1
|
Al-Qudah AM, Thirumala PD, Anetakis KM, Crammond DJ, Algarni SA, AlMajali M, Shandal V, Gross BA, Lang M, Bhatt NR, Al-Bayati AR, Nogueira RG, Balzer JR. Intraoperative neuromonitoring as real-time diagnostic for cerebral ischemia in endovascular treatment of ruptured brain aneurysms. Clin Neurophysiol 2024; 161:69-79. [PMID: 38452426 DOI: 10.1016/j.clinph.2024.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 01/11/2024] [Accepted: 02/19/2024] [Indexed: 03/09/2024]
Abstract
OBJECTIVE To evaluate the diagnostic accuracy of intraoperative neurophysiological monitoring (IONM) during endovascular treatment (EVT) of ruptured intracranial aneurysms (rIA). METHODS IONM and clinical data from 323 patients who underwent EVT for rIA from 2014-2019 were retrospectively reviewed. Significant IONM changes and outcomes were evaluated based on visual review of data and clinical documentation. RESULTS Of the 323 patients undergoing EVT, significant IONM changes were noted in 30 patients (9.29%) and 46 (14.24%) experienced postprocedural neurological deficits (PPND). 22 out of 30 (73.33%) patients who had significant IONM changes experienced PPND. Univariable analysis showed changes in somatosensory evoked potential (SSEP) and electroencephalogram (EEG) were associated with PPND (p-values: <0.001 and <0.001, retrospectively). Multivariable analysis showed that IONM changes were significantly associated with PPND (Odd ratio (OR) 20.18 (95%CI:7.40-55.03, p-value: <0.001)). Simultaneous changes in both IONM modalities had specificity of 98.9% (95% CI: 97.1%-99.7%). While sensitivity when either modality had a change was 47.8% (95% CI: 33.9%-62.0%) to predict PPND. CONCLUSIONS Significant IONM changes during EVT for rIA are associated with an increased risk of PPND. SIGNIFICANCE IONM can be used confidently as a real time neurophysiological diagnostic guide for impending neurological deficits during EVT treatment of rIA.
Collapse
Affiliation(s)
- Abdullah M Al-Qudah
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Parthasarathy D Thirumala
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Katherine M Anetakis
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Donald J Crammond
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Saleh A Algarni
- Department of Clinical Neurosciences, College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia; Neuroscience Centre, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Mohammad AlMajali
- Department of Neurology, University of Iowa College of Medicine, Iowa City, IA, USA
| | - Varun Shandal
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Bradley A Gross
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael Lang
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Nirav R Bhatt
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alhamza R Al-Bayati
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Raul G Nogueira
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jeffrey R Balzer
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
| |
Collapse
|
2
|
Gorijala VK, Reddy RP, Anetakis KM, Balzer J, Crammond DJ, Shandal V, Shaw JD, Christie MR, Thirumala PD. Diagnostic utility of different types of somatosensory evoked potential changes in pediatric idiopathic scoliosis correction surgery. Eur Spine J 2024; 33:1644-1656. [PMID: 38285275 DOI: 10.1007/s00586-023-08063-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 09/24/2023] [Accepted: 11/21/2023] [Indexed: 01/30/2024]
Abstract
PURPOSE To evaluate the diagnostic accuracy of intraoperative somatosensory evoked potential (SSEP) monitoring and types of SSEP changes in predicting the risk of postoperative neurological outcomes during correction surgery for idiopathic scoliosis (IS) in the pediatric age group (≤ 21 years). METHODS Database review was performed to identify literature on pediatric patients with IS who underwent correction with intraoperative neuromonitoring. The sensitivity, specificity, and diagnostic odds ratio (DOR) of transient and persistent SSEP changes and complete SSEP loss in predicting postoperative neurological deficits were calculated. RESULTS Final analysis included 3778 patients. SSEP changes had a sensitivity of 72.9%, specificity of 96.8%, and DOR of 102.3, while SSEP loss had a sensitivity of 41.8%, specificity of 99.3%, and DOR of 133.2 for predicting new neurologic deficits. Transient and persistent SSEP changes had specificities of 96.8% and 99.1%, and DORs of 16.6 and 59, respectively. CONCLUSION Intraoperative SSEP monitoring can predict perioperative neurological injury and improve surgical outcomes in pediatric scoliosis fusion surgery. LEVEL OF EVIDENCE Level 2. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
Collapse
Affiliation(s)
- Vamsi Krishna Gorijala
- Department of Neurological Surgery, Center for Clinical Neurophysiology, University of Pittsburgh Medical Center, UPMC, Presbyterian-Suite-B-400, 200 Lothrop Suite, Pittsburgh, PA, 15213, USA
| | - Rajiv P Reddy
- Pittsburgh Orthopedic Spine Research, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Katherine M Anetakis
- Department of Neurological Surgery, Center for Clinical Neurophysiology, University of Pittsburgh Medical Center, UPMC, Presbyterian-Suite-B-400, 200 Lothrop Suite, Pittsburgh, PA, 15213, USA
| | - Jeffrey Balzer
- Department of Neurological Surgery, Center for Clinical Neurophysiology, University of Pittsburgh Medical Center, UPMC, Presbyterian-Suite-B-400, 200 Lothrop Suite, Pittsburgh, PA, 15213, USA
| | - Donald J Crammond
- Department of Neurological Surgery, Center for Clinical Neurophysiology, University of Pittsburgh Medical Center, UPMC, Presbyterian-Suite-B-400, 200 Lothrop Suite, Pittsburgh, PA, 15213, USA
| | - Varun Shandal
- Department of Neurological Surgery, Center for Clinical Neurophysiology, University of Pittsburgh Medical Center, UPMC, Presbyterian-Suite-B-400, 200 Lothrop Suite, Pittsburgh, PA, 15213, USA
| | - Jeremy D Shaw
- Pittsburgh Orthopedic Spine Research, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michelle R Christie
- Department of Neurology and Rehabilitation Medicine, Texas Scottish Rite Hospital, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Parthasarathy D Thirumala
- Department of Neurological Surgery, Center for Clinical Neurophysiology, University of Pittsburgh Medical Center, UPMC, Presbyterian-Suite-B-400, 200 Lothrop Suite, Pittsburgh, PA, 15213, USA.
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| |
Collapse
|
3
|
Al-Qudah AM, Ta'ani OA, Thirumala PD, Sultan I, Visweswaran S, Nadkarni N, Kiselevskaya V, Crammond DJ, Balzer J, Anetakis KM, Shandal V, Subramaniam K, Subramanium B, Sadhasivam S. Role of Intraoperative Neuromonitoring to Predict Postoperative Delirium in Cardiovascular Surgery. J Cardiothorac Vasc Anesth 2024; 38:526-533. [PMID: 37838509 DOI: 10.1053/j.jvca.2023.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 08/20/2023] [Accepted: 09/09/2023] [Indexed: 10/16/2023]
Abstract
OBJECTIVE Postoperative delirium (POD) can occur in up to 50% of older patients undergoing cardiovascular surgery, resulting in hospitalization and significant morbidity and mortality. This study aimed to determine whether intraoperative neurophysiologic monitoring (IONM) modalities can be used to predict delirium in patients undergoing cardiovascular surgery. DESIGN Adult patients undergoing cardiovascular surgery with IONM between 2019 and 2021 were reviewed retrospectively. Delirium was assessed multiple times using the Intensive Care Delirium Screening Checklist (ICDSC). Patients with an ICDSC score ≥4 were considered to have POD. Significant IONM changes were evaluated based on a visual review of electroencephalography (EEG) and somatosensory evoked potentials data and documentation of significant changes during surgery. SETTING University of Pittsburgh Medical Center hospitals. PARTICIPANTS Patients 18 years old and older undergoing cardiovascular surgery with IONM monitoring. MEASUREMENTS AND MAIN RESULTS Of the 578 patients undergoing cardiovascular surgery with IONM, 126 had POD (21.8%). Significant IONM changes were noted in 134 patients, of whom 49 patients had delirium (36.6%). In contrast, 444 patients had no IONM changes during surgery, of whom 77 (17.3%) patients had POD. Upon multivariate analysis, IONM changes were associated with POD (odds ratio 2.12; 95% CI 1.31-3.44; p < 0.001). Additionally, baseline EEG abnormalities were associated with POD (p = 0.002). CONCLUSION Significant IONM changes are associated with an increased risk of POD in patients undergoing cardiovascular surgery. These findings offer a basis for future research and analysis of EEG and somatosensory evoked potential monitoring to predict, detect, and prevent POD.
Collapse
Affiliation(s)
- Abdullah M Al-Qudah
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Omar Al Ta'ani
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Parthasarathy D Thirumala
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
| | - Ibrahim Sultan
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Shyam Visweswaran
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Neelesh Nadkarni
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Victoria Kiselevskaya
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Donald J Crammond
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jeffrey Balzer
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Katherine M Anetakis
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Varun Shandal
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Kathirvel Subramaniam
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Balachundhar Subramanium
- Department of Anesthesiology, Critical Care & Pain Management, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Senthilkumar Sadhasivam
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| |
Collapse
|
4
|
Jimenez JE, Omar M, Adams GM, Costacou T, Thirumala PD, Crammond DJ, Anetakis KM, Balzer JR, Shandal V, Snyderman CH, Gardner PA, Zenonos GA, Wang EW. Electromyographic predictors of abducens nerve palsy after endoscopic skull base surgery. J Neurosurg 2023:1-7. [PMID: 38157534 DOI: 10.3171/2023.10.jns23648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 10/17/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVE Recovery of abducens nerve palsy (ANP) after endoscopic endonasal skull base surgery (ESBS) has been shown to be potentially predicted by postoperative ophthalmological examination. Triggered electromyography (t-EMG) and free-run electromyography (f-EMG) activity provide an intraoperative assessment of abducens nerve function, but associations with long-term ANP outcomes have not been explored. The objective of this study was to describe intraoperative abducens EMG characteristics and determine whether these electrophysiological profiles are associated with immediately postoperative and long-term ANP outcomes after ESBS. METHODS The authors conducted a 5-year (2011-2016) retrospective case-control study of patients who underwent ESBS in whom the abducens nerve was stimulated (t-EMG). Electrophysiological metrics were compared between patients with a new postoperative ANP (cases) and those without ANP (controls). Pathologies included chordoma, pituitary adenoma, meningioma, cholesterol granuloma, and chondrosarcoma. Electrophysiological data included the presence of abnormal f-EMG activity, t-EMG stimulation voltage, stimulation threshold, evoked compound muscle action potential (CMAP) amplitude, onset latency, peak latency, and CMAP duration at various stages of the dissection. Controls were selected such that pathologies were similarly distributed between cases and controls. RESULTS Fifty-six patients were included, 26 with new postoperative ANP and 30 controls without ANP. Abnormal f-EMG activity (28.0% vs 3.3%, p = 0.02) and lack of response to stimulation (27% vs 0%, p = 0.006) were more frequent in patients with immediately postoperative ANP than in controls. Patients with immediately postoperative ANP also had a lower median CMAP amplitude (35.0 vs 71.2 μV, p = 0.02) and longer onset latency (5.2 vs 2.8 msec, p = 0.04). Comparing patients with transient versus persistent ANP on follow-up, those with persistent ANP tended to have a lower CMAP amplitude (12.8 vs 57 μV, p = 0.07) and higher likelihood of not responding to stimulation at the end of the case (45.5% vs 7.1%, p = 0.06). Abnormal f-EMG was not associated with long-term ANP outcomes. CONCLUSIONS The presence of f-EMG activity, lack of CMAP response to stimulation, decreased CMAP amplitude, and increased CMAP onset latency were associated with immediately postoperative ANP. Long-term ANP outcomes may be associated with t-EMG parameters, including whether the nerve is able to be stimulated once identified and CMAP amplitude. Future prospective studies may be designed to standardize abducens nerve electrophysiological monitoring protocols to further refine operative and prognostic utility.
Collapse
Affiliation(s)
| | - Mahmoud Omar
- 2University of Pittsburgh School of Medicine, Pittsburgh; and
| | | | - Tina Costacou
- 4Department of Epidemiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | | | | | | | | | | | - Paul A Gardner
- 5Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh
| | - Georgios A Zenonos
- 5Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh
| | - Eric W Wang
- 1Department of Otolaryngology-Head & Neck Surgery
| |
Collapse
|
5
|
Ho JC, Grigsby EM, Damiani A, Liang L, Balaguer JM, Kallakuri S, Barrios-Martinez J, Karapetyan V, Fields D, Gerszten PC, Kevin Hitchens T, Constantine T, Adams GM, Crammond DJ, Capogrosso M, Gonzalez-Martinez JA, Pirondini E. POTENTIATION OF CORTICO-SPINAL OUTPUT VIA TARGETED ELECTRICAL STIMULATION OF THE MOTOR THALAMUS. medRxiv 2023:2023.03.08.23286720. [PMID: 36945514 PMCID: PMC10029067 DOI: 10.1101/2023.03.08.23286720] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
Cerebral white matter lesions prevent cortico-spinal descending inputs from effectively activating spinal motoneurons, leading to loss of motor control. However, in most cases, the damage to cortico-spinal axons is incomplete offering a potential target for new therapies aimed at improving volitional muscle activation. Here we hypothesized that, by engaging direct excitatory connections to cortico-spinal motoneurons, stimulation of the motor thalamus could facilitate activation of surviving cortico-spinal fibers thereby potentiating motor output. To test this hypothesis, we identified optimal thalamic targets and stimulation parameters that enhanced upper-limb motor evoked potentials and grip forces in anesthetized monkeys. This potentiation persisted after white matter lesions. We replicated these results in humans during intra-operative testing. We then designed a stimulation protocol that immediately improved voluntary grip force control in a patient with a chronic white matter lesion. Our results show that electrical stimulation targeting surviving neural pathways can improve motor control after white matter lesions.
