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Wilkinson MF, Pederson K, Kawalec P, Silvaggio J, Abdul-Salaam MS. Does persistent crossover (ipsilateral) motor evoked potential (MEP) responses represent a technical failure for intracranial motor tract monitoring? A case example and practical solution. Acta Neurochir (Wien) 2024; 166:495. [PMID: 39641813 DOI: 10.1007/s00701-024-06390-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Accepted: 11/22/2024] [Indexed: 12/07/2024]
Abstract
PURPOSE Attention to motor evoked potential (MEP) stimulation intensity is necessary to avoid false negative MEP results during intracranial procedures. Observing ipsilateral (crossover) MEP responses has been hypothesized to indicate inappropriately strong stimulation intensity. We describe a case where persistent crossover MEP responses falsely suggested that stimulus intensity was too high and describe an alternative method to guide the selection of MEP stimulation intensity. METHODS A patient undergoing a suboccipital craniotomy for tumor resection had bilateral transcranial electrical MEP monitoring under total intravenous anesthesia. MEP results were obtained from left and right hand using C4-Cz and C3-Cz stimulation montages respectively. Selection of an appropriately superficial stimulus intensity was guided using MEP onset latencies. RESULTS MEP acquisition proceeded normally for contralateral left hand (C4-Cz montage). However, using the C3-Cz montage, persistent crossover responses were noted at stimulation intensities as low as threshold for contralateral right hand MEP (94 V/166 mA). Appropriate MEP stimulus intensity for subsequent monitoring (approximately 96 V/172 mA) was determined utilizing onset latency measurements from contralateral hand MEP responses. The stimulus intensity chosen was predicated on onset latency being ≥ 2 ms longer than latency at maximal stimulus level (shortest latency). A stimulus intensity-latency plot was generated offline to illustrate this important relationship for intracranial MEP use. MEP acquisition proceeded without incident and gross total resection was achieved without postoperative motor deficits. CONCLUSION Despite crossover appearance contralateral hand MEP were quantitatively validated for intraoperative application using onset latency guidance.
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Affiliation(s)
- Marshall F Wilkinson
- Section of Neurosurgery Health Sciences Centre, GB 1 - 820 Sherbrook Street, Winnipeg, MB, R3A 1R9, Canada.
| | - Kristine Pederson
- Section of Neurosurgery Health Sciences Centre, GB 1 - 820 Sherbrook Street, Winnipeg, MB, R3A 1R9, Canada
| | - Philip Kawalec
- Section of Neurosurgery Health Sciences Centre, GB 1 - 820 Sherbrook Street, Winnipeg, MB, R3A 1R9, Canada
| | - Joseph Silvaggio
- Section of Neurosurgery Health Sciences Centre, GB 1 - 820 Sherbrook Street, Winnipeg, MB, R3A 1R9, Canada
| | - M Suheel Abdul-Salaam
- Section of Neurosurgery Health Sciences Centre, GB 1 - 820 Sherbrook Street, Winnipeg, MB, R3A 1R9, Canada
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Takada S, Kamata T, Yamashita H, Ogasawara S, Sadamasa N, Taki W. False-Negative Motor-Evoked Potential Due to Contrast-Induced Encephalopathy During Coil Embolization for Intracranial Aneurysm: A Case Report. Cureus 2024; 16:e73487. [PMID: 39540192 PMCID: PMC11560081 DOI: 10.7759/cureus.73487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2024] [Indexed: 11/16/2024] Open
Abstract
Contrast-induced encephalopathy (CIE) is a rare neurological complication that can occur following the use of contrast media during angiographic procedures. It can lead to neurological deficits, such as motor weakness. Transcranial motor-evoked potential (TcMEP) monitoring is commonly used to detect pyramidal tract disorders during embolization for intracranial aneurysms. However, it remains unclear whether TcMEP monitoring is effective in cases of motor weakness associated with CIE. We present a case of a false-negative motor-evoked potential caused by CIE during coil embolization for unruptured internal carotid artery aneurysms. A 68-year-old woman with dizziness underwent an MRI, which revealed multiple unruptured cerebral aneurysms, including a right anterior choroidal artery aneurysm (Ach AAn) and a posterior communicating artery aneurysm (Pcom AAn). Coil embolization was performed for the right Ach AAn and Pcom AAn with intraoperative TcMEP monitoring under general anesthesia. Throughout the procedure, no abnormalities were detected in the TcMEP monitoring. A total of 360 mL of contrast medium was used. After regaining consciousness, the patient experienced left hemiplegia and unilateral spatial neglect. Cerebral angiography revealed no missing branches, including those of the Ach A and Pcom A. MRI showed no acute ischemic or hemorrhagic changes. However, CT revealed CIE. The left hemiplegia and unilateral spatial neglect gradually improved and were completely resolved by postoperative day four. This case suggests that CIE-associated motor weakness may not be detected by intraoperative TcMEP monitoring. Therefore, in patients who develop motor weakness immediately after coil embolization for intracranial aneurysms without changes in TcMEP, brain CT should be performed to exclude CIE.
