvs.1999.1009] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES to analyse whether preoperative transcranial Doppler (TCD) variables can predict intraoperative shunt requirement. DESIGN AND METHODS the blood-flow velocity (BFV) in the major basal cerebral arteries was measured preoperatively with TCD, in 178 patients scheduled for CEA. Carotid artery compression and CO2 reactivity tests were also performed. Intraoperative electroencephalography was used to decide whether a shunt was needed. Differences in the probability of shunt requirement between the categories of variables were assessed with crosstabs statistics. RESULTS preoperative TCD criteria clearly identified a subgroup of 59 patients (33%) who did not require a shunt. In general, these patients appeared to have adequate collateral flow through the anterior communicating artery. In contrast, prediction of the need for a shunt was less reliable. TCD variables could predict the need for a shunt with a probability of only 60%. CONCLUSIONS preoperative TCD can be used to identify patients who do not require a shunt during carotid endarterectomy.
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Affiliation(s)
- G H Visser
- Department of Clinical Neurophysiology, University Hospital Rotterdam, The Netherlands
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Blohmé L, Sandström V, Hellström G, Swedenborg J, Takolander R. Complications in carotid endarterectomy are predicted by qualifying symptoms and preoperative CT findings. Eur J Vasc Endovasc Surg 1999; 17:213-8. [PMID: 10092893 DOI: 10.1053/ejvs.1998.0743] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To relate the 30-day perioperative rate of stroke or death in carotid endarterectomy (CEA) to preoperative qualifying symptoms and to the presence of cerebral infarction (CI) demonstrated on computed tomography (CT). DESIGN Retrospective clinical study. MATERIAL AND METHODS Two hundred and seventy-two consecutive CEAs for symptomatic stenosis in 262 patients were analysed. RESULTS The total complication rate was 5.9%. Patients with retinal symptoms (n = 81) had no complications, TIA patients (n = 76) had 6.6% (p < 0.001). Patients qualifying with minor stroke (n = 113) had complications in 9.7% (N.S. compared to TIA patients). Patients qualifying with cortical symptoms had a significantly higher complication rate compared to those with retinal (8.4% vs. 0%, p = 0.004). The presence of a preoperative CT-verified infarction resulted in a higher risk for stroke or death (9.8% vs 2.8%, p = 0.008). Within the subgroup presenting with minor stroke, the presence of CI resulted in stroke or death in 13.9%. In patients without CI the corresponding figure was 2.4% (p = 0.017). CONCLUSION The qualifying symptoms and the presence of CI visualized by CT influence the complication rate in CEA. When evaluating risk and comparing outcome, these parameters should be included in reporting standards.
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Affiliation(s)
- L Blohmé
- Department of Surgery, Karolinska Hospital, Stockholm, Sweden
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Guérit JM. Neuromonitoring in the operating room: why, when, and how to monitor? ELECTROENCEPHALOGRAPHY AND CLINICAL NEUROPHYSIOLOGY 1998; 106:1-21. [PMID: 9680160 DOI: 10.1016/s0013-4694(97)00077-1] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
This review considers the main principles and indications of EEG and evoked potential (EP) neuromonitoring in the operating room. Neuromonitoring has a threefold purpose: to warn the surgeon that he has to adjust his strategy, to confirm his decision, and to help him improve subsequent procedures. The pathophysiology of intraoperative events liable to alter the EEG or the EPs is first considered. The usefulness of neuromonitoring in preventing neurological complication relies on its ability to detect neurological dysfunction at a reversible stage. This applies especially to ischemia and compressive damage. The anesthetic influences on EEG and EPs are then considered. Knowledge of them is essential to disentangle these neurophysiological alterations due to intraoperative events from those merely due to anesthesia and to use neurophysiological parameters to evaluate the depth of anesthesia. Third, the main indications and limitations of neuromonitoring are considered: prevention of ischemic brain or spinal cord damage, prevention of mechanical injuries of the brain, spinal cord or peripheral nerve, and localization of the motor cortex in cortical neurosurgery or of cranial nerves in posterior fossa surgery. Finally, the 3 levels of neuromonitoring (neurophysiological feature extraction, neurophysiological pattern recognition, clinical integration of the neurophysiological patterns) are discussed together with the rules that should guide the dialogue between the surgeon, the anesthesiologist, and the neurophysiologist.
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Affiliation(s)
- J M Guérit
- Clinical Neurophysiology Unit, Cliniques Saint-Luc, University of Louvain Medical School, Brussels, Belgium.
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