Collapse
Affiliation(s)
- Jonathan C. Ho
- School of Medicine, University of Pittsburgh, 3550 Terrace St, Pittsburgh, PA, USA 15213
- Rehab Neural Engineering Labs, University of Pittsburgh, 3520 Fifth Avenue, Suite 300, Pittsburgh, PA, USA, 15213
| | - Erinn M. Grigsby
- Rehab Neural Engineering Labs, University of Pittsburgh, 3520 Fifth Avenue, Suite 300, Pittsburgh, PA, USA, 15213
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, 3471 Fifth Avenue, Suite 910, Pittsburgh, PA, USA, 15213
| | - Arianna Damiani
- Rehab Neural Engineering Labs, University of Pittsburgh, 3520 Fifth Avenue, Suite 300, Pittsburgh, PA, USA, 15213
- Department of Bioengineering, University of Pittsburgh, 151 Benedum Hall, Pittsburgh, PA, USA, 15261
- Center for the Neural Basis of Cognition, 4400 Fifth Avenue, Suite 115, Pittsburgh, PA, USA, 15213
| | - Lucy Liang
- Rehab Neural Engineering Labs, University of Pittsburgh, 3520 Fifth Avenue, Suite 300, Pittsburgh, PA, USA, 15213
- Department of Bioengineering, University of Pittsburgh, 151 Benedum Hall, Pittsburgh, PA, USA, 15261
- Center for the Neural Basis of Cognition, 4400 Fifth Avenue, Suite 115, Pittsburgh, PA, USA, 15213
| | - Josep-Maria Balaguer
- Rehab Neural Engineering Labs, University of Pittsburgh, 3520 Fifth Avenue, Suite 300, Pittsburgh, PA, USA, 15213
- Department of Bioengineering, University of Pittsburgh, 151 Benedum Hall, Pittsburgh, PA, USA, 15261
- Center for the Neural Basis of Cognition, 4400 Fifth Avenue, Suite 115, Pittsburgh, PA, USA, 15213
| | - Sridula Kallakuri
- Rehab Neural Engineering Labs, University of Pittsburgh, 3520 Fifth Avenue, Suite 300, Pittsburgh, PA, USA, 15213
- Department of Neuroscience, University of Pittsburgh, A210 Langley Hall, Pittsburgh, PA, USA, 15260
| | - Jessica Barrios-Martinez
- Department of Neurological Surgery, University of Pittsburgh, 200 Lothrop Street, suite b-400, Pittsburgh, PA, USA, 15213
| | - Vahagn Karapetyan
- Rehab Neural Engineering Labs, University of Pittsburgh, 3520 Fifth Avenue, Suite 300, Pittsburgh, PA, USA, 15213
- Department of Bioengineering, University of Pittsburgh, 151 Benedum Hall, Pittsburgh, PA, USA, 15261
- Center for the Neural Basis of Cognition, 4400 Fifth Avenue, Suite 115, Pittsburgh, PA, USA, 15213
| | - Daryl Fields
- Rehab Neural Engineering Labs, University of Pittsburgh, 3520 Fifth Avenue, Suite 300, Pittsburgh, PA, USA, 15213
- Department of Neurological Surgery, University of Pittsburgh, 200 Lothrop Street, suite b-400, Pittsburgh, PA, USA, 15213
| | - Peter C. Gerszten
- Department of Neurological Surgery, University of Pittsburgh, 200 Lothrop Street, suite b-400, Pittsburgh, PA, USA, 15213
| | - T. Kevin Hitchens
- Department of Neurobiology, University of Pittsburgh, 200 Lothrop Street, Room E1440, Pittsburgh, PA, USA, 15213
| | - Theodora Constantine
- Department of Neurological Surgery, University of Pittsburgh, 200 Lothrop Street, suite b-400, Pittsburgh, PA, USA, 15213
| | - Gregory M. Adams
- Department of Neurological Surgery, University of Pittsburgh, 200 Lothrop Street, suite b-400, Pittsburgh, PA, USA, 15213
| | - Donald J. Crammond
- Department of Neurological Surgery, University of Pittsburgh, 200 Lothrop Street, suite b-400, Pittsburgh, PA, USA, 15213
| | - Marco Capogrosso
- Rehab Neural Engineering Labs, University of Pittsburgh, 3520 Fifth Avenue, Suite 300, Pittsburgh, PA, USA, 15213
- Department of Bioengineering, University of Pittsburgh, 151 Benedum Hall, Pittsburgh, PA, USA, 15261
- Center for the Neural Basis of Cognition, 4400 Fifth Avenue, Suite 115, Pittsburgh, PA, USA, 15213
- Department of Neurological Surgery, University of Pittsburgh, 200 Lothrop Street, suite b-400, Pittsburgh, PA, USA, 15213
| | - Jorge A. Gonzalez-Martinez
- Department of Neurological Surgery, University of Pittsburgh, 200 Lothrop Street, suite b-400, Pittsburgh, PA, USA, 15213
- Department of Neurobiology, University of Pittsburgh, 200 Lothrop Street, Room E1440, Pittsburgh, PA, USA, 15213
| | - Elvira Pirondini
- Rehab Neural Engineering Labs, University of Pittsburgh, 3520 Fifth Avenue, Suite 300, Pittsburgh, PA, USA, 15213
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, 3471 Fifth Avenue, Suite 910, Pittsburgh, PA, USA, 15213
- Department of Bioengineering, University of Pittsburgh, 151 Benedum Hall, Pittsburgh, PA, USA, 15261
- Center for the Neural Basis of Cognition, 4400 Fifth Avenue, Suite 115, Pittsburgh, PA, USA, 15213
- Department of Neurological Surgery, University of Pittsburgh, 200 Lothrop Street, suite b-400, Pittsburgh, PA, USA, 15213
- Department of Neurobiology, University of Pittsburgh, 200 Lothrop Street, Room E1440, Pittsburgh, PA, USA, 15213
| |
Collapse
|
6
|
Reddy RP, Singh-Varma A, Chang R, Vedire A, Anetakis KM, Balzer JR, Crammond DJ, Shandal V, Lee JY, Shaw JD, Thirumala PD. Transcranial Motor Evoked Potentials as a Predictive Modality for Postoperative Deficit in Cervical Spine Decompression Surgery - A Systematic Review and Meta-Analysis. Global Spine J 2023:21925682231219224. [PMID: 38047537 DOI: 10.1177/21925682231219224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2023] Open
Abstract
STUDY DESIGN Systematic Review and Meta-analysis. OBJECTIVE The purpose of this study was to evaluate whether transcranial motor evoked potential (TcMEP) alarms can predict postoperative neurologic complications in patients undergoing cervical spine decompression surgery. METHODS A meta-analysis of the literature was performed using PubMed, Web of Science, and Embase to retrieve published reports on intraoperative TcMEP monitoring for patients undergoing cervical spine decompression surgery. The sensitivity, specificity, and diagnostic odds ratio (DOR), of overall, reversible, and irreversible TcMEP changes for predicting postoperative neurological deficit were calculated. A subgroup analysis was performed to compare anterior vs posterior approaches. RESULTS Nineteen studies consisting of 4608 patients were analyzed. The overall incidence of postoperative neurological deficits was 2.58% (119/4608). Overall TcMEP changes had a sensitivity of 56%, specificity of 94%, and DOR of 19.26 for predicting deficit. Reversible and irreversible changes had sensitivities of 16% and 49%, specificities of 95% and 98%, and DORs of 3.54 and 71.74, respectively. In anterior procedures, TcMEP changes had a DOR of 17.57, sensitivity of 49%, and specificity of 94%. In posterior procedures, TcMEP changes had a DOR of 21.01, sensitivity of 55%, and specificity of 94%. CONCLUSION TcMEP monitoring has high specificity but low sensitivity for predicting postoperative neurological deficit in cervical spine decompression surgery. Patients with new postoperative neurological deficits were 19 times more likely to have experienced intraoperative TcMEP changes than those without new deficits, with irreversible TcMEP changes indicating a much higher risk of deficit than reversible TcMEP changes.
Collapse
Affiliation(s)
- Rajiv P Reddy
- Pittsburgh Orthopaedic Spine Research, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Anya Singh-Varma
- Pittsburgh Orthopaedic Spine Research, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Robert Chang
- Pittsburgh Orthopaedic Spine Research, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Abhinav Vedire
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Katherine M Anetakis
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jeffrey R Balzer
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Donald J Crammond
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Varun Shandal
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Joon Y Lee
- Pittsburgh Orthopaedic Spine Research, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jeremy D Shaw
- Pittsburgh Orthopaedic Spine Research, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Parthasarathy D Thirumala
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| |
Collapse
|
7
|
Reddy RP, Gorijala VK, Kaithi VR, Shandal V, Anetakis KM, Balzer JR, Crammond DJ, Shaw JD, Lee JY, Thirumala PD. Utility of transcranial motor-evoked potential changes in predicting postoperative deficit in lumbar decompression and fusion surgery: a systematic review and meta-analysis. Eur Spine J 2023; 32:3321-3332. [PMID: 37626247 DOI: 10.1007/s00586-023-07879-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 07/14/2023] [Accepted: 07/29/2023] [Indexed: 08/27/2023]
Abstract
PURPOSE The primary aim of this study was to evaluate whether TcMEP alarms can predict the occurrence of postoperative neurological deficit in patients undergoing lumbar spine surgery. The secondary aim was to determine whether the various types of TcMEP alarms including transient and persistent changes portend varying degrees of injury risk. METHODS This was a systematic review and meta-analysis of the literature from PubMed, Web of Science, and Embase regarding outcomes of transcranial motor-evoked potential (TcMEP) monitoring during lumbar decompression and fusion surgery. The sensitivity, specificity, and diagnostic odds ratio (DOR) of TcMEP alarms for predicting postoperative deficit were calculated and presented with forest plots and a summary receiver operating characteristic curve. RESULTS Eight studies were included, consisting of 4923 patients. The incidence of postoperative neurological deficit was 0.73% (36/4923). The incidence of deficits in patients with significant TcMEP changes was 11.79% (27/229), while the incidence in those without changes was 0.19% (9/4694). All TcMEP alarms had a pooled sensitivity and specificity of 63 and 95% with a DOR of 34.92 (95% CI 7.95-153.42). Transient and persistent changes had sensitivities of 29% and 47%, specificities of 96% and 98%, and DORs of 8.04 and 66.06, respectively. CONCLUSION TcMEP monitoring has high specificity but low sensitivity for predicting postoperative neurological deficit in lumbar decompression and fusion surgery. Patients who awoke with new postoperative deficits were 35 times more likely to have experienced TcMEP changes intraoperatively, with persistent changes indicating higher risk of deficit than transient changes. LEVEL OF EVIDENCE II Diagnostic Systematic Review.
Collapse
Affiliation(s)
- Rajiv P Reddy
- Pittsburgh Orthopaedic Spine Research, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | - Vamsi K Gorijala
- Pittsburgh Orthopaedic Spine Research, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Varun R Kaithi
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Varun Shandal
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Katherine M Anetakis
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jeffrey R Balzer
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Donald J Crammond
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jeremy D Shaw
- Pittsburgh Orthopaedic Spine Research, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Joon Y Lee
- Pittsburgh Orthopaedic Spine Research, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Parthasarathy D Thirumala
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| |
Collapse
|
8
|
Adams GM, Crammond DJ, Shandal V, Gardner PA, Snyderman CH, Anetakis KM, Balzer JR, Thirumala PD. Minimally invasive extraocular cranial nerve electromyography. J Neurosurg 2023; 139:864-872. [PMID: 36840739 DOI: 10.3171/2023.1.jns221690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 01/12/2023] [Indexed: 02/26/2023]
Abstract
OBJECTIVE A reluctance to monitor extraocular cranial nerve (EOCN) function has restricted skull base surgery worldwide. Spontaneous and triggered electromyography (EMG) monitoring can be recorded intraoperatively to identify and assess potential cranial nerve injury. Determining the conductive function of EOCNs requires the collection of clear, reliable, and repeatable compound muscle action potentials (CMAPs) secondary to stimulation. EOCN EMG needle electrodes can, although infrequently, cause ocular morbidity including hematoma, edema, and scleral laceration. The aim of this study was to ascertain if minimally invasive 7-mm superficial needle electrodes would record CMAPs as well as standard 13-mm intraorbital electrodes. METHODS Conventionally, the authors have monitored EOCN function with intraorbital placement of paired 13-mm needle electrodes into three extraocular muscles: medial rectus, superior oblique, and lateral rectus. A prospective case-control study was performed using shorter (7-mm) needle electrodes. A single minimally invasive electrode was placed superficially near each extraocular muscle and coupled with a common reference. CMAPs were recorded from the minimally invasive electrodes and compared with CMAPs recorded from the paired intraorbital electrodes. The presence or absence of CMAPs was analyzed and compared among EMG recording techniques. RESULTS A total of 429 CMAPs were analyzed from 71 EOCNs in 25 patients. The experimental setup yielded 167 true-positive (39%), 106 false-positive (25%), 17 false-negative (4%), and 139 true-negative (32%) responses. These values were used to calculate the sensitivity (91%), specificity (57%), positive predictive value (61%), and negative predictive value (89%). EOCN electrodes were placed in 82 total eyes in 58 patients (CMAPs were obtained in 25 patients). Twenty-six eyes showed some degree of edema, bruising, or bleeding, which was transient and self-resolving. Three eyes in different patients had complications from needle placement or extraction including conjunctival hemorrhage, periorbital ecchymosis, and corneal abrasion, ptosis, and upper eyelid edema. CONCLUSIONS Because of artifact contamination, 106 false-positive responses (25%), and 17 false-negative responses (4%), the minimally invasive EMG technique cannot reliably record CMAP responses intraoperatively as well as the intraorbital technique. Less-invasive techniques can lead to an inaccurate EOCN assessment and potential postoperative morbidity. EOCN palsies can be debilitating and lifelong; therefore, the benefits of preserving EOCN function outweigh the potential risks of morbidity from electrode placement. EMG monitoring with intraorbital electrodes remains the most reliable method of intraoperative EOCN assessment.
Collapse
Affiliation(s)
| | | | | | | | | | - Katherine M Anetakis
- Departments of1Neurological Surgery
- 3Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Parthasarathy D Thirumala
- Departments of1Neurological Surgery
- 3Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| |
Collapse
|
9
|
Fleseriu CM, Sultan I, Brown JA, Mina A, Frenchman J, Crammond DJ, Balzer J, Anetakis KM, Subramaniam K, Shandal V, Navid F, Thirumala PD. Role of Intraoperative Neurophysiological Monitoring in Preventing Stroke After Cardiac Surgery. Ann Thorac Surg 2023; 116:623-629. [PMID: 36634835 DOI: 10.1016/j.athoracsur.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 12/09/2022] [Accepted: 01/03/2023] [Indexed: 01/11/2023]
Abstract
BACKGROUND Perioperative stroke after cardiac surgical procedures carries significant morbidity. Dual intraoperative neurophysiological monitoring with electroencephalography (EEG) and somatosensory-evoked potentials detects cerebral hypoperfusion and predicts postoperative stroke in noncardiac procedures. We further evaluated preoperative risk factors and intraoperative neuromonitoring ability to predict postoperative stroke after cardiac operations. METHODS All patients who underwent cardiac operations with intraoperative neurophysiological monitoring from 2009 to 2020 at a single academic medical center were retrospectively analyzed. Patients with circulatory arrest were excluded. Risks factors analyzed were sex, age, tobacco use, hypertension, diabetes mellitus, dyslipidemia, atrial fibrillation, prior cerebrovascular accident, cerebrovascular disease, antiplatelet/anticoagulant use, abnormal somatosensory-evoked potentials and EEG baselines, and significant somatosensory-evoked potentials and EEG change as well as their permanence. Patients were divided into 2 groups by 30-day postoperative stroke occurrence. Univariate and multivariate logistical regressions were used for postoperative stroke significant predictors, and Kaplan-Meier curves estimated survival. RESULTS The study included 620 patients (67.6% men), mean age 65.1 ± 14.1 years, with stroke in 5.32%. In univariate analysis, diabetes (odds ratio [OR], 2.62) and permanence of EEG change (OR, 5.35) were each associated with increased postoperative stroke odds. In multivariate analysis, diabetes (OR, 2.64) and permanent EEG change (OR, 4.22) were independently significantly associated with postoperative stroke. Overall survival was significantly better for patients with no intraoperative neurophysiological monitoring changes (P < .005). CONCLUSIONS Permanent EEG change and diabetes were significant postoperative stroke predictors in cardiac operations. Furthermore, overall survival out to 10 years postoperatively was significantly higher in the group without intraoperative neurophysiological monitoring changes, emphasizing its important predictive role.