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Affiliation(s)
- Shigeki Takada
- Department of Neurosurgery, Koseikai Takeda Hospital, Kyoto, JPN
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, JPN
| | - Takahiko Kamata
- Department of Neurosurgery, Koseikai Takeda Hospital, Kyoto, JPN
| | - Haruki Yamashita
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, JPN
| | - Shota Ogasawara
- Department of Clinical Laboratory, Koseikai Takeda Hospital, Kyoto, JPN
| | | | - Waro Taki
- Department of Neurosurgery, Koseikai Takeda Hospital, Kyoto, JPN
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Bocanegra-Becerra JE, Simoni G, Mendieta CD, Acha Sánchez JL, Palavani LB, Wouters K, Punukollu A, Mangas G, Bertani R, Lopez-Gonzalez MA. Awake microsurgical management of brain aneurysms: a comprehensive systematic review and meta-analysis on rationale, safety and clinical outcomes. Neurochirurgie 2024; 70:101600. [PMID: 39366123 DOI: 10.1016/j.neuchi.2024.101600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2024] [Revised: 09/06/2024] [Accepted: 09/10/2024] [Indexed: 10/06/2024]
Abstract
INTRODUCTION Awake microsurgery for brain aneurysm treatment has emerged as a tool for real-time intraoperative monitoring, opportune detection of ischemic complications, and reduction of surgical morbidity. Herein, we aimed to explore the current state of the procedure's rationale, safety and clinical outcomes. METHODS In accordance with PRISMA guidelines, five databases were queried for articles reporting awake microsurgical management of brain aneurysms. Aggregate study results were combined using random-effects meta-analyses. Publication bias was evaluated through funnel plot analysis and Egger's regression test. RESULTS Out of 847 articles, 11 records satisfied the inclusion criteria. Seventy-five patients (68% female) with 75 brain aneurysms (68% unruptured) were analyzed. Clipping was the predominant technique (58%), followed by bypass (17%). Monitored anesthesia care was the principal anesthesia protocol (60%). The incidence of anesthesia-related complications was 1% [95%CI, 0.00-0.05, I2 = 19%], and the conversion rate from an awake-induced anesthesia protocol to general anesthesia was 1% [95%CI, 0.00-0.05, I2 = 0%]. No permanent anesthesia-related morbidity and mortality was reported. Complete aneurysm repair, occlusion and bypass patency rate was 100% [95%CI, 0.96-1.00, I2 = 0%]. The transient postoperative symptomatic event rate was 34% [95%CI, 0.06-0.81, I2 = 77%]. The overall morbidity rate was 4% [95%CI, 0.00-0.09, I2 = 0%], and the overall mortality rate was 0% [95%CI, 0.00-0.03, I2 = 0%]. CONCLUSION Awake microsurgery of brain aneurysms is feasible, yet current evidence stems from observational studies. This procedure can reduce surgical morbidity by providing accurate and real-time neurological monitoring during aneurysm repair. While this technique appears to be tolerated, higher level evidence is needed to evaluate judiciously its safety and preference over existing practices for intraoperative neurological monitoring.
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Affiliation(s)
- Jhon E Bocanegra-Becerra
- Academic Department of Surgery, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru.
| | - Gabriel Simoni
- Centro Universitário de Várzea Grande, Mato Grosso, Várzea Grande, Brazil
| | - Cristian D Mendieta
- Universidad Mayor Real y Pontificia de San Francisco Xavier de Chuquisaca, Bolivia
| | - José Luis Acha Sánchez
- Vascular and Skull Base Division, Department of Neurosurgery, Hospital Nacional Dos de Mayo, Lima, Peru
| | - Lucca B Palavani
- Faculty of Medicine, Max Planck University Center, Indaiatuba, Brazil
| | - Kim Wouters
- Open Universiteit Heerle Nederland, Netherlands
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Guidelines for Awake Surgery. Neurol Med Chir (Tokyo) 2024; 64:1-27. [PMID: 38220155 PMCID: PMC10835579 DOI: 10.2176/jns-nmc.2023-0111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 08/07/2023] [Indexed: 01/16/2024] Open
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Wilkinson MF, Silvaggio J, Kaufmann A. Cathodal Genesis of Ipsilateral Hand (Crossover) Motor Evoked Potentials: Evidence from a Patient with Previous Stroke. Neurodiagn J 2023:1-7. [PMID: 36919532 DOI: 10.1080/21646821.2023.2178807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
A case is described where baseline transcranial electrical motor evoked potentials (TcMEP) and somatosensory evoked potentials (SSEP) results were unilaterally absent in a patient with previous hemispheric stroke undergoing a right-sided carotid endarterectomy. SSEP data confirmed right cortical pathology and excluded a technical rationale for absent motor evoked responses. Attempts at generating left-hand (contralateral) TcMEP from right cortical anodal stimulation failed despite high stimulus intensities. However, TcMEP responses from anodal stimulation of the right cortex were recorded from the right-hand (ipsilateral) which were attributed to "crossover." Ipsilateral TcMEP onset latencies derived from the stimulus-response data supports the idea that crossover is a product of cathodal stimulation initially acting on pericortical motor pathways.
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Affiliation(s)
- Marshall F Wilkinson
- Section of Neurosurgery, University of Manitoba and Health Sciences Centre, Winnipeg, Manitoba, Canada
| | - Joseph Silvaggio
- Section of Neurosurgery, University of Manitoba and Health Sciences Centre, Winnipeg, Manitoba, Canada
| | - Anthony Kaufmann
- Section of Neurosurgery, University of Manitoba and Health Sciences Centre, Winnipeg, Manitoba, Canada
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Wilkinson MF, Chowdhury T, Kaufmann AM. A novel method for quantitative evaluation of motor evoked potential monitoring during cerebrovascular surgeries. J Clin Neurosci 2022; 98:29-36. [DOI: 10.1016/j.jocn.2022.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 11/08/2021] [Accepted: 01/22/2022] [Indexed: 11/29/2022]
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Intraoperative motor-evoked potential monitoring during coil embolization for anterior choroidal artery aneurysms. Neuroradiology 2021; 64:1221-1229. [PMID: 34791541 DOI: 10.1007/s00234-021-02847-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 10/26/2021] [Indexed: 02/03/2023]
Abstract
PURPOSE Intraoperative motor-evoked potential (MEP) monitoring is widely used in the neck clipping of cerebral aneurysms. Little is known regarding the usefulness of intraoperative MEP monitoring in endovascular aneurysm surgery. The purpose of this study was to validate the feasibility of intraoperative MEP monitoring during the coil embolization of anterior choroidal artery (AChA) aneurysms. METHODS Clinical and angiographic data of consecutive patients who underwent coil embolization for unruptured AChA aneurysms with or without intraoperative MEP monitoring between January 2014 and December 2018 at our institute were abstracted and analyzed retrospectively. RESULTS Twenty-three unruptured AChA aneurysms were treated. Eleven patients received MEP monitoring, and three of them experienced intraoperative reduction or disappearance of the MEP wave. Even during MEP changes, AChA filling showed no change in any of the three cases. Although one case with MEP monitoring encountered the disappearance of AChA filling, there was no change in MEP. This might be due to retrograde filling of the AChA from the anastomosis with the lateral posterior choroidal artery. AChA blood flow detected by angiography did not always reflect MEP status. When comparing the presence or absence of MEP monitoring, the volume embolization ratio of coiled aneurysms was significantly better in the MEP group. CONCLUSION Intraoperative MEP monitoring during endovascular coiling for AChA aneurysms may be feasible. AChA blood flow detected by angiography does not always reflect MEP status.
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Zhou HY, Chen HY, Li Y. Anesthetic technique for awake artery malformation clipping with motor evoked potential and somatosensory evoked potential: A case report. World J Clin Cases 2021; 9:8207-8213. [PMID: 34621882 PMCID: PMC8462218 DOI: 10.12998/wjcc.v9.i27.8207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 07/09/2021] [Accepted: 08/06/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Awake craniotomy has been widely used for tumor resection, epilepsy surgery, deep brain stimulation, and carotid endarterectomy. The report on awake artery malformation clipping is rare, especially for anesthesia management.
CASE SUMMARY A 62-year-old female diagnosed with malformation of anterior cerebral artery at the right side. We clipped the artery malformation with intraoperative neuromonitoring (IONM) in awake craniotomy. Spontaneous respiration was maintained throughout the procedure by nasopharyngeal airway during the surgery successfully.
CONCLUSION The technique of monitoring anesthesia care can be performed successfully for the patient with IONM.