Collapse
Affiliation(s)
- Cara M Fleseriu
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ibrahim Sultan
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - James A Brown
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Amir Mina
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jacob Frenchman
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Donald J Crammond
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jeffrey Balzer
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Katherine M Anetakis
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kathirvel Subramaniam
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Varun Shandal
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Forozan Navid
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Parthasarathy D Thirumala
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
| |
Collapse
|
10
|
Bata A, Al Qudah A, Algarni S, Al Ta'ani O, Balzer JR, Crammond DJ, Shandal V, Gross BA, Lang MJ, Anetakis KM, Narayanan S, Mina A, Thirumala PD. Diagnostic Accuracy of Somatosensory Evoked Potentials and EEG during Endovascular Treatment of Unruptured Cerebral Aneurysms. World Neurosurg 2023:S1878-8750(23)00863-X. [PMID: 37380051 DOI: 10.1016/j.wneu.2023.06.087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 06/18/2023] [Accepted: 06/19/2023] [Indexed: 06/30/2023]
Abstract
OBJECTIVE Endovascular treatment (EVT) of unruptured cerebral aneurysms (UCA) offers a safer alternative to clipping. However, it is still associated with an increased risk for Post Procedural Neurological Deficits (PPND). Prompt recognition using intraoperative neurophysiologic monitoring (IONM) and intervention can reduce the incidence and impact of new post-operative neurological complications. We aim to evaluate the diagnostic accuracy of IONM in predicting PPND after EVT of UCA. METHODS We included 414 patients who underwent EVT for UCA from 2014 to 2019. The sensitivities, specificities, and diagnostic odds ratio of SSEP and EEG monitoring methods were calculated. We also determined their diagnostic accuracy using receiver operating characteristic (ROC) plots. RESULTS The highest sensitivity of 67.7% (95% CI, 34.9-90.1%) was obtained when either modality had a change. Simultaneous changes in both modalities have the highest specificity of 97.8% (95% CI, 95.8-99.0%). The area under the ROC curve was 0.795 (95% CI, 0.655-0.935) for changes in either modality. CONCLUSIONS IONM with SSEP alone or in combination with EEG has high diagnostic accuracy in detecting periprocedural complications and resultant PPND during EVT of UCA. SIGNIFICANCE IONM allows for confident and early intervention when obvious complications may not be evident to the endovascular professional.
Collapse
Affiliation(s)
- Ammar Bata
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Abdullah Al Qudah
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Saleh Algarni
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA; Department of Clinical Neurosciences, College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia
| | - Omar Al Ta'ani
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jeffery R Balzer
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Donald J Crammond
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Varun Shandal
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Bradley A Gross
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael J Lang
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Katherine M Anetakis
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sandra Narayanan
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Amir Mina
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Parthasarathy D Thirumala
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh, Pittsburgh, Pa, USA.
| |
Collapse
|
11
|
Reddy RP, Chang R, Coutinho DV, Meinert JW, Anetakis KM, Crammond DJ, Balzer JR, Shaw JD, Lee JY, Thirumala PD. Triggered Electromyography is a Useful Intraoperative Adjunct to Predict Postoperative Neurological Deficit Following Lumbar Pedicle Screw Instrumentation. Global Spine J 2022; 12:1003-1011. [PMID: 34013769 PMCID: PMC9344508 DOI: 10.1177/21925682211018472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Systematic review and meta-analysis. OBJECTIVES Malposition of pedicle screws during instrumentation in the lumbar spine is associated with complications secondary to spinal cord or nerve root injury. Intraoperative triggered electromyographic monitoring (t-EMG) may be used during instrumentation for early detection of malposition. The association between lumbar pedicle screws stimulated at low EMG thresholds and postoperative neurological deficits, however, remains unknown. The purpose of this study is to assess whether a low threshold t-EMG response to lumbar pedicle screw stimulation can serve as a predictive tool for postoperative neurological deficit. METHODS The present study is a meta-analysis of the literature from PubMed, Web of Science, and Embase identifying prospective/retrospective studies with outcomes of patients who underwent lumbar spinal fusion with t-EMG testing. RESULTS The total study cohort consisted of 2,236 patients and the total postoperative neurological deficit rate was 3.04%. 10.78% of the patients incurred at least 1 pedicle screw that was stimulated below the respective EMG alarm threshold intraoperatively. The incidence of postoperative neurological deficits in patients with a lumbar pedicle screw stimulated below EMG alarm threshold during placement was 13.28%, while only 1.80% in the patients without. The pooled DOR was 10.14. Sensitivity was 49% while specificity was 88%. CONCLUSIONS Electrically activated lumbar pedicle screws resulting in low t-EMG alarm thresholds are highly specific but weakly sensitive for new postoperative neurological deficits. Patients with new postoperative neurological deficits after lumbar spine surgery were 10 times more likely to have had a lumbar pedicle screw stimulated at a low EMG threshold.
Collapse
Affiliation(s)
- Rajiv P. Reddy
- Department of Orthopaedic Surgery, University of Pittsburgh Medical
Center, Pittsburgh, PA, USA
| | - Robert Chang
- Department of Neurological Surgery, University of Pittsburgh Medical
Center, Pittsburgh, PA, USA
| | - Dominic V. Coutinho
- Department of Neurological Surgery, University of Pittsburgh Medical
Center, Pittsburgh, PA, USA
| | - Justin W. Meinert
- Department of Neurological Surgery, University of Pittsburgh Medical
Center, Pittsburgh, PA, USA
| | - Katherine M. Anetakis
- Department of Neurological Surgery, University of Pittsburgh Medical
Center, Pittsburgh, PA, USA,Department of Neurology, University of Pittsburgh Medical
Center, Pittsburgh, PA, USA
| | - Donald J. Crammond
- Department of Neurological Surgery, University of Pittsburgh Medical
Center, Pittsburgh, PA, USA,Department of Neurology, University of Pittsburgh Medical
Center, Pittsburgh, PA, USA
| | - Jeffrey R. Balzer
- Department of Neurological Surgery, University of Pittsburgh Medical
Center, Pittsburgh, PA, USA,Department of Neurology, University of Pittsburgh Medical
Center, Pittsburgh, PA, USA
| | - Jeremy D. Shaw
- Department of Orthopaedic Surgery, University of Pittsburgh Medical
Center, Pittsburgh, PA, USA
| | - Joon Y. Lee
- Department of Orthopaedic Surgery, University of Pittsburgh Medical
Center, Pittsburgh, PA, USA
| | - Parthasarathy D. Thirumala
- Department of Neurological Surgery, University of Pittsburgh Medical
Center, Pittsburgh, PA, USA,Department of Neurology, University of Pittsburgh Medical
Center, Pittsburgh, PA, USA,Parthasarathy D. Thirumala, Department of
Neurologic Surgery, Center for Clinical Neurophysiology, University of
Pittsburgh Medical Center, UPMC Presbyterian-Suite-B-400, 200 Lothrop St,
Pittsburgh, PA 15213, USA.
| |
Collapse
|
12
|
Paras S, Mina A, Crammond DJ, Visweswaran S, Anetakis KM, Balzer JR, Shandal V, Thirumala PD. Cardiovascular-related mortality after intraoperative neurophysiologic monitoring changes during carotid endarterectomy. Clin Neurophysiol 2022; 139:43-48. [DOI: 10.1016/j.clinph.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 04/10/2022] [Accepted: 04/11/2022] [Indexed: 11/03/2022]
|
13
|
Thirumala PD, Altibi AM, Chang R, Saca EE, Iyengar P, Reddy R, Anetakis K, Crammond DJ, Balzer JR, Sekula RF. The Utility of Intraoperative Lateral Spread Recording in Microvascular Decompression for Hemifacial Spasm: A Systematic Review and Meta-Analysis. Neurosurgery 2021. [DOI: 10.1093/neuros/nyaa069_s023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
14
|
Dastolfo-Hromack C, Bush A, Chrabaszcz A, Alhourani A, Lipski W, Wang D, Crammond DJ, Shaiman S, Dickey MW, Holt LL, Turner RS, Fiez JA, Richardson RM. Articulatory Gain Predicts Motor Cortex and Subthalamic Nucleus Activity During Speech. Cereb Cortex 2021; 32:1337-1349. [PMID: 34470045 DOI: 10.1093/cercor/bhab251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 06/14/2021] [Accepted: 06/18/2021] [Indexed: 11/12/2022] Open
Abstract
Speaking precisely is important for effective verbal communication, and articulatory gain is one component of speech motor control that contributes to achieving this goal. Given that the basal ganglia have been proposed to regulate the speed and size of limb movement, that is, movement gain, we explored the basal ganglia contribution to articulatory gain, through local field potentials (LFP) recorded simultaneously from the subthalamic nucleus (STN), precentral gyrus, and postcentral gyrus. During STN deep brain stimulation implantation for Parkinson's disease, participants read aloud consonant-vowel-consonant syllables. Articulatory gain was indirectly assessed using the F2 Ratio, an acoustic measurement of the second formant frequency of/i/vowels divided by/u/vowels. Mixed effects models demonstrated that the F2 Ratio correlated with alpha and theta activity in the precentral gyrus and STN. No correlations were observed for the postcentral gyrus. Functional connectivity analysis revealed that higher phase locking values for beta activity between the STN and precentral gyrus were correlated with lower F2 Ratios, suggesting that higher beta synchrony impairs articulatory precision. Effects were not related to disease severity. These data suggest that articulatory gain is encoded within the basal ganglia-cortical loop.
Collapse
Affiliation(s)
- C Dastolfo-Hromack
- Department of Communication Science and Disorders, University of Pittsburgh School of Health and Rehabilitation Sciences, Pittsburgh, PA 15260, USA
| | - A Bush
- Department of Neurological Surgery, Massachusetts General Hospital, MA 02114, USA.,Harvard Medical School, Boston, MA 02115, USA
| | - A Chrabaszcz
- Department of Psychology, University of Pittsburgh, Pittsburgh, PA 15260, USA
| | - A Alhourani
- Department of Neurosurgery, University of Louisville, Louisville, KY 40292, USA
| | - W Lipski
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - D Wang
- School of Medicine, Tsinghua University, Beijing 100084, China
| | - D J Crammond
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - S Shaiman
- Department of Communication Science and Disorders, University of Pittsburgh School of Health and Rehabilitation Sciences, Pittsburgh, PA 15260, USA
| | - M W Dickey
- Department of Communication Science and Disorders, University of Pittsburgh School of Health and Rehabilitation Sciences, Pittsburgh, PA 15260, USA
| | - L L Holt
- Department of Psychology, Carnegie Mellon University, Pittsburgh, PA 15213, USA
| | - R S Turner
- Department of Neurobiology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - J A Fiez
- Department of Psychology, University of Pittsburgh, Pittsburgh, PA 15260, USA
| | - R M Richardson
- Department of Neurological Surgery, Massachusetts General Hospital, MA 02114, USA.,Harvard Medical School, Boston, MA 02115, USA
| |
Collapse
|
15
|
Alhourani A, Korzeniewska A, Wozny TA, Lipski WJ, Kondylis ED, Ghuman AS, Crone NE, Crammond DJ, Turner RS, Richardson RM. Subthalamic Nucleus Activity Influences Sensory and Motor Cortex during Force Transduction. Cereb Cortex 2021; 30:2615-2626. [PMID: 31989165 DOI: 10.1093/cercor/bhz264] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 08/23/2019] [Accepted: 09/17/2019] [Indexed: 12/12/2022] Open
Abstract
The subthalamic nucleus (STN) is proposed to participate in pausing, or alternately, in dynamic scaling of behavioral responses, roles that have conflicting implications for understanding STN function in the context of deep brain stimulation (DBS) therapy. To examine the nature of event-related STN activity and subthalamic-cortical dynamics, we performed primary motor and somatosensory electrocorticography while subjects (n = 10) performed a grip force task during DBS implantation surgery. Phase-locking analyses demonstrated periods of STN-cortical coherence that bracketed force transduction, in both beta and gamma ranges. Event-related causality measures demonstrated that both STN beta and gamma activity predicted motor cortical beta and gamma activity not only during force generation but also prior to movement onset. These findings are consistent with the idea that the STN participates in motor planning, in addition to the modulation of ongoing movement. We also demonstrated bidirectional information flow between the STN and somatosensory cortex in both beta and gamma range frequencies, suggesting robust STN participation in somatosensory integration. In fact, interactions in beta activity between the STN and somatosensory cortex, and not between STN and motor cortex, predicted PD symptom severity. Thus, the STN contributes to multiple aspects of sensorimotor behavior dynamically across time.
Collapse
Affiliation(s)
- Ahmad Alhourani
- Department of Neurological Surgery, University of Louisville, Louisville, KY 40292, USA
| | - Anna Korzeniewska
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Thomas A Wozny
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Witold J Lipski
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Efstathios D Kondylis
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Avniel S Ghuman
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA.,Brain Institute, University of Pittsburgh, Pittsburgh, PA 15260, USA
| | - Nathan E Crone
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Donald J Crammond
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Robert S Turner
- Brain Institute, University of Pittsburgh, Pittsburgh, PA 15260, USA.,Department of Neurobiology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - R Mark Richardson
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA 02114, USA.,Harvard Medical School, Boston, MA 02115, USA
| |
Collapse
|
16
|
Sultan I, Brown JA, Serna-Gallegos D, Thirumala PD, Balzer JR, Paras S, Fleseriu C, Crammond DJ, Anetakis KM, Kilic A, Navid F, Gleason TG. Intraoperative neurophysiologic monitoring during aortic arch surgery. J Thorac Cardiovasc Surg 2021; 165:1971-1981.e2. [PMID: 34384591 DOI: 10.1016/j.jtcvs.2021.07.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 06/16/2021] [Accepted: 07/09/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To evaluate the ability of intraoperative neurophysiologic monitoring (IONM) during aortic arch reconstruction with hypothermic circulatory arrest (HCA) to predict early (<48 hours) adverse neurologic events (ANE; stroke or transient ischemic attack) and operative mortality. METHODS This was an observational study of aortic arch surgeries requiring HCA from 2010 to 2018. Patients were monitored with electroencephalogram (EEG) and somatosensory evoked potentials (SSEP). Baseline characteristics and postoperative outcomes were compared according to presence or absence of IONM changes, which were defined as any acute variation in SSEP or EEG, compared with baseline. Multivariable logistic regression analysis was used to assess the association of IONM changes with operative mortality and early ANE. RESULTS A total of 563 patients underwent aortic arch reconstruction with HCA and IONM. Of these, 119 (21.1%) patients had an IONM change, whereas 444 (78.9%) did not. Patients with IONM changes had increased operative mortality (22.7% vs 4.3%) and increased early ANE (10.9% vs 2.9%). In multivariable analysis, SSEP changes were correlated with early ANE (odds ratio [OR], 4.68; 95% confidence interval [CI], 1.51-14.56; P = .008), whereas EEG changes were not (P = .532). Permanent SSEP changes were correlated with early ANE (OR, 4.56; 95% CI, 1.51-13.77; P = .007), whereas temperature-related SSEP changes were not (P = .997). Finally, any IONM change (either SSEP or EEG) was correlated with operative mortality (OR, 5.82; 95% CI, 2.72-12.49; P < .001). CONCLUSIONS Abnormal IONM events during aortic arch reconstruction with HCA portend worse neurologic outcomes and operative mortality and have a negative predictive value of 97.1%. SSEP might be more sensitive than EEG for predicting early ANE, especially when SSEP changes are permanent.