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Affiliation(s)
- Hong-Yu Zhou
- Department of Anesthesiology, West China Hospital, Chengdu 610041, Sichuan Province, China
| | - Hong-Yang Chen
- Department of Anesthesiology, West China Hospital, Chengdu 610041, Sichuan Province, China
| | - Yu Li
- Department of Anesthesiology, West China Hospital, Chengdu 610041, Sichuan Province, China
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Shils J, Kochanski RB, Borghei A, Candocia A, Pal GD, Afshari M, Verhagen LM, Sani S. Motor Evoked Potential Recordings During Segmented Deep Brain Stimulation-A Feasibility Study. Oper Neurosurg (Hagerstown) 2021; 20:419-425. [PMID: 33428767 DOI: 10.1093/ons/opaa414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 10/07/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Segmented deep brain stimulation (DBS) leads, which are capable of steering current in the direction of any 1 of 3 segments, can result in a wider therapeutic window by directing current away from unintended structures, particularly, the corticospinal tract (CST). It is unclear whether the use of motor evoked potentials (MEPs) is feasible during DBS surgery via stimulation of individual contacts/segments in order to quantify CST activation thresholds and optimal contacts/segments intraoperatively. OBJECTIVE To assess the feasibility of using MEP to identify CST thresholds for ring and individual segments of the DBS lead under general anesthesia. METHODS MEP testing was performed during pulse generator implantation under general anesthesia on subjects who underwent DBS lead implantation into the subthalamic nucleus (STN). Stimulation of each ring and segmented contacts of the directional DBS lead was performed until CST threshold was reached. Stereotactic coordinates and thresholds for each contact/segment were recorded along with the initially activated muscle group. RESULTS A total of 34 hemispheres were included for analysis. MEP thresholds were recorded from 268 total contacts/segments. For segmented contacts (2 and 3, respectively), the mean highest CST thresholds were 2.33 and 2.62 mA, while the mean lowest CST thresholds were 1.7 and 1.89 mA, suggesting differential thresholds in relation to CST. First dorsal interosseous and abductor pollicis brevis (34% each) were the most commonly activated muscle groups. CONCLUSION MEP threshold recording from segmented DBS leads is feasible. MEP recordings can identify segments with highest CST thresholds and may identify segment orientation in relation to CST.
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Affiliation(s)
- Jay Shils
- Department of Anesthesia, Rush University Medical Center, Chicago, Illinois
| | - Ryan B Kochanski
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois
| | - Alireza Borghei
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois
| | - Alexander Candocia
- Department of Anesthesia, Rush University Medical Center, Chicago, Illinois
| | - Gian D Pal
- Department of Neurological Sciences, Section of Movement Disorders, Rush University Medical Center, Chicago, Illinois
| | - Mitra Afshari
- Department of Neurological Sciences, Section of Movement Disorders, Rush University Medical Center, Chicago, Illinois
| | - Leonard Metman Verhagen
- Department of Neurological Sciences, Section of Movement Disorders, Rush University Medical Center, Chicago, Illinois
| | - Sepehr Sani
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois
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Asimakidou E, Abut PA, Raabe A, Seidel K. Motor Evoked Potential Warning Criteria in Supratentorial Surgery: A Scoping Review. Cancers (Basel) 2021; 13:2803. [PMID: 34199853 PMCID: PMC8200078 DOI: 10.3390/cancers13112803] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/30/2021] [Accepted: 05/31/2021] [Indexed: 12/31/2022] Open
Abstract
During intraoperative monitoring of motor evoked potentials (MEP), heterogeneity across studies in terms of study populations, intraoperative settings, applied warning criteria, and outcome reporting exists. A scoping review of MEP warning criteria in supratentorial surgery was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Sixty-eight studies fulfilled the eligibility criteria. The most commonly used alarm criteria were MEP signal loss, which was always a major warning sign, followed by amplitude reduction and threshold elevation. Irreversible MEP alterations were associated with a higher number of transient and persisting motor deficits compared with the reversible changes. In almost all studies, specificity and Negative Predictive Value (NPV) were high, while in most of them, sensitivity and Positive Predictive Value (PPV) were rather low or modest. Thus, the absence of an irreversible alteration may reassure the neurosurgeon that the patient will not suffer a motor deficit in the short-term and long-term follow-up. Further, MEPs perform well as surrogate markers, and reversible MEP deteriorations after successful intervention indicate motor function preservation postoperatively. However, in future studies, a consensus regarding the definitions of MEP alteration, critical duration of alterations, and outcome reporting should be determined.