Collapse
Affiliation(s)
- Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
| | - James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | | | - Jeffrey R Balzer
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Stephanie Paras
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Cara Fleseriu
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Donald J Crammond
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pa
| | | | - Arman Kilic
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Forozan Navid
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Thomas G Gleason
- Division of Cardiac Surgery, Department of Surgery, University of Maryland, College Park, Md
| |
Collapse
|
17
|
Faraji AH, Kokkinos V, Sweat JC, Crammond DJ, Richardson RM. Robotic-Assisted Stereotaxy for Deep Brain Stimulation Lead Implantation in Awake Patients. Oper Neurosurg (Hagerstown) 2021; 19:444-452. [PMID: 32147722 DOI: 10.1093/ons/opaa029] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 12/15/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Robotic-assisted stereotaxy has been increasingly adopted for lead implantation in stereoelectroencephalography based on its efficiency, accuracy, and precision. Despite initially being developed for use in deep brain stimulation (DBS) surgery, adoption for this indication has not been widespread. OBJECTIVE To describe a recent robotic-assisted stereotaxy experience and workflow for DBS lead implantation in awake patients with and without microelectrode recording (MER), including considerations for intraoperative research using electrocorticography (ECoG). METHODS A retrospective review of 20 consecutive patients who underwent simultaneous bilateral DBS lead implantation using robotic-assisted stereotaxy was performed. Radial error was determined by comparing the preoperative target with the DBS lead position in the targeting plane on postoperative computed tomography. Information regarding any postoperative complications was obtained by chart review. RESULTS A novel method for robot coregistration was developed. We describe a standard workflow that allows for MER and/or ECoG research, and a streamlined workflow for cases in which MER is not required. The overall radial error for lead placement across all 20 patients was 1.14 ± 0.11 mm. A significant difference (P = .006) existed between the radial error of the first 10 patients (1.46 ± 0.19 mm) as compared with the second 10 patients (0.86 ± 0.09 mm). No complications were encountered. CONCLUSION Robotic-assisted stereotaxy has the potential to increase precision and reduce human error, compared to traditional frame-based DBS surgery, without negatively impacting patient safety or the ability to perform awake neurophysiology research.
Collapse
Affiliation(s)
- Amir H Faraji
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Vasileios Kokkinos
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | - James C Sweat
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Donald J Crammond
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - R Mark Richardson
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| |
Collapse
|
18
|
Melachuri SR, Melachuri MK, Mina A, Anetakis K, Crammond DJ, Balzer JR, Shandal V, Thirumala PD. Optimal "Low" Pedicle Screw Stimulation Threshold to Predict New Postoperative Lower-Extremity Neurologic Deficits During Lumbar Spinal Fusions. World Neurosurg 2021; 151:e250-e256. [PMID: 33872842 DOI: 10.1016/j.wneu.2021.04.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 04/06/2021] [Accepted: 04/06/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Previous studies have shown that pedicle screw stimulation thresholds ≤6-8 mA yield a high diagnostic accuracy of detecting misplaced screws. Our objective was to determine the optimal "low" stimulation threshold to predict new postoperative neurologic deficits and identify additional risk factors associated with deficits. METHODS We included patients with complete pedicle screw stimulation testing who underwent posterior lumbar spinal fusion surgeries from 2010-2012. We calculated the diagnostic accuracy of pedicle screw responses of ≤4 mA, ≤6 mA, ≤8 mA, ≤10 mA, ≤12 mA, and ≤20 mA to predict new postoperative lower-extremity (LE) neurologic deficits. We used multivariate modeling to determine the best logistic regression model to predict LE deficits and identify additional risk factors. Statistics software packages used were Python3.8.5, NumPy 1.19.1, Pandas 1.1.1, and SPSS26. RESULTS We studied 1179 patients who underwent 8584 pedicle screw stimulations with somatosensory evoked potential and free-run electromyographic monitoring for posterior lumbar spinal fusion. Twenty-five (2.1%) patients had new LE neurologic deficits. A stimulation threshold of ≤8 mA had a sensitivity/specificity of 32%/90% and a diagnostic odds ratio/area under the curve of 4.34 [95% confidence interval: 1.83, 10.27]/0.61 [0.49, 0.74] in predicting postoperative deficit. Multivariate analysis showed that patients who had pedicle screws with stimulation thresholds ≤8 mA are 3.15 [1.26, 7.83]× more likely to have postoperative LE deficits while patients who have undergone a revision lumbar spinal fusion surgery are 3.64 [1.38, 9.61]× more likely. CONCLUSIONS Our results show that low thresholds are indicative of not only screw proximity to the nerve but also an increased likelihood of postoperative neurologic deficit. Thresholds ≤8 mA prove to be the optimal "low" threshold to help guide a correctly positioned pedicle screw placement and detect postoperative deficits.
Collapse
Affiliation(s)
- Samyuktha R Melachuri
- Departments of Neurological Surgery and Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Manasa K Melachuri
- Departments of Neurological Surgery and Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Amir Mina
- Departments of Neurological Surgery and Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Katherine Anetakis
- Departments of Neurological Surgery and Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Donald J Crammond
- Departments of Neurological Surgery and Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jeffrey R Balzer
- Departments of Neurological Surgery and Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Varun Shandal
- Departments of Neurological Surgery and Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Parthasarathy D Thirumala
- Departments of Neurological Surgery and Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
| |
Collapse
|
19
|
Reddy RP, Chang R, Rosario BP, Sudadi S, Anetakis KM, Balzer JR, Crammond DJ, Shaw JD, Thirumala PD. What is the predictive value of intraoperative somatosensory evoked potential monitoring for postoperative neurological deficit in cervical spine surgery?-a meta-analysis. Spine J 2021; 21:555-570. [PMID: 33460808 DOI: 10.1016/j.spinee.2021.01.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 12/13/2020] [Accepted: 01/04/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Cervical decompression and fusion surgery remains a mainstay of treatment for a variety of cervical pathologies. Potential intraoperative injury to the spinal cord and nerve roots poses nontrivial risk for consequent postoperative neurologic deficits. Although neuromonitoring with intraoperative somatosensory evoked potentials (SSEPs) is often used in cervical spine surgery, its therapeutic value remains controversial. PURPOSE The purpose of the present study was to evaluate whether significant SSEP changes can predict postoperative neurologic complications in cervical spine surgery. A subgroup analysis was performed to compare the predictive power of SSEP changes in both anterior and posterior approaches. STUDY DESIGN The present study was a meta-analysis of the literature from PubMed, Web of Science, and Embase to identify prospective/retrospective studies with outcomes of patients who underwent cervical spine surgeries with intraoperative SSEP monitoring. PATIENT SAMPLE The total cohort consisted of 7,747 patients who underwent cervical spine surgery with intraoperative SSEP monitoring. METHODS Inclusion criteria for study selection were as follows: (1) prospective or retrospective cohort studies, (2) studies conducted in patients undergoing elective cervical spine surgery not due to aneurysm, tumor, or trauma with intraoperative SSEP monitoring, (3) studies that reported postoperative neurologic outcomes, (4) studies conducted with a sample size ≥20 patients, (5) studies with only adult patients ≥18 years of age, (6) studies published in English, (7) studies inclusive of an abstract. OUTCOME MEASURES The sensitivity, specificity, diagnostic odds ratio (DOR), and likelihood ratios of overall SSEP changes, reversible SSEP changes, irreversible SSEP changes, and SSEP loss for predicting postoperative neurological deficit were calculated. RESULTS The total rate of postoperative neurological deficits was 2.50% (194/7,747) and the total rate of SSEP changes was 7.36% (570/7,747). The incidence of postoperative neurological deficit in patients with intraoperative SSEP changes was 16.49% (94/570) while only 1.39% (100/7,177) in patients without. All significant intraoperative SSEP changes had a sensitivity of 46.0% and specificity of 96.7% with a DOR of 27.32. Reversible and irreversible SSEP changes had sensitivities of 17.7% and 37.1% and specificities of 97.5% and 99.5%, respectively. The DORs for reversible and irreversible SSEP changes were 9.01 and 167.90, respectively. SSEP loss had a DOR of 51.39, sensitivity of 17.3% and specificity 99.6%. In anterior procedures, SSEP changes had a DOR of 9.60, sensitivity of 34.2%, and specificity of 94.7%. In posterior procedures, SSEP changes had a DOR of 13.27, sensitivity of 42.6%, and specificity of 94.0%. CONCLUSIONS SSEP monitoring is highly specific but weakly sensitive for postoperative neurological deficit following cervical spine surgery. The analysis found that patients with new postoperative neurological deficits were nearly 27 times more likely to have had significant intraoperative SSEP change. Loss of SSEP signals and irreversible SSEP changes seem to indicate a much higher risk of injury than reversible SSEP changes.
Collapse
Affiliation(s)
- Rajiv P Reddy
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Robert Chang
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Brian P Rosario
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Shreya Sudadi
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Katherine M Anetakis
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jeffrey R Balzer
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Donald J Crammond
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jeremy D Shaw
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Parthasarathy D Thirumala
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| |
Collapse
|
20
|
Senthamarai Siddharthan YP, Bata A, Anetakis K, Crammond DJ, Balzer JR, Snyderman C, Gardner P, Thirumala PD. Role of Intraoperative Neurophysiologic Monitoring in Internal Carotid Artery Injury During Endoscopic Endonasal Skull Base Surgery. World Neurosurg 2020; 148:e43-e57. [PMID: 33301995 DOI: 10.1016/j.wneu.2020.11.154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 11/26/2020] [Accepted: 11/27/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE In the present study, we investigated the role of intraoperative neuromonitoring (IONM) in internal carotid artery (ICA) injury during endoscopic endonasal skull base surgery (EESBS). METHODS The study group included all 13 patients who had experienced an ICA injury during EESBS with IONM from 2004 to 2017. The medical records were reviewed for the perioperative data. The IONM reports were reviewed to evaluate the baseline somatosensory evoked potentials (SSEP), electroencephalography (EEG), and brainstem auditory evoked potentials (BAEP) and their significant changes related to ICA injury and/or the subsequent surgical/endovascular interventions. RESULTS All 13 patients had undergone SSEP and 7 patients had BAEP monitoring during surgery. EEG was added during emergent angiography following the surgery for 5 patients. Two patients showed significant SSEP changes, and one showed significant SSEP and EEG changes, indicating cerebral hypoperfusion. Of these 3 patients, patient 1 had experienced irreversible SSEP loss with postoperative stroke. Patients 2 and 3 had SSEP and/or EEG changes that had recovered to baseline after interventions without postoperative deficits. Despite ICA injury, 10 patients showed no significant SSEP and/or EEG changes, and all 7 patients with BAEP monitoring showed no significant BAEP changes, indicating adequate cerebral and brainstem perfusion, respectively. The injured ICA was sacrificed in 4 patients, of whom 3 showed stable SSEP and 1 had experienced irreversible SSEP loss. IONM correlated with the postoperative neurologic examination findings in all cases, adequately predicting the neurologic outcomes after ICA injury. CONCLUSION SSEP and EEG monitoring can accurately detect cerebral hypoperfusion and provide real-time feedback during surgery. SSEP and EEG changes predicted for neurologic outcomes and guide surgical decisions regarding the preservation or sacrifice of the ICA. Comprehensive multimodality monitoring according to the surgical risks can serve to detect and guide the management of ICA injury in EESBS.
Collapse
Affiliation(s)
| | - Ammar Bata
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Katherine Anetakis
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Donald J Crammond
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jeffrey R Balzer
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Carl Snyderman
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Paul Gardner
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Parthasarathy D Thirumala
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
| |
Collapse
|
21
|
Chang R, Reddy R, Altibi AM, Iyengar P, Anetakis K, Crammond DJ, Balzer JR, Sekula R, Thirumala PD. In Reply: The Utility of Intraoperative Lateral Spread Recording in Microvascular Decompression for Hemifacial Spasm: A Systematic Review and Meta-Analysis. Neurosurgery 2020; 87:E598-E599. [PMID: 32761240 DOI: 10.1093/neuros/nyaa345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Robert Chang
- Department of Neurological Surgery University of Pittsburgh Medical Center Pittsburgh, Pennsylvania
| | - Rajiv Reddy
- Department of Neurological Surgery University of Pittsburgh Medical Center Pittsburgh, Pennsylvania
| | - Ahmed M Altibi
- Department of Neurology University of Pittsburgh Medical Center Pittsburgh, Pennsylvania
| | - Pragnya Iyengar
- Department of Neurological Surgery University of Pittsburgh Medical Center Pittsburgh, Pennsylvania
| | - Katherine Anetakis
- Department of Neurological Surgery University of Pittsburgh Medical Center Pittsburgh, Pennsylvania
| | - Donald J Crammond
- Department of Neurological Surgery University of Pittsburgh Medical Center Pittsburgh, Pennsylvania
| | - Jeffrey R Balzer
- Department of Neurological Surgery University of Pittsburgh Medical Center Pittsburgh, Pennsylvania
- Department of Neuroscience University of Pittsburgh Pittsburgh, Pennsylvania
| | - Raymond Sekula
- Department of Neurological Surgery University of Pittsburgh Medical Center Pittsburgh, Pennsylvania
| | - Parthasarathy D Thirumala
- Department of Neurological Surgery University of Pittsburgh Medical Center Pittsburgh, Pennsylvania
- Department of Neurology University of Pittsburgh Medical Center Pittsburgh, Pennsylvania
| |
Collapse
|
22
|
Anetakis KM, Dolia JN, Desai SM, Balzer JR, Crammond DJ, Thirumala PD, Castellano JF, Gross BA, Jadhav AP. Last Electrically Well: Intraoperative Neurophysiological Monitoring for Identification and Triage of Large Vessel Occlusions. J Stroke Cerebrovasc Dis 2020; 29:105158. [PMID: 32912500 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105158] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 07/12/2020] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Intra-operative stroke (IOS) is associated with poor clinical outcome as detection is often delayed and time of symptom onset or patient's last known well (LKW) is uncertain. Intra-operative neurophysiological monitoring (IONM) is uniquely capable of detecting onset of neurological dysfunction in anesthetized patients, thereby precisely defining time last electrically well (LEW). This novel parameter may aid in the detection of large vessel occlusion (LVO) and prompt treatment with endovascular thrombectomy (EVT). METHODS We performed a retrospective analysis of a prospectively maintained AIS and LVO database from May 2018-August 2019. Inclusion criteria required any surgical procedure under general anesthesia (GA) utilizing EEG (electroencephalography) and/or SSEP (somatosensory evoked potentials) monitoring with development of intraoperative focal persistent changes using predefined alarm criteria and who were considered for EVT. RESULT Five cases were identified. LKW to closure time ranged from 66 to 321 minutes, while LEW to closure time ranged from 43 to 174 min. All LVOs were in the anterior circulation. Angiography was not pursued in two cases due to large established infarct (both patients expired in the hospital). EVT was pursued in two cases with successful recanalization and spontaneous recanalization was noted in one patient (mRS 0-3 at 90 days was achieved in all 3 cases). CONCLUSIONS This study demonstrates that significant IONM changes can accurately identify patients with an acute LVO in the operative setting. Given the challenges of recognizing peri-operative stroke, LEW may be an appropriate surrogate to quickly identify and treat IOS.
Collapse
Affiliation(s)
- Katherine M Anetakis
- The Departments of Neurology and Neurological Surgery, University of Pittsburgh Medical, Center, Pittsburgh, PA USA
| | - Jay N Dolia
- The Departments of Neurology and Neurological Surgery, University of Pittsburgh Medical, Center, Pittsburgh, PA USA
| | - Shashvat M Desai
- The Departments of Neurology and Neurological Surgery, University of Pittsburgh Medical, Center, Pittsburgh, PA USA
| | - Jeffrey R Balzer
- The Departments of Neurology and Neurological Surgery, University of Pittsburgh Medical, Center, Pittsburgh, PA USA
| | - Donald J Crammond
- The Departments of Neurology and Neurological Surgery, University of Pittsburgh Medical, Center, Pittsburgh, PA USA
| | - Parthasarathy D Thirumala
- The Departments of Neurology and Neurological Surgery, University of Pittsburgh Medical, Center, Pittsburgh, PA USA
| | - James F Castellano
- The Departments of Neurology and Neurological Surgery, University of Pittsburgh Medical, Center, Pittsburgh, PA USA
| | - Bradley A Gross
- The Departments of Neurology and Neurological Surgery, University of Pittsburgh Medical, Center, Pittsburgh, PA USA
| | - Ashutosh P Jadhav
- The Departments of Neurology and Neurological Surgery, University of Pittsburgh Medical, Center, Pittsburgh, PA USA.
| |
Collapse
|
23
|
Chang R, Reddy RP, Sudadi S, Balzer J, Crammond DJ, Anetakis K, Thirumala PD. Diagnostic accuracy of various EEG changes during carotid endarterectomy to detect 30-day perioperative stroke: A systematic review. Clin Neurophysiol 2020; 131:1508-1516. [DOI: 10.1016/j.clinph.2020.03.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 03/01/2020] [Accepted: 03/23/2020] [Indexed: 10/24/2022]
|
24
|
Thirumala PD, Altibi AM, Chang R, Saca EE, Iyengar P, Reddy R, Anetakis K, Crammond DJ, Balzer JR, Sekula RF. The Utility of Intraoperative Lateral Spread Recording in Microvascular Decompression for Hemifacial Spasm: A Systematic Review and Meta-Analysis. Neurosurgery 2020; 87:E473-E484. [DOI: 10.1093/neuros/nyaa069] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 01/30/2020] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Microvascular decompression (MVD) is the surgical treatment of choice for hemifacial spasm (HFS). During MVD, monitoring of the abnormal lateral spread response (LSR), an evoked response to facial nerve stimulation, has been traditionally used to monitor adequacy of cranial nerve (CN) VII decompression.
OBJECTIVE
To assess the utility of LSR monitoring in predicting spasm-free status after MVD postoperatively.
METHODS
We searched PubMed, Web of Science, and Embase for relevant publications. We included studies reporting on intraoperative LSR monitoring during MVD for HFS and spasm-free status following the procedure. Sensitivity of LSR, specificity, diagnostic odds ratio, and positive predictive value were calculated.
RESULTS
From 148 studies, 26 studies with 7479 patients were ultimately included in this meta-analysis. The final intraoperative LSR status predicted the clinical outcome of MVD with the following specificities and sensitivities: 89% (0.83- 0.93) and 40% (0.30- 0.51) at discharge, 90% (0.84-0.94) and 41% (0.29-0.53) at 3 mo, 89% (0.83-0.93) and 40% (0.30-0.51) at 1 yr. When LSR persisted after MVD, the probability (95% CI) for HFS persistence was 47.8% (0.33-0.63) at discharge, 40.8% (0.23-0.61) at 3 mo, and 24.4% (0.13-0.41) at 1 yr. However, when LSR resolved, the probability for HFS persistence was 7.3% at discharge, 4.2% at 3 mo, and 4.0% at 1 yr.
CONCLUSION
Intraoperative LSR monitoring has high specificity but modest sensitivity in predicting the spasm-free status following MVD. Persistence of LSR carries high risk for immediate and long-term facial spasm persistence. Therefore, adequacy of decompression should be thoroughly investigated before closing in cases where intraoperative LSR persists.
Collapse
Affiliation(s)
- Parthasarathy D Thirumala
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ahmed M Altibi
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Robert Chang
- Department of Neuroscience, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Eyad E Saca
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Pragnya Iyengar
- Department of Neuroscience, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Rajiv Reddy
- Department of Neuroscience, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Katherine Anetakis
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Donald J Crammond
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jeffrey R Balzer
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Department of Neuroscience, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Raymond F Sekula
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| |
Collapse
|
25
|
Ferreira CJA, Sherer M, Anetakis K, Crammond DJ, Balzer JR, Thirumala PD. Neurophysiological Characteristics of Cranial Nerves V- and VII-Triggered EMG in Endoscopic Endonasal Approach Skull Base Surgery. J Neurol Surg B Skull Base 2020; 82:e342-e348. [PMID: 34306959 DOI: 10.1055/s-0040-1701649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 12/24/2019] [Indexed: 10/24/2022] Open
Abstract
Objective This study proposes to present reference parameters for trigeminal (V) and facial (VII) cranial nerves (CNs)-triggered electromyography (tEMG) during endoscopic endonasal approach (EEA) skull base surgeries to allow more precise and accurate mapping of these CNs. Study Design We retrospectively reviewed EEA procedures performed at the University of Pittsburgh Medical Center between 2009 and 2015. tEMG recorded in response to stimulation of CN V and VII was analyzed. Analysis of tEMG waveforms included latencies and amplitudes. Medical records were reviewed to determine the presence of perioperative neurologic deficits. Results A total of 28 patients were included. tEMG from 34 CNs (22 V and 12 VII) were analyzed. For CN V, the average onset latency was 2.9 ± 1.1 ms and peak-to-peak amplitude was 525 ± 436.94 μV ( n = 22). For CN VII, the average onset latency and peak-to-peak amplitude were 5.1 ± 1.43 ms and 315 ± 352.58 μV for the orbicularis oculi distribution ( n = 09), 5.9 ± 0.67 ms and 517 ± 489.07 μV on orbicularis oris ( n = 08), and 5.3 ± 0.98 ms 303.1 ± 215.3 μV on mentalis ( n = 07), respectively. Conclusion Our data support the notion that onset latency may be a feasible parameter in the differentiation between the CN V and VII during the crosstalk phenomenon in EEA surgeries but the particularities of this type of procedure should be taken into consideration. A prospective analysis with a larger data set is necessary.
Collapse
Affiliation(s)
- Carla J A Ferreira
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Marcus Sherer
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Katherine Anetakis
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Donald J Crammond
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Jeffrey R Balzer
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Parthasarathy D Thirumala
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| |
Collapse
|
26
|
Melachuri SR, Stopera C, Melachuri MK, Anetakis K, Crammond DJ, Castellano JF, Balzer JR, Thirumala PD. The efficacy of somatosensory evoked potentials in evaluating new neurological deficits after spinal thoracic fusion and decompression. J Neurosurg Spine 2020; 33:1-6. [PMID: 32114528 DOI: 10.3171/2019.12.spine191157] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 12/31/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Posterior thoracic fusion (PTF) is used as a surgical treatment for a wide range of pathologies. The monitoring of somatosensory evoked potentials (SSEPs) is used to detect and prevent injury during many neurological surgeries. The authors conducted a study to evaluate the efficacy of SSEPs in predicting perioperative lower-extremity (LE) neurological deficits during spinal thoracic fusion surgery. METHODS The authors included patients who underwent PTF with SSEP monitoring performed throughout the entire surgery from 2010 to 2015 at the University of Pittsburgh Medical Center (UPMC). The sensitivity, specificity, odds ratio, and receiver operating characteristic curve were calculated to evaluate the diagnostic accuracy of SSEP changes in predicting postoperative deficits. Univariate analysis was completed to determine the impact of age exceeding 65 years, sex, obesity, abnormal baseline testing, surgery type, and neurological deficits on the development of intraoperative changes. RESULTS From 2010 to 2015, 771 eligible patients underwent SSEP monitoring during PTF at UPMC. Univariate and linear regression analyses showed that LE SSEP changes significantly predicted LE neurological deficits. Significant changes in LE SSEPs had a sensitivity and specificity of 19% and 96%, respectively, in predicting LE neurological deficits. The diagnostic odds ratio for patients with new LE neurological deficits who had significant changes in LE SSEPs was 5.86 (95% CI 2.74-12.5). However, the results showed that a loss of LE waveforms had a poor predictive value for perioperative LE deficits (diagnostic OR 1.58 [95% CI 0.19-12.83]). CONCLUSIONS Patients with new postoperative LE neurological deficits are 5.9 times more likely to have significant changes in LE SSEPs during PTF. Surgeon awareness of an LE SSEP loss may alter surgical strategy and positively impact rates of postoperative LE neurological deficit status. The relatively poor sensitivity of LE SSEP monitoring may indicate a need for multimodal neurophysiological monitoring, including motor evoked potentials, in thoracic fusion surgery.
Collapse
Affiliation(s)
- Samyuktha R Melachuri
- Departments of1Neurological Surgery and
- 2Neurology, University of Pittsburgh, Pennsylvania
| | - Carolyn Stopera
- Departments of1Neurological Surgery and
- 2Neurology, University of Pittsburgh, Pennsylvania
| | - Manasa K Melachuri
- Departments of1Neurological Surgery and
- 2Neurology, University of Pittsburgh, Pennsylvania
| | - Katherine Anetakis
- Departments of1Neurological Surgery and
- 2Neurology, University of Pittsburgh, Pennsylvania
| | - Donald J Crammond
- Departments of1Neurological Surgery and
- 2Neurology, University of Pittsburgh, Pennsylvania
| | - James F Castellano
- Departments of1Neurological Surgery and
- 2Neurology, University of Pittsburgh, Pennsylvania
| | - Jeffrey R Balzer
- Departments of1Neurological Surgery and
- 2Neurology, University of Pittsburgh, Pennsylvania
| | | |
Collapse
|
27
|
Fadia NB, Bliley JM, DiBernardo GA, Crammond DJ, Schilling BK, Sivak WN, Spiess AM, Washington KM, Waldner M, Liao HT, James IB, Minteer DM, Tompkins-Rhoades C, Cottrill AR, Kim DY, Schweizer R, Bourne DA, Panagis GE, Asher Schusterman M, Egro FM, Campwala IK, Simpson T, Weber DJ, Gause T, Brooker JE, Josyula T, Guevara AA, Repko AJ, Mahoney CM, Marra KG. Long-gap peripheral nerve repair through sustained release of a neurotrophic factor in nonhuman primates. Sci Transl Med 2020; 12:12/527/eaav7753. [DOI: 10.1126/scitranslmed.aav7753] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 08/26/2019] [Accepted: 11/25/2019] [Indexed: 01/09/2023]
Abstract
Severe injuries to peripheral nerves are challenging to repair. Standard-of-care treatment for nerve gaps >2 to 3 centimeters is autografting; however, autografting can result in neuroma formation, loss of sensory function at the donor site, and increased operative time. To address the need for a synthetic nerve conduit to treat large nerve gaps, we investigated a biodegradable poly(caprolactone) (PCL) conduit with embedded double-walled polymeric microspheres encapsulating glial cell line–derived neurotrophic factor (GDNF) capable of providing a sustained release of GDNF for >50 days in a 5-centimeter nerve defect in a rhesus macaque model. The GDNF-eluting conduit (PCL/GDNF) was compared to a median nerve autograft and a PCL conduit containing empty microspheres (PCL/Empty). Functional testing demonstrated similar functional recovery between the PCL/GDNF-treated group (75.64 ± 10.28%) and the autograft-treated group (77.49 ± 19.28%); both groups were statistically improved compared to PCL/Empty-treated group (44.95 ± 26.94%). Nerve conduction velocity 1 year after surgery was increased in the PCL/GDNF-treated macaques (31.41 ± 15.34 meters/second) compared to autograft (25.45 ± 3.96 meters/second) and PCL/Empty (12.60 ± 3.89 meters/second) treatment. Histological analyses included assessment of Schwann cell presence, myelination of axons, nerve fiber density, and g-ratio. PCL/GDNF group exhibited a statistically greater average area occupied by individual Schwann cells at the distal nerve (11.60 ± 33.01 μm2) compared to autograft (4.62 ± 3.99 μm2) and PCL/Empty (4.52 ± 5.16 μm2) treatment groups. This study demonstrates the efficacious bridging of a long peripheral nerve gap in a nonhuman primate model using an acellular, biodegradable nerve conduit.