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Affiliation(s)
- Evridiki Asimakidou
- Department of Neurosurgery, Inselspital, Bern University Hospital, 3010 Bern, Switzerland; (E.A.); (P.A.A.); (A.R.)
| | - Pablo Alvarez Abut
- Department of Neurosurgery, Inselspital, Bern University Hospital, 3010 Bern, Switzerland; (E.A.); (P.A.A.); (A.R.)
- Department of Neurosurgery, Clínica 25 de Mayo, 7600 Mar del Plata, Argentina
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, 3010 Bern, Switzerland; (E.A.); (P.A.A.); (A.R.)
| | - Kathleen Seidel
- Department of Neurosurgery, Inselspital, Bern University Hospital, 3010 Bern, Switzerland; (E.A.); (P.A.A.); (A.R.)
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Kumar S, Sahana D, Menon G. Optimal Use of Temporary Clip Application during Aneurysm Surgery - In Search of the Holy Grail. Asian J Neurosurg 2021; 16:237-242. [PMID: 34268145 PMCID: PMC8244713 DOI: 10.4103/ajns.ajns_465_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 01/29/2021] [Indexed: 11/04/2022] Open
Abstract
Temporary clips are invaluable safety tools during the clipping of an aneurysm. Controversies regarding maximum permissible duration and safety, however, remain unanswered. This descriptive narrative attempts to review the literature to provide valuable insights on controversies clouding the use of temporary clips among neurosurgeons. Popular databases, including Pub Med, Medline/Medscape, Scopus, Cochrane, Embase, Google Scholar, were searched to find available literature on temporary clips. The searched MeSH terms were "Temporary Clip," "Temporary Clipping," "Cerebral Aneurysm," and "Aneurysm." Temporary clips have been in use since 1928 and have undergone considerable structural and technical modifications. A temporary clip's optimal safety limit is not yet defined with literature evidence ranging from immediate to 93 min. It is not yet definite whether temporary clips application aggravates vasospasm, but emergency temporary clips application, especially in poor-grade aneurysmal subarachnoid hemorrhage patients, is associated with poor outcomes. A temporary clip needs to be applied with caution in patients treated earlier by endovascular technique and having indwelling stents. Nitinol Stent is feasible, while a Cobalt-Chromium alloy stent does not get occluded and gets deformed under the closing pressure of a temporary clip. Although a temporary clip application is a fundamental strategy during the clipping of an aneurysm; the exact safe duration remains to be decided in randomized control trials. Their utility for the shorter duration is beneficial under un-conclusive evidence of neuroprotective agents and intraoperative monitoring. Neurosurgeons need to consider all aspects of their pros and cons for optimal use.
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Affiliation(s)
- Sanjeev Kumar
- Department of Neurosurgery, DKS Postgraduate Institute and Research Center, Raipur, Chhattisgarh, India
| | - Debabrata Sahana
- Department of Neurosurgery, DKS Postgraduate Institute and Research Center, Raipur, Chhattisgarh, India
| | - Girish Menon
- Department of Neurosurgery, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Byoun HS, Oh CW, Kwon OK, Lee SU, Ban SP, Kim SH, Kim T, Bang JS, Kim SU, Choi J, Park KS. Intraoperative neuromonitoring during microsurgical clipping for unruptured anterior choroidal artery aneurysm. Clin Neurol Neurosurg 2019; 186:105503. [PMID: 31494461 DOI: 10.1016/j.clineuro.2019.105503] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 08/18/2019] [Accepted: 08/26/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate the safety and unexpected finding of the intraoperative neuromonitoring (IONM) including somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) during microsurgical clipping of an unruptured anterior choroidal artery (AChA) aneurysm. PATIENTS AND METHODS From January 2011 to March 2018, the neurophysiological, clinical, and radiological data of 115 patients who underwent microsurgical clipping for an unruptured AChA aneurysm under IONM were retrospectively analyzed. The incidence of ischemic complications after microsurgical clipping of unruptured AChA aneurysms as well as the false-negative rate, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of IONM during surgery were calculated. RESULTS Ischemic complications after the microsurgical clipping of an AChA aneurysm under IONM occurred in 7 of 115 patients (6.08%). Among them, 3 were symptomatic (2.6%). The false-negative rate of IONM for ischemic complications was 6.08% (7 patients). High specificity; 100% (95% confidence interval [95% CI] = 0.972-1.000), PPVs; 100% (95% CI = 0.055-1.000), and NPVs; 93% (95% CI = 0.945-0.973) with low sensitivity; 11.1% (95% CI = 0.006-0.111) were calculated. CONCLUSIONS IONM including transcranial MEP during microsurgical clipping of unruptured AChA aneurysm might have limited usefulness. Therefore, other MEP monitoring using direct cortical stimulation or modified transcranial methodology should be considered to compensate for it.