Collapse
Affiliation(s)
- Neil B. Fadia
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Jacqueline M. Bliley
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | | | - Donald J. Crammond
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | | | - Wesley N. Sivak
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Alexander M. Spiess
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Kia M. Washington
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Matthias Waldner
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Han-Tsung Liao
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Isaac B. James
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Danielle M. Minteer
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | | | - Adam R. Cottrill
- Department of Neuroscience, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Deok-Yeol Kim
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Riccardo Schweizer
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Debra A. Bourne
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - George E. Panagis
- Department of Biology, University of Pittsburgh, Greensburg, PA 15601, USA
| | - M. Asher Schusterman
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Francesco M. Egro
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | | | - Tyler Simpson
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Douglas J. Weber
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA 15213, USA
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA 15219, USA
| | - Trent Gause
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Jack E. Brooker
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Tvisha Josyula
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Astrid A. Guevara
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Alexander J. Repko
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | | | - Kacey G. Marra
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA 15213, USA
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA 15219, USA
| |
Collapse
|
28
|
Feroze RA, McDowell MM, Balzer J, Crammond DJ, Thirumala P, Sekula RF. Estimation of Intraoperative Stimulation Threshold of the Facial Nerve in Patients Undergoing Microvascular Decompression. J Neurol Surg B Skull Base 2019; 80:599-603. [PMID: 31750045 DOI: 10.1055/s-0038-1677538] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 12/09/2018] [Indexed: 10/27/2022] Open
Abstract
Introduction Facial weakness can result from surgical manipulation of the facial nerve. Intraoperative neuromonitoring reduces functional impairment but no clear guidelines exist regarding interpretation of intraoperative electrophysiological results. Most studies describe subjects with facial nerves encumbered by tumors or those with various grades of facial nerve weakness. We sought to obtain the neurophysiological parameters and stimulation threshold following intraoperative facial nerve triggered electromyography (t-EMG) stimulation during microvascular decompression for trigeminal neuralgia to characterize the response of normal facial nerves via t-EMG. Methods Facial nerve t-EMG stimulation was performed in seven patients undergoing microvascular decompression for trigeminal neuralgia. Using constant current stimulation, single stimulation pulses of 0.025 to 0.2 mA intensity were applied to the proximal facial nerve. Compound muscle action potentials, duration to onset, and termination of t-EMG responses were recorded for the orbicularis oculi and mentalis muscles. Patients were evaluated for facial weakness following the surgical procedure. Results Quantifiable t-EMG responses were generated in response to all tested stimulation currents of 0.025, 0.05, 0.1, and 0.2 mA in both muscles, indicating effective nerve conduction. No patients developed facial weakness postoperatively. Conclusions The presence of t-EMG amplitudes in response to 0.025 mA suggests that facial nerve conduction can take place at lower stimulation intensities than previously reported in patients with tumor burden. Proximal facial nerve stimulation that yields responses with thresholds less than 0.05 mA may be a preferred reference baseline for surgical procedures within the cerebellopontine angle to prevent iatrogenic injury.
Collapse
Affiliation(s)
- Rafey A Feroze
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Michael M McDowell
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Jeffrey Balzer
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Donald J Crammond
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Partha Thirumala
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Raymond F Sekula
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| |
Collapse
|
29
|
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] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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.
| |
Collapse
|
30
|
Moshayedi P, Elmer J, Habeych M, Thirumala PD, Crammond DJ, Callaway CW, Balzer JR, Rittenberger JC. Evoked potentials improve multimodal prognostication after cardiac arrest. Resuscitation 2019; 139:92-98. [PMID: 30995538 DOI: 10.1016/j.resuscitation.2019.04.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 03/27/2019] [Accepted: 04/03/2019] [Indexed: 01/06/2023]
Abstract
AIM Predicting recovery in comatose post-cardiac arrest patients requires multiple modalities of prognostic assessment. In isolation, absent N20 cortical responses in somatosensory evoked potentials (SSEPs) are a specific predictor of poor outcome. It is unknown whether SSEP results, when assessed in the context of prior knowledge (demographic and clinical information), change the pretest predicted probability of recovery. METHODS In a single center retrospective study, a cohort of 323 patients admitted to post-cardiac arrest service at a tertiary care center were classified into a group based on SSEP testing. We built adjusted logistic regression models including clinical examination findings on the day SSEPs were recorded to generate a pre-test outcome probability for awakening, withdrawal of life-sustaining therapy (WLST) and survival to discharge. We then added the upper extremity N20 cortical response results to the model to obtain updated outcome probabilities. ROC curve was used to determine the additive effect of using SSEPs to the model. Survival to discharge, awakening, and WLST due to neurological reasons were designated as primary, secondary and tertiary outcomes, respectively. RESULTS Analyses showed that evoked potentials are ordered in sicker patients. Adding SSEP to the model increased the proportion of patients with less than 1% and 5% chance of survival, as well as the proportion of patients with over 95% chance of WLST. AUC for survival increased from 0.85 to 0.93 when SSEP was included (p = 0.006). CONCLUSION Adding the N20 SSEP response results to prior knowledge changed the predicted probability of WLST and survival to discharge in comatose post-arrest patients.
Collapse
Affiliation(s)
- Pouria Moshayedi
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Miguel Habeych
- Center for Clinical Neurophysiology, Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Parthasarathy D Thirumala
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; Center for Clinical Neurophysiology, Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Donald J Crammond
- Center for Clinical Neurophysiology, Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jeffrey R Balzer
- Center for Clinical Neurophysiology, Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jon C Rittenberger
- Department of Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| |
Collapse
|
31
|
Melachuri SR, Kaur J, Melachuri MK, Ninaci D, Crammond DJ, Balzer JR, Thirumala PD. The diagnostic accuracy of somatosensory evoked potentials in evaluating neurological deficits during 1057 lumbar interbody fusions. J Clin Neurosci 2018; 61:78-83. [PMID: 30528129 DOI: 10.1016/j.jocn.2018.10.140] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 10/27/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Lumbar interbody spinal fusion (LIF) surgeries are performed to treat or prevent back pain in patients with degenerated intervertebral discs and a variety of spinal diseases. However, post-operative neurological complications may ensue. Intraoperative monitoring techniques have been used to predict and potentially reduce the risk of complications. METHODS This study examined the diagnostic accuracy of significant changes of somatosensory evoked potentials (SSEPs) to evaluate and predict post-operative neurological deficits after LIF. All patients underwent LIF at UPMC from 2010 to 2012. One thousand fifty-seven patients had pre-operative baseline and continuous intraoperative SSEP monitoring. Statistical analysis was completed using SPSS version 22. No relevant disclosure. RESULTS Patient outcomes were not significantly affected by age over 65, gender, obesity, and abnormal baselines. Lower extremity (LE) significant changes in SSEPs and LE loss of responses resulted in a sensitivity/specificity of 0.03/0.99 and 0.03/0.99; they had an AUC of 0.54/0.73 with a 95% confidence interval (CI) of [0.34, 0.74]/[0.29, 1.00]. CONCLUSIONS Significant SSEP changes during LIF are a very specific but poorly sensitive indicator of perioperative neurological deficits. The odds ratio for LE loss of responses was 29.14 with a 95% CI of 1.79-475.5, so LE SSEP loss of responses can serve as a biomarker of perioperative neurological deficits after LIF.
Collapse
Affiliation(s)
| | - Jaspreet Kaur
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Manasa K Melachuri
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - David Ninaci
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Donald J Crammond
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jeffrey R Balzer
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Parthasarathy D Thirumala
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA.
| |
Collapse
|
32
|
Reddy RP, Brahme IS, Karnati T, Balzer JR, Crammond DJ, Anetakis KM, Thirumala PD. Diagnostic value of somatosensory evoked potential changes during carotid endarterectomy for 30-day perioperative stroke. Clin Neurophysiol 2018; 129:1819-1831. [DOI: 10.1016/j.clinph.2018.05.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 04/25/2018] [Accepted: 05/09/2018] [Indexed: 11/24/2022]
|
33
|
Lee PS, Weiner GM, Corson D, Kappel J, Chang YF, Suski VR, Berman SB, Homayoun H, Van Laar AD, Crammond DJ, Richardson RM. Outcomes of Interventional-MRI Versus Microelectrode Recording-Guided Subthalamic Deep Brain Stimulation. Front Neurol 2018; 9:241. [PMID: 29695996 PMCID: PMC5904198 DOI: 10.3389/fneur.2018.00241] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 03/26/2018] [Indexed: 12/14/2022] Open
Abstract
In deep brain stimulation (DBS) of the subthalamic nucleus (STN) for Parkinson’s disease (PD), there is debate concerning the use of neuroimaging alone to confirm correct anatomic placement of the DBS lead into the STN, versus the use of microelectrode recording (MER) to confirm functional placement. We performed a retrospective study of a contemporaneous cohort of 45 consecutive patients who underwent either interventional-MRI (iMRI) or MER-guided DBS lead implantation. We compared radial lead error, motor and sensory side effect, and clinical benefit programming thresholds, and pre- and post-operative unified PD rating scale scores, and levodopa equivalent dosages. MER-guided surgery was associated with greater radial error compared to the intended target. In general, side effect thresholds during initial programming were slightly lower in the MER group, but clinical benefit thresholds were similar. No significant difference in the reduction of clinical symptoms or medication dosage was observed. In summary, iMRI lead implantation occurred with greater anatomic accuracy, in locations demonstrated to be the appropriate functional region of the STN, based on the observation of similar programming side effect and benefit thresholds obtained with MER. The production of equivalent clinical outcomes suggests that surgeon and patient preference can be used to guide the decision of whether to recommend iMRI or MER-guided DBS lead implantation to appropriate patients with PD.
Collapse
Affiliation(s)
- Philip S Lee
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Gregory M Weiner
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Danielle Corson
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Jessica Kappel
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Yue-Fang Chang
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Valerie R Suski
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Sarah B Berman
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Houman Homayoun
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Amber D Van Laar
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Donald J Crammond
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - R Mark Richardson
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.,University of Pittsburgh Brain Institute, University of Pittsburgh, Pittsburgh, PA, United States
| |
Collapse
|
34
|
Saca EE, Kashkoush AI, Crammond DJ, Balzer JR, Thirumala PD. Abstract TP80: Improving Perioperative Stroke Detection During Intracranial Aneurysm Surgery Using Somatosensory Evoked Potential Waveform Analysis. Stroke 2018. [DOI: 10.1161/str.49.suppl_1.tp80] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Current alarm criteria for evaluating impending perioperative stroke using somatosensory evoked potential (SSEP) intraoperative monitoring is a 50% reduction in amplitude or a 10% increase in latency. In this study, we aim to evaluate the diagnostic accuracy of SSEP changes for predicting perioperative stroke during intracranial aneurysm surgery.
Methods:
We retrospectively reviewed the intraoperative neurophysiological records of 100 patients who underwent intracranial aneurysm clipping at our institution between 2009-2013. Of those 100 patients, 25 patients incurred a new onset perioperative stroke and 75 age- and sex-matched controls did not. Quantitative analysis was done to evaluate SSEP amplitude and latency changes during various surgical events including pre-incision, incision, dural opening, before clipping (both temporary and permanent), after clipping, and during dural closure. Diagnostic accuracy was calculated as the area under the receiver operating characteristic curve (AUC) for maximum SSEP amplitude and latency changes from a baseline set at incision. Statistical analysis was performed using R Statistical Software v3.4.1.
Results:
The mean age (with standard deviation) of our cohort was 55.3 ± 11.2 yrs (24 male, 76 female). Preoperative rupture rate was similar in patients with perioperative stroke (36%) and controls (25%) (p=0.440). SSEP amplitude reduction was significantly greater in patients with perioperative stroke relative to controls after temporary clipping (54.6% vs. 24.3%, p<0.001). AUC for maximum amplitude reduction was calculated to be 0.80 (95% CI, 0.70-.0.90). Notably, latency prolongation was found to be a non-significant discriminator of stroke, with an AUC of 0.60 (95% CI, 0.47-0.73). AUC for 50% SSEP amplitude reduction was calculated to be 0.73 (95% CI, 0.63-0.84) and the AUC for 10% latency prolongation was found to be 0.54 (95% CI, 0.44-0.64).
Conclusion:
SSEP amplitude changes, but not latency changes, are strongly predictive of stroke during intracranial aneurysm surgery. However, the current alarm criteria of 50% reduction in amplitude have limited value in informing the surgeon of impending perioperative stroke due to their predictive nature.
Collapse
Affiliation(s)
- Eyad E Saca
- Dept of Neurology, Univ of Pittsburgh Med Cntr, Pittsburgh, PA
| | - Ahmed I Kashkoush
- Dept of Neurological Surgery, Univ of Pittsburgh Med Cntr, Pittsburgh, PA
| | - Donald J Crammond
- Dept of Neurological Surgery, Univ of Pittsburgh Med Cntr, Pittsburgh, PA
| | - Jeffrey R Balzer
- Dept of Neurological Surgery, Univ of Pittsburgh Med Cntr, Pittsburgh, PA
| | | |
Collapse
|
35
|
Lee PS, Crammond DJ, Richardson RM. Deep Brain Stimulation of the Subthalamic Nucleus and Globus Pallidus for Parkinson's Disease. Prog Neurol Surg 2018; 33:207-221. [PMID: 29332085 DOI: 10.1159/000481105] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The concept of deep brain stimulation (DBS) for Parkinson's disease (PD) was introduced over 20 years ago, but our understanding of the nuances of this procedure continues to improve. The average motor outcomes of internal segment of the globus pallidus (GPi) and subthalamic nucleus (STN) DBS appear to be similar, although GPi DBS may allow greater recovery of verbal fluency and may provide greater relief of depression symptoms and improvement in the quality of life, and STN DBS appears more likely to result in decrease in levodopa equivalent doses. Despite the lack of consensus on whether STN or GPi DBS is most appropriate for a given clinical phenotype, the general expansion of patient selection criteria to include younger and older patients and the advent of real-time imaging-confirmed that DBS electrode placement are making life-changing treatment available to greater numbers of movement disorder patients.
Collapse
|
36
|
Melachuri SR, Kaur J, Melachuri MK, Crammond DJ, Balzer JR, Thirumala PD. The diagnostic accuracy of somatosensory evoked potentials in evaluating neurological deficits during 1036 posterior spinal fusions. Neurol Res 2017; 39:1073-1079. [DOI: 10.1080/01616412.2017.1378413] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Samyuktha R. Melachuri
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jaspreet Kaur
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Manasa K. Melachuri
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Donald J. Crammond
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jeffrey R. Balzer
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Parthasarathy D. Thirumala
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
- Center for Clinical Neurophysiology, Department of Neurological Surgery, UPMC Presbyterian, Pittsburgh, PA, USA
| |
Collapse
|
37
|
Kashkoush AI, Jankowitz BT, Gardner P, Friedlander RM, Chang YF, Crammond DJ, Balzer JR, Thirumala PD. Somatosensory Evoked Potentials During Temporary Arterial Occlusion for Intracranial Aneurysm Surgery: Predictive Value for Perioperative Stroke. World Neurosurg 2017; 104:442-451. [DOI: 10.1016/j.wneu.2017.05.036] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 05/04/2017] [Accepted: 05/06/2017] [Indexed: 11/17/2022]
|
38
|
Ares WJ, Grandhi RM, Panczykowski DM, Weiner GM, Thirumala P, Habeych ME, Crammond DJ, Horowitz MB, Jankowitz BT, Jadhav A, Jovin TG, Ducruet AF, Balzer J. Diagnostic Accuracy of Somatosensory Evoked Potential Monitoring in Evaluating Neurological Complications During Endovascular Aneurysm Treatment. Oper Neurosurg (Hagerstown) 2017. [DOI: 10.1093/ons/opx104] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Somatosensory evoked potential (SSEP) monitoring is used extensively for early detection and prevention of neurological complications in patients undergoing many different neurosurgical procedures. However, the predictive ability of SSEP monitoring during endovascular treatment of cerebral aneurysms is not well detailed.
OBJECTIVE
To evaluate the performance of intraoperative SSEP in the prediction postprocedural neurological deficits (PPNDs) after coil embolization of intracranial aneurysms.
METHODS
This population-based cohort study included patients ≥18 years of age undergoing intracranial aneurysm embolization with concurrent SSEP monitoring between January 2006 and August 2012. The ability of SSEP to predict PPNDs was analyzed by multiple regression analyses and assessed by the area under the receiver operating characteristic curve.
RESULTS
In a population of 888 patients, SSEP changes occurred in 8.6% (n = 77). Twenty-eight patients (3.1%) suffered PPNDs. A 50% to 99% loss in SSEP waveform was associated with a 20-fold increase in risk of PPND; a total loss of SSEP waveform, regardless of permanence, was associated with a greater than 200-fold risk of PPND. SSEPs displayed very good predictive ability for PPND, with an area under the receiver operating characteristic curve of 0.84 (95% CI 0.76-0.92).
CONCLUSION
This study supports the predictive ability of SSEPs for the detection of PPNDs. The magnitude and persistence of SSEP changes is clearly associated with the development of PPNDs. The utility of SSEP monitoring in detecting ischemia may provide an opportunity for neurointerventionalists to respond to changes intraoperatively to mitigate the potential for PPNDs.
Collapse
Affiliation(s)
- William J Ares
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ramesh M Grandhi
- Department of Neurological Surgery, University of Texas Health Center at San Antonio, San Antonio, Texas
| | - David M Panczykowski
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Gregory M Weiner
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Parthasarathy Thirumala
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Center for Clinical Neurophysiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Miguel E Habeych
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Center for Clinical Neurophysiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Donald J Crammond
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Center for Clinical Neurophysiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Brian T Jankowitz
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ashutosh Jadhav
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Tudor G Jovin
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Andrew F Ducruet
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jeffrey Balzer
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Center for Clinical Neurophysiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| |
Collapse
|
39
|
Lipski WJ, Wozny TA, Alhourani A, Kondylis ED, Turner RS, Crammond DJ, Richardson RM. Dynamics of human subthalamic neuron phase-locking to motor and sensory cortical oscillations during movement. J Neurophysiol 2017; 118:1472-1487. [PMID: 28592690 DOI: 10.1152/jn.00964.2016] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 05/01/2017] [Accepted: 06/01/2017] [Indexed: 01/19/2023] Open
Abstract
Coupled oscillatory activity recorded between sensorimotor regions of the basal ganglia-thalamocortical loop is thought to reflect information transfer relevant to movement. A neuronal firing-rate model of basal ganglia-thalamocortical circuitry, however, has dominated thinking about basal ganglia function for the past three decades, without knowledge of the relationship between basal ganglia single neuron firing and cortical population activity during movement itself. We recorded activity from 34 subthalamic nucleus (STN) neurons, simultaneously with cortical local field potentials and motor output, in 11 subjects with Parkinson's disease (PD) undergoing awake deep brain stimulator lead placement. STN firing demonstrated phase synchronization to both low- and high-beta-frequency cortical oscillations, and to the amplitude envelope of gamma oscillations, in motor cortex. We found that during movement, the magnitude of this synchronization was dynamically modulated in a phase-frequency-specific manner. Importantly, we found that phase synchronization was not correlated with changes in neuronal firing rate. Furthermore, we found that these relationships were not exclusive to motor cortex, because STN firing also demonstrated phase synchronization to both premotor and sensory cortex. The data indicate that models of basal ganglia function ultimately will need to account for the activity of populations of STN neurons that are bound in distinct functional networks with both motor and sensory cortices and code for movement parameters independent of changes in firing rate.NEW & NOTEWORTHY Current models of basal ganglia-thalamocortical networks do not adequately explain simple motor functions, let alone dysfunction in movement disorders. Our findings provide data that inform models of human basal ganglia function by demonstrating how movement is encoded by networks of subthalamic nucleus (STN) neurons via dynamic phase synchronization with cortex. The data also demonstrate, for the first time in humans, a mechanism through which the premotor and sensory cortices are functionally connected to the STN.
Collapse
Affiliation(s)
- Witold J Lipski
- Brain Modulation Laboratory, Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Center for the Neural Basis of Cognition, University of Pittsburgh, Pittsburgh, Pennsylvania; and
| | - Thomas A Wozny
- Brain Modulation Laboratory, Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Ahmad Alhourani
- Brain Modulation Laboratory, Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Efstathios D Kondylis
- Brain Modulation Laboratory, Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert S Turner
- Department of Neurobiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Center for the Neural Basis of Cognition, University of Pittsburgh, Pittsburgh, Pennsylvania; and.,University of Pittsburgh Brain Institute, Pittsburgh, Pennsylvania
| | - Donald J Crammond
- Brain Modulation Laboratory, Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert Mark Richardson
- Brain Modulation Laboratory, Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; .,Department of Neurobiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Center for the Neural Basis of Cognition, University of Pittsburgh, Pittsburgh, Pennsylvania; and.,University of Pittsburgh Brain Institute, Pittsburgh, Pennsylvania
| |
Collapse
|
40
|
Thirumala PD, Crammond DJ, Loke YK, Cheng HL, Huang J, Balzer JR. Diagnostic accuracy of motor evoked potentials to detect neurological deficit during idiopathic scoliosis correction: a systematic review. J Neurosurg Spine 2017; 26:374-383. [DOI: 10.3171/2015.7.spine15466] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE
The goal of this study was to evaluate the efficacy of intraoperative transcranial motor evoked potential (TcMEP) monitoring in predicting an impending neurological deficit during corrective spinal surgery for patients with idiopathic scoliosis (IS).
METHODS
The authors searched the PubMed and Web of Science database for relevant lists of retrieved reports and/or experiments published from January 1950 through October 2014 for studies on TcMEP monitoring use during IS surgery. The primary analysis of this review fit the operating characteristic into a hierarchical summary receiver operating characteristic curve model to determine the efficacy of intraoperative TcMEP-predicted change.
RESULTS
Twelve studies, with a total of 2102 patients with IS were included. Analysis found an observed incidence of neurological deficits of 1.38% (29/2102) in the sample population. Of the patients who sustained a neurological deficit, 82.8% (24/29) also had irreversible TcMEP change, whereas 17.2% (5/29) did not. The pooled analysis using the bivariate model showed TcMEP change with sensitivity (mean 91% [95% CI 34%–100%]) and specificity (mean 96% [95% CI 92–98%]). The diagnostic odds ratio indicated that it is 250 times more likely to observe significant TcMEP changes in patients who experience a new-onset motor deficit immediately after IS correction surgery (95% CI 11–5767). TcMEP monitoring showed high discriminant ability with an area under the curve of 0.98.
CONCLUSIONS
A patient with a new neurological deficit resulting from IS surgery was 250 times more likely to have changes in TcMEPs than a patient without new deficit. The authors' findings from 2102 operations in patients with IS show that TcMEP monitoring is a highly sensitive and specific test for detecting new spinal cord injuries in patients undergoing corrective spinal surgery for IS. They could not assess the value of TcMEP monitoring as a therapeutic adjunct owing to the limited data available and their study design.
Collapse
Affiliation(s)
- Parthasarathy D. Thirumala
- Departments of 1Neurological Surgery and
- 3Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and
| | | | - Yoon K. Loke
- 4Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | | | | | - Jeffrey R. Balzer
- Departments of 1Neurological Surgery and
- 2Neuroscience, University of Pittsburgh
| |
Collapse
|
41
|
Udesh R, Natarajan P, Thiagarajan K, Wechsler LR, Crammond DJ, Balzer JR, Thirumala PD. Transcranial Doppler Monitoring in Carotid Endarterectomy: A Systematic Review and Meta-analysis. J Ultrasound Med 2017; 36:621-630. [PMID: 28127789 DOI: 10.7863/ultra.16.02077] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 06/13/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To evaluate the efficacy of intraoperative transcranial Doppler monitoring in predicting perioperative strokes after carotid endarterectomy (CEA). METHODS An electronic search of PubMed, Embase, and Web of Science databases was conducted for studies on transcranial Doppler monitoring in CEA published from January 1970 through September 2015. All titles and abstracts were independently screened on the basis of predetermined inclusion criteria, which included randomized clinical trials and prospective or retrospective cohort reviews, patients who underwent CEA with intraoperative transcranial Doppler monitoring (either middle cerebral artery velocity [MCAV] or cerebral microembolic signals [MES]) and postoperative neurologic assessments up to 30 days after the surgery, and studies including an abstract, published in English on adult humans 18 years and older with a sample size of 50 or greater. RESULTS A total of 25articles with a sample population of 4705 patients were analyzed. Among the study patients, 189 developed perioperative strokes. Transcranial Doppler monitoring (either MCAV or MES) showed specificity of 72.7% (95% confidence interval [CI], 61.2%-81.8%) and sensitivity of 56.1% (95% CI, 46.8%-65.0%) for predicting perioperative strokes. Intraoperative MCAV changes during CEA showed strong specificity of 84.1% (95% CI, 74.4%-90.6) and sensitivity of 49.7% (95% CI, 40.6%-58.8) for predicting perioperative strokes. CONCLUSIONS Patients with perioperative strokes are 4 times more likely to have had transcranial Doppler changes (either MCAV or MES) during CEA compared to patients without strokes. Simultaneous MCAV and MES monitoring by transcranial Doppler sonography and combined intraoperative monitoring of transcranial Doppler sonography with somatosensory evoked potentials and electroencephalography during CEA to predict perioperative stroke could not be evaluated because of a lack of clinical studies combining these measures.
Collapse
Affiliation(s)
- Reshmi Udesh
- Department of Neurologic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Piruthiviraj Natarajan
- Department of Neurologic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Karthy Thiagarajan
- Department of Neurologic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lawrence R Wechsler
- Department of Neurologic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Donald J Crammond
- Department of Neurologic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jeffrey R Balzer
- Department of Neurologic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Parthasarathy D Thirumala
- Department of Neurologic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
42
|
Thirumala PD, Cheng HL, Loke YK, Kojo Hamilton D, Balzer J, Crammond DJ. Diagnostic accuracy of somatosensory evoked potential monitoring during scoliosis fusion. J Clin Neurosci 2016; 30:8-14. [DOI: 10.1016/j.jocn.2016.01.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 01/04/2016] [Accepted: 01/17/2016] [Indexed: 11/30/2022]
|
43
|
Thirumala PD, Natarajan P, Thiagarajan K, Crammond DJ, Habeych ME, Chaer RA, Avgerinos ED, Friedlander R, Balzer JR. Diagnostic accuracy of somatosensory evoked potential and electroencephalography during carotid endarterectomy. Neurol Res 2016; 38:698-705. [PMID: 27342607 DOI: 10.1080/01616412.2016.1200707] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND PURPOSE Perioperative stroke risk following carotid endarterectomy (CEA) is reported to be approximately 2-3%. The diagnostic accuracies of intraoperative EEG and SSEP monitoring during CEA have been studied separately. However, to date, the effectiveness of simultaneous EEG and SSEP monitoring during CEA has only been evaluated in small study populations. This study examined the diagnostic accuracy of combined EEG and SSEP monitoring in a large (N = 1165) patient population. METHODS This study included 1165 patients who underwent CEA from 2000 to 2012 at the University of Pittsburgh Medical Center. The sensitivities, specificities, and diagnostic odds ratio of EEG and SSEP monitoring methods were examined separately and together. Receiver operating characteristic curves were plotted to assess sensitivity and specificity of single and combined Intraoperative monitoring (IONM) methods. RESULTS Maximum sensitivity was obtained with multimodality monitoring with an IONM change in either EEG or SSEP of 50.00 (95% CI, 30.66-69.34). The specificity of simultaneous EEG and SSEP changes was 93.95 (95% CI, 92.28-95.35%). Maximum area under ROC curve obtained for IONM change in either EEG or SSEP was 0.660 (95% CI, 0.547-0.773, p-value 0.004). CONCLUSION The diagnostic accuracy of multimodality IONM during CEA is higher than an approach using single modality IONM. Simultaneous EEG and SSEP monitoring improves the likelihood of detecting periprocedural strokes after CEA. Neuro protective therapies to prevent periprocedural strokes can be based on changes in SSEP and EEG during CEA.
Collapse
Affiliation(s)
- Parthasarathy D Thirumala
- a Department of Neurological Surgery , Universityof Pittsburgh Medical Center , Pittsburgh , PA , USA.,b Department of Neurology , University of Pittsburgh Medical Center , Pittsburgh , PA , USA
| | - Piruthiviraj Natarajan
- a Department of Neurological Surgery , Universityof Pittsburgh Medical Center , Pittsburgh , PA , USA
| | - Karthy Thiagarajan
- a Department of Neurological Surgery , Universityof Pittsburgh Medical Center , Pittsburgh , PA , USA
| | - Donald J Crammond
- a Department of Neurological Surgery , Universityof Pittsburgh Medical Center , Pittsburgh , PA , USA
| | - Miguel E Habeych
- a Department of Neurological Surgery , Universityof Pittsburgh Medical Center , Pittsburgh , PA , USA
| | - Rabih A Chaer
- c Division of Vascular Surgery , University of Pittsburgh Medical Center , Pittsburgh , PA , USA
| | - Efthymios D Avgerinos
- c Division of Vascular Surgery , University of Pittsburgh Medical Center , Pittsburgh , PA , USA
| | - Robert Friedlander
- a Department of Neurological Surgery , Universityof Pittsburgh Medical Center , Pittsburgh , PA , USA
| | - Jeffrey R Balzer
- a Department of Neurological Surgery , Universityof Pittsburgh Medical Center , Pittsburgh , PA , USA
| |
Collapse
|
44
|
Kondylis ED, Randazzo MJ, Alhourani A, Lipski WJ, Wozny TA, Pandya Y, Ghuman AS, Turner RS, Crammond DJ, Richardson RM. Movement-related dynamics of cortical oscillations in Parkinson's disease and essential tremor. Brain 2016; 139:2211-23. [PMID: 27329771 DOI: 10.1093/brain/aww144] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 05/04/2016] [Indexed: 11/13/2022] Open
Abstract
Recent electrocorticography data have demonstrated excessive coupling of beta-phase to gamma-amplitude in primary motor cortex and that deep brain stimulation facilitates motor improvement by decreasing baseline phase-amplitude coupling. However, both the dynamic modulation of phase-amplitude coupling during movement and the general cortical neurophysiology of other movement disorders, such as essential tremor, are relatively unexplored. To clarify the relationship of these interactions in cortical oscillatory activity to movement and disease state, we recorded local field potentials from hand sensorimotor cortex using subdural electrocorticography during a visually cued, incentivized handgrip task in subjects with Parkinson's disease (n = 11), with essential tremor (n = 9) and without a movement disorder (n = 6). We demonstrate that abnormal coupling of the phase of low frequency oscillations to the amplitude of gamma oscillations is not specific to Parkinson's disease, but also occurs in essential tremor, most prominently for the coupling of alpha to gamma oscillations. Movement kinematics were not significantly different between these groups, allowing us to show for the first time that robust alpha and beta desynchronization is a shared feature of sensorimotor cortical activity in Parkinson's disease and essential tremor, with the greatest high-beta desynchronization occurring in Parkinson's disease and the greatest alpha desynchronization occurring in essential tremor. We also show that the spatial extent of cortical phase-amplitude decoupling during movement is much greater in subjects with Parkinson's disease and essential tremor than in subjects without a movement disorder. These findings suggest that subjects with Parkinson's disease and essential tremor can produce movements that are kinematically similar to those of subjects without a movement disorder by reducing excess sensorimotor cortical phase-amplitude coupling that is characteristic of these diseases.