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Affiliation(s)
- Hyoung Soo Byoun
- Department of Neurosurgery, Chungnam National University Hospital, Daejeon, South Korea
| | - Chang Wan Oh
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - O-Ki Kwon
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Si Un Lee
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Seung Pil Ban
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Sung Hoon Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Tackeun Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Jae Seung Bang
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea.
| | - Sung Un Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Jongsuk Choi
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Kyung Seok Park
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea.
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Tachibana S, Omote M, Yamakage M. Successful awake craniotomy in an aged patient with a severe hearing impairment using a bone conduction voice amplifier: a case report. JA Clin Rep 2019; 5:37. [PMID: 32026961 PMCID: PMC6966765 DOI: 10.1186/s40981-019-0258-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 05/31/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The main purposes of awake craniotomy are to minimize postoperative brain dysfunction caused by the surgical procedure and to maximize the tumor resection range. In awake craniotomy, it is important to have a good quality of awakening and to obtain patient's obedience in the awake phase. CASE PRESENTATION The patient was a 75-year-old woman with an advanced hearing impairment who was scheduled for awake craniotomy. We used a bone conduction voice amplifier before and during the awake phase and communicated with the patient smoothly. CONCLUSIONS We were able to complete awake craniotomy fully, and overcoming the deafness problem might have contributed to the patient's good outcome. This case report indicates that awake craniotomy can be performed in a patient with an advanced hearing impairment under the condition of careful anesthetic management.
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Affiliation(s)
- Shunsuke Tachibana
- Department of Anesthesiology, School of Medicine, Sapporo Medical University, South 1, West 16, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan.
| | - Masahito Omote
- Department of Anesthesiology, School of Medicine, Sapporo Medical University, South 1, West 16, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| | - Michiaki Yamakage
- Department of Anesthesiology, School of Medicine, Sapporo Medical University, South 1, West 16, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
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Seng LB, Yasuhiro Y, Rajagopal N, Mohammad AA, Takao T, Kyosuke M, Tsukasa K, Kato Y. Loss of Contralateral Upper Limb Motor Evoked Potential Due to Occlusion of the Internal Carotid Artery in Microsurgical Clipping of Basilar Tip Aneurysm. Asian J Neurosurg 2019; 14:295-299. [PMID: 30937059 PMCID: PMC6417339 DOI: 10.4103/ajns.ajns_157_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The motor evoked potential (MEP) monitoring is routinely used as an adjunct in the microsurgical clipping of anterior circulation. We describe a case of unruptured basilar tip aneurysm treated with microsurgical clipping developed loss in MEP recording of the left abductor pollicis brevis (APB) following clipping of basilar tip aneurysm. A 58-year-old man was referred to the Fujita Health University Banbuntane-Hotokukai Hospital, Nagoya, Aichi, Japan, with incidental finding of unruptured 6.5 mm basilar tip saccular aneurysm. He underwent right anterior temporal approach of basilar tip aneurysm clipping. The internal carotid artery (ICA) was mobilized laterally to allow direct visualization of the neck of the basilar tip aneurysm. Following the application of temporary clip and subsequently permanent clip at the neck of the aneurysm, the MEP signal was lost in the left APB. The temporary clip was immediately removed. Dual-image videoangiography (DIVA) showed a filling defect in the right ICA and a branch of middle cerebral artery (MCA). The MEP was absent for about 23 minutes and the amplitude improved to only 75% of the baseline recording at 38 minutes till the end of the surgery. A repeat DIVA showed good flow within the right ICA and MCA. Glasgow coma score was 15/15 on postoperative day 1 and there was no gross motor or sensory deficit except right oculomotor nerve palsy with complete recovery at 6 months follow-up. This is the first reported ICA occlusion due to its mobilization in microsurgical clipping of basilar tip aneurysm. The use of neuromonitoring especially MEP is essential even in the posterior circulation aneurysm surgery especially when excessive manipulation of the ICA is unavoidable. When performing intraoperative angiography for aneurysm surgery, it is prudent to detect any filling defect within the surrounding vessels.