Collapse
Affiliation(s)
- Efstathios D Kondylis
- 1 Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Michael J Randazzo
- 1 Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Ahmad Alhourani
- 1 Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Witold J Lipski
- 1 Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Thomas A Wozny
- 1 Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Yash Pandya
- 1 Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Avniel S Ghuman
- 1 Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA 2 Department of Neurobiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA 3 Center for the Neural Basis of Cognition, University of Pittsburgh, Pittsburgh, PA, USA 4 University of Pittsburgh Brain Institute, Pittsburgh, PA, USA
| | - Robert S Turner
- 2 Department of Neurobiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA 3 Center for the Neural Basis of Cognition, University of Pittsburgh, Pittsburgh, PA, USA 4 University of Pittsburgh Brain Institute, Pittsburgh, PA, USA
| | - Donald J Crammond
- 1 Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - R M Richardson
- 1 Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA 2 Department of Neurobiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA 3 Center for the Neural Basis of Cognition, University of Pittsburgh, Pittsburgh, PA, USA 4 University of Pittsburgh Brain Institute, Pittsburgh, PA, USA
| |
Collapse
|
45
|
Thirumala PD, Carnovale G, Loke Y, Habeych ME, Crammond DJ, Balzer JR, Sekula RF. Brainstem Auditory Evoked Potentials' Diagnostic Accuracy for Hearing Loss: Systematic Review and Meta-Analysis. J Neurol Surg B Skull Base 2016; 78:43-51. [PMID: 28180042 DOI: 10.1055/s-0036-1584557] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 02/03/2016] [Indexed: 10/21/2022] Open
Abstract
Background Microvascular decompression (MVD) utilizes brainstem auditory evoked potential (BAEP) intraoperative monitoring to reduce the risk of iatrogenic hearing loss. Studies report varying efficacy and hearing loss rates during MVD with intraoperative monitoring. Objectives This study aims to perform a comprehensive review and study of diagnostic accuracy of BAEPs during MVD to predict hearing loss in studies published from January 1984 to December 2013. Methods The PubMed/MEDLINE and World Science databases were searched. Studies performed MVD for trigeminal neuralgia, hemifacial spasm, glossopharyngeal neuralgia or geniculate neuralgia and monitored intraoperative BAEPs to prevent hearing loss. Retrospectively, BAEP parameters were compared with postoperative hearing. The diagnostic accuracy of significant change in BAEPs, which includes loss of response, was tested using summary receiver operative curve and diagnostic odds ratio (DOR). Results A total of 13 studies were included in the analysis with a total of 2,540 cases. Loss of response pooled sensitivity, specificity, and DOR with 95% confidence interval being 74% (60-84%), 98% (88-100%), and 69.3 (18.2-263%), respectively. The similar significant change results were 88% (77-94%), 63% (40-81%), and 9.1 (3.9-21.6%). Conclusion Patients with hearing loss after MVD are more likely to have shown loss of BAEP responses intraoperatively. Loss of responses has high specificity in evaluating hearing loss. Patients undergoing MVD should have BAEP monitoring to prevent hearing loss.
Collapse
Affiliation(s)
- Parthasarathy D Thirumala
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States; Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Gregory Carnovale
- Department of Neuroscience, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Yoon Loke
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Miguel E Habeych
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Donald J Crammond
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Jeffrey R Balzer
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States; Department of Neuroscience, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Raymond F Sekula
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| |
Collapse
|
46
|
Thirumala PD, Udesh R, Muralidharan A, Thiagarajan K, Crammond DJ, Chang YF, Balzer JR. Diagnostic Value of Somatosensory-Evoked Potential Monitoring During Cerebral Aneurysm Clipping: A Systematic Review. World Neurosurg 2016; 89:672-80. [DOI: 10.1016/j.wneu.2015.12.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 12/10/2015] [Accepted: 12/12/2015] [Indexed: 10/22/2022]
|
47
|
Cheng HL, Thirumala PD, Crammond DJ, Habeych ME, Balzer J. Comparison of Subdermal Needle and Surface Adhesive Stimulating Electrodes for Somatosensory Evoked Potential Monitoring during Anterior Cervical Discectomy and Fusion. Neurodiagn J 2016; 56:186-200. [PMID: 28436771 DOI: 10.1080/21646821.2016.1202695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Needle stick injuries remain a physical and psychological burden to healthcare workers. Noninvasive surface adhesive stimulating electrodes used to generate somatosensory evoked potentials can help decrease this risk. METHODS We performed a retrospective observational study of patients who underwent anterior cervical discectomy and fusion (ACDF) surgery to determine the utility and variability of using surface adhesive stimulating electrodes. Our analysis for utility compared alarm (significant changes) frequency, defined by established alarm criteria, between subdermal needle (Group I) and surface adhesive electrodes (Group II). We compared the variability by comparing the frequency of alarms based on establishing baselines during various stages of the procedure. RESULTS Between Group I and Group II, no significant differences were found in demographic, age, number of levels decompressed and fused, and length of surgery variability. However, stimulation intensity was significantly higher in Group II. Significant differences in the mean frequency of alarm of cortical, subcortical, and Erb's somatosensory evoked potential (SSEP) responses for the upper extremities between the two groups were only observed for the upper left Erb's point amplitude (p = 0.03) at retraction and upper right cortical amplitude at incision (p = 0.02). The frequency of alarms of the amplitude of left ulnar cortical responses from SSEPs using surface adhesives when baselines were established at the beginning of the procedure, at the time of incision, and at placement of retractors were 13.83 % (±14.08%), 7.50 % (±7.56%) and 3.42 % (±3.48%), respectively. Comparatively, the frequencies of alarms of the amplitude of left ulnar cortical responses from SSEPs using needle electrodes were 18.07 % (±22.85%), 12.13 % (±17.30%) and 7.37 % (±11.82%), respectively. Similar results were observed from frequency for alarms from the right ulnar SSEPs. CONCLUSION This study found little significant difference between the frequencies of alarm in patients who had SSEP responses obtained using surface adhesive electrodes when compared to needle electrodes. This lack of significant difference was observed even when alarms were established at various stages of the surgery before any major manipulation. For short procedures monitoring the upper extremities only, surface adhesive electrodes may provide a reliable alternative to invasive needle electrodes.
Collapse
Affiliation(s)
- Hannah L Cheng
- a Department of Neurologic Surgery , University of Pittsburgh Medical Center , Pittsburgh , Pennsylvania
| | - Parthasarathy D Thirumala
- a Department of Neurologic Surgery , University of Pittsburgh Medical Center , Pittsburgh , Pennsylvania.,b Department of Neurology , University of Pittsburgh Medical Center , Pittsburgh , Pennsylvania
| | - Donald J Crammond
- a Department of Neurologic Surgery , University of Pittsburgh Medical Center , Pittsburgh , Pennsylvania
| | - Miguel E Habeych
- a Department of Neurologic Surgery , University of Pittsburgh Medical Center , Pittsburgh , Pennsylvania
| | - Jeffrey Balzer
- a Department of Neurologic Surgery , University of Pittsburgh Medical Center , Pittsburgh , Pennsylvania.,c Department of Neuroscience , University of Pittsburgh , Pittsburgh , Pennsylvania
| |
Collapse
|
48
|
Kondylis ED, Randazzo MJ, Alhourani A, Wozny TA, Lipski WJ, Crammond DJ, Richardson RM. High frequency activation data used to validate localization of cortical electrodes during surgery for deep brain stimulation. Data Brief 2015; 6:204-7. [PMID: 26862560 PMCID: PMC4707179 DOI: 10.1016/j.dib.2015.11.057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 11/22/2015] [Indexed: 11/05/2022] Open
Abstract
Movement related synchronization of high frequency activity (HFA, 76–100 Hz) is a somatotopic process with spectral power changes occurring during movement in the sensorimotor cortex (Miller et al., 2007) [1]. These features allowed movement-related changes in HFA to be used to functionally validate the estimations of subdural electrode locations, which may be placed temporarily for research in deep brain stimulation surgery, using the novel tool described in Randazzo et al. (2015) [2]. We recorded electrocorticography (ECoG) signals and localized electrodes in the region of the sensorimotor cortex during an externally cued hand grip task in 8 subjects. Movement related HFA was determined for each trial by comparing HFA spectral power during movement epochs to pre-movement baseline epochs. Significant movement related HFA was found to be focal in time and space, occurring only during movement and only in a subset of electrodes localized to the pre- and post-central gyri near the hand knob. To further demonstrate the use of movement related HFA to aid electrode localization, we provide a sample of the electrode localization tool, with data loaded to allow readers to map movement related HFA onto the cortical surface of a sample patient.
Collapse
Affiliation(s)
- Efstathios D Kondylis
- Brain Modulation Laboratory, Department of Neurological Surgery, University of Pittsburgh School of Medicine, United States
| | - Michael J Randazzo
- Brain Modulation Laboratory, Department of Neurological Surgery, University of Pittsburgh School of Medicine, United States
| | - Ahmad Alhourani
- Brain Modulation Laboratory, Department of Neurological Surgery, University of Pittsburgh School of Medicine, United States
| | - Thomas A Wozny
- Brain Modulation Laboratory, Department of Neurological Surgery, University of Pittsburgh School of Medicine, United States
| | - Witold J Lipski
- Brain Modulation Laboratory, Department of Neurological Surgery, University of Pittsburgh School of Medicine, United States
| | - Donald J Crammond
- Brain Modulation Laboratory, Department of Neurological Surgery, University of Pittsburgh School of Medicine, United States
| | - R Mark Richardson
- Brain Modulation Laboratory, Department of Neurological Surgery, University of Pittsburgh School of Medicine, United States; Department of Neurobiology, University of Pittsburgh School of Medicine, United States; Center for the Neural Basis of Cognition, University of Pittsburgh, United States
| |
Collapse
|
49
|
Randazzo MJ, Kondylis ED, Alhourani A, Wozny TA, Lipski WJ, Crammond DJ, Richardson RM. Three-dimensional localization of cortical electrodes in deep brain stimulation surgery from intraoperative fluoroscopy. Neuroimage 2015; 125:515-521. [PMID: 26520771 DOI: 10.1016/j.neuroimage.2015.10.076] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 10/09/2015] [Accepted: 10/25/2015] [Indexed: 11/28/2022] Open
Abstract
Electrophysiological recordings from subdural electrocorticography (ECoG) electrodes implanted temporarily during deep brain stimulation (DBS) surgeries offer a unique opportunity to record cortical activity for research purposes. The optimal utilization of this important research method relies on accurate and robust localization of ECoG electrodes, and intraoperative fluoroscopy is often the only imaging modality available to visualize electrode locations. However, the localization of a three-dimensional electrode position using a two-dimensional fluoroscopic image is problematic due to the lost dimension orthogonal to the fluoroscopic image, a parallax distortion implicit to fluoroscopy, and variability of visible skull contour among fluoroscopic images. Here, we present a method to project electrodes visible on the fluoroscopic image onto a reconstructed cortical surface by leveraging numerous common landmarks to translate, rotate, and scale coregistered computed tomography (CT) and magnetic resonance imaging (MRI) reconstructed surfaces in order to recreate the coordinate framework in which the fluoroscopic image was acquired, while accounting for parallax distortion. Validation of this approach demonstrated high precision with an average total Euclidian distance between three independent reviewers of 1.65±0.68mm across 8 patients and 82 electrodes. Spatial accuracy was confirmed by correspondence between recorded neural activity over sensorimotor cortex during hand movement. This semi-automated interface reliably estimates the location of temporarily implanted subdural ECoG electrodes visible on intraoperative fluoroscopy to a cortical surface.
Collapse
Affiliation(s)
- Michael J Randazzo
- Brain Modulation Laboratory, Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Efstathios D Kondylis
- Brain Modulation Laboratory, Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ahmad Alhourani
- Brain Modulation Laboratory, Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Thomas A Wozny
- Brain Modulation Laboratory, Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Witold J Lipski
- Brain Modulation Laboratory, Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Donald J Crammond
- Brain Modulation Laboratory, Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - R Mark Richardson
- Brain Modulation Laboratory, Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; Department of Neurobiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Center for the Neural Basis of Cognition, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| |
Collapse
|
50
|
Nwachuku EL, Balzer JR, Yabes JG, Habeych ME, Crammond DJ, Thirumala PD. Diagnostic value of somatosensory evoked potential changes during carotid endarterectomy: a systematic review and meta-analysis. JAMA Neurol 2015; 72:73-80. [PMID: 25383418 DOI: 10.1001/jamaneurol.2014.3071] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Perioperative stroke is a persistent complication of carotid endarterectomy (CEA) for patients with symptomatic carotid stenosis (CS). OBJECTIVE To evaluate whether changes in somatosensory evoked potential (SSEP) during CEA are diagnostic of perioperative stroke in patients with symptomatic CS. DESIGN, SETTING, AND PARTICIPANTS We searched PubMed and the World Science Database for reference lists of retrieved studies and/or experiments on SSEP use in postoperative outcomes following CEA in patients with symptomatic CS from January 1, 1950, through January 1, 2013. We independently screened all titles and abstracts to identify studies that met the inclusion criteria and extracted relevant articles in a uniform manner. Inclusion criteria included randomized clinical trials, prospective studies, or retrospective cohort reviews; population of symptomatic CS; use of intraoperative SSEP monitoring during CEA; immediate postoperative assessment and/or as long as a 3-month follow-up; a total sample size of 50 or more patients; studies with adult humans 18 years or older; and studies published in English. MAIN OUTCOME AND MEASURE Whether intraoperative SSEP changes were diagnostic of perioperative stroke indicated by postoperative neurological examination. RESULTS Four-hundred sixty-four articles were retrieved, and 15 prospective and retrospective cohort studies were included in the data analysis. A 4557-patient cohort composed the total sample population for all the studies, 3899 of whom had symptomatic CS. A change in SSEP exhibited a strong pooled mean specificity of 91% (95% CI, 86-94) but a weaker pooled mean sensitivity of 58% (95% CI, 49-68). A pooled diagnostic odds ratio for individual studies of patients with neurological deficit with changes in SSEPs was 14.39 (95% CI, 8.34-24.82), indicating that the odds of observing an SSEP change among those with neurologic deficits were 14 times higher than in individuals without neurologic deficit. CONCLUSIONS AND RELEVANCE Intraoperative SSEP is a highly specific test in predicting neurological outcome following CEA. Patients with perioperative neurological deficits are 14 times more likely to have had changes in SSEPs during the procedure. The use of SSEPs to design prevention strategies is valuable in reducing perioperative cerebral infarctions during CEA.
Collapse
Affiliation(s)
- Enyinna L Nwachuku
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jeffrey R Balzer
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jonathan G Yabes
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Miguel E Habeych
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Donald J Crammond
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | |
Collapse
|