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Affiliation(s)
- Liew Boon Seng
- Department of Neurosurgery, Hospital Sungai Buloh, Sungai Buloh, Selangor, Malaysia
| | - Yamada Yasuhiro
- Department of Neurosurgery, Banbuntane Hotokukai Hospital, Fujita Health University, Nagoya, Japan
| | - Niranjana Rajagopal
- Department of Neurosurgery, Sathya Sai Institute of Higher Medical Sciences, Bengaluru, Karnataka, India
| | | | - Teranishi Takao
- Department of Neurosurgery, Banbuntane Hotokukai Hospital, Fujita Health University, Nagoya, Japan
| | - Miyatani Kyosuke
- Department of Neurosurgery, Banbuntane Hotokukai Hospital, Fujita Health University, Nagoya, Japan
| | - Kawase Tsukasa
- Department of Neurosurgery, Banbuntane Hotokukai Hospital, Fujita Health University, Nagoya, Japan
| | - Yoko Kato
- Department of Neurosurgery, Banbuntane Hotokukai Hospital, Fujita Health University, Nagoya, Japan
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Winkler EA, Lu A, Burkhardt JK, Rutledge WC, Yue JK, Birk HS, Alotaibi N, Choudhri O, Lawton MT. Microsurgical Clipping of Anterior Choroidal Artery Aneurysms: A Systematic Approach to Reducing Ischemic Complications in an Experience with 146 Patients. Oper Neurosurg (Hagerstown) 2019; 17:413-423. [DOI: 10.1093/ons/opz007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 01/31/2019] [Indexed: 02/07/2023] Open
Abstract
Abstract
BACKGROUND
Aneurysms of the anterior choroidal artery (AChA) have been associated with high treatment-associated morbidity due to ischemic complications.
OBJECTIVE
To report a large clinical experience of microsurgically treated AChA aneurysms and describe a systematic approach to reduce ischemic complications.
METHODS
One hundred forty-six patients with AChA aneurysms were retrospectively reviewed from a prospectively maintained database. Clinical characteristics, surgical techniques, clinical outcomes, arterial infarction, and use of intraoperative adjuncts (ie, ultrasonography, indocyanine green videoangiography, and neuromonitoring) were analyzed.
RESULTS
In total, one hundred forty-three aneurysms (97.9%) were clipped. Temporary clipping was utilized in 47 cases (32.2%) with mean occlusion time of 5.6 min. Arterial infarction occurred in 12 patients (8.2%). In clipped aneurysms, 90.5% were completely obliterated, 8.8% had minimal residual (<5% of original), and 0.7% were incompletely occluded (>5% of original). Mortality (2.7%) was limited to patients with high-grade subarachnoid hemorrhage. Indocyanine green videoangiography and neuromonitoring altered operative technique in ∼20% of cases. Multivariate logistic regression identified intraoperative rupture as the sole predictor for arterial infarction.
CONCLUSION
Open microsurgical clipping remains a safe, effective treatment for AChA aneurysms. Microsurgical technique is paramount in preserving AChA patency and reducing ischemic complications. Despite increasing reliance on qualitative measures of AChA blood flow (videoangiography and ultrasonography) and neurophysiological monitoring, these technologies aid us infrequently. However, these adjuncts provide important safety checks for AChA patency. Temporary clipping must be used judiciously to lower the risk of intraoperative rupture while limiting possible ischemia in the AChA territory.
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Affiliation(s)
- Ethan A Winkler
- Department of Neurological Surgery, University of California - San Francisco, San Francisco, California
| | - Alex Lu
- Department of Neurological Surgery, University of California - San Francisco, San Francisco, California
| | - Jan-Karl Burkhardt
- Department of Neurological Surgery, University of California - San Francisco, San Francisco, California
- Department of Neurosurgery, Baylor College of Medicine Medical Center, Houston, Texas
| | - W Caleb Rutledge
- Department of Neurological Surgery, University of California - San Francisco, San Francisco, California
| | - John K Yue
- Department of Neurological Surgery, University of California - San Francisco, San Francisco, California
| | - Harjus S Birk
- Department of Neurological Surgery, University of California - San Francisco, San Francisco, California
| | - Naif Alotaibi
- Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Omar Choudhri
- Department of Neurological Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael T Lawton
- Department of Neurological Surgery, University of California - San Francisco, San Francisco, California
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
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Chung J, Park W, Hong SH, Park JC, Ahn JS, Kwun BD, Lee SA, Kim SH, Jeon JY. Intraoperative use of transcranial motor/sensory evoked potential monitoring in the clipping of intracranial aneurysms: evaluation of false-positive and false-negative cases. J Neurosurg 2019; 130:936-948. [PMID: 29570008 DOI: 10.3171/2017.8.jns17791] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 08/21/2017] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Somatosensory and motor evoked potentials (SEPs and MEPs) are often used to prevent ischemic complications during aneurysm surgeries. However, surgeons often encounter cases with suspicious false-positive and false-negative results from intraoperative evoked potential (EP) monitoring, but the incidence and possible causes for these results are not well established. The aim of this study was to investigate the efficacy and reliability of EP monitoring in the microsurgical treatment of intracranial aneurysms by evaluating false-positive and false-negative cases. METHODS From January 2012 to April 2016, 1514 patients underwent surgery for unruptured intracranial aneurysms (UIAs) with EP monitoring at the authors' institution. An EP amplitude decrease of 50% or greater compared with the baseline amplitude was defined as a significant EP change. Correlations between immediate postoperative motor weakness and EP monitoring results were retrospectively reviewed. The authors calculated the sensitivity, specificity, and positive and negative predictive values of intraoperative MEP monitoring, as well as the incidence of false-positive and false-negative results. RESULTS Eighteen (1.19%) of the 1514 patients had a symptomatic infarction, and 4 (0.26%) had a symptomatic hemorrhage. A total of 15 patients showed motor weakness, with the weakness detected on the immediate postoperative motor function test in 10 of these cases. Fifteen false-positive cases (0.99%) and 8 false-negative cases (0.53%) were reported. Therefore, MEP during UIA surgery resulted in a sensitivity of 0.10, specificity of 0.94, positive predictive value of 0.01, and negative predictive value of 0.99. CONCLUSIONS Intraoperative EP monitoring has high specificity and negative predictive value. Both false-positive and false-negative findings were present. However, it is likely that a more meticulously designed protocol will make EP monitoring a better surrogate indicator of possible ischemic neurological deficits.
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Affiliation(s)
| | | | | | | | | | | | | | - Sung-Hoon Kim
- 3Anesthesiology and Pain Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Shekhtman OD, Gorozhanin VA, Kulikov AS, Okisheva EA. [Proximal clipping of a large fusiform aneurysm of the A2 segment of the left anterior cerebral artery with awakening of the patient (a case report and literature review)]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2018; 82:97-102. [PMID: 30137043 DOI: 10.17116/neiro201882497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Arterial aneurysms of the A2 segment are very rare (<1%) peripheral aneurysms of the anterior cerebral artery (ACA) territory. Usually, these are saccular aneurysms; there are single reports of fusiform aneurysms of this location. Surgical treatment of these aneurysms involves both microsurgical and endovascular interventions. In the presented case, we used deconstructive surgery (proximal clipping of the aneurysm) with intraoperative awakening of the patient, which verified sufficient collateral blood flow. In the case of focal deficit development, we planned to simultaneously perform an interarterial anastomosis between the A3 segments of the right and left ACAs.
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Affiliation(s)
| | | | - A S Kulikov
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - E A Okisheva
- Sechenov First Moscow State Medical University, Moscow, Russia
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18
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Awake craniotomy for excision of arteriovenous malformations? A qualitative comparison study with stereotactic radiosurgery. J Clin Neurosci 2018. [DOI: 10.1016/j.jocn.2018.02.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Idris Z, Kandasamy R, Neoh YY, Abdullah JM, Wan Hassan WMN, Mat Hassan ME. The First Awake Clipping of a Brain Aneurysm in Malaysia and in ASEAN: Achieving International Standards. Malays J Med Sci 2018; 25:1-4. [PMID: 29599629 DOI: 10.21315/mjms2018.25.1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 12/31/2017] [Indexed: 10/17/2022] Open
Abstract
World-renowned neurosurgeon, Professor Saleem Abdulrauf, has been featured in several medical journals for his successful "Awake Brain Aneurysm Surgery". Regarded as a "world first", this surgery, involves clipping un-ruptured brain aneurysms while patients are awake. Only one or two neurosurgery centres worldwide are capable of this. Performing the surgery while the patient is awake lowers risks of brain ischemia with neurological deficits and ventilator associated morbidities. The technique has been viewed as the start of a new era in brain surgery. Physicians from the Universiti Sains Malaysia (USM) School of Medical Sciences, at the Health Campus in Kelantan, headed by Professor Dr Zamzuri Idris (neurosurgeon) and Dr Wan Mohd Nazaruddin Wan Hassan (neuroanaesthetist), recently performed a similar procedure, the first such surgery in Malaysia and Southeast Asia. The USM team can therefore be considered to be among the first few to have done this brain surgery and achieved successful patient outcomes.
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Affiliation(s)
- Zamzuri Idris
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Jalan Sultanah Zainab 2, 16150 Kubang Kerian, Kelantan, Malaysia.,Center for Neuroscience Services and Research, Health Campus, Universiti Sains Malaysia, Jalan Sultanah Zainab 2, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Regunath Kandasamy
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Jalan Sultanah Zainab 2, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Yee Yik Neoh
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Jalan Sultanah Zainab 2, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Jafri Malin Abdullah
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Jalan Sultanah Zainab 2, 16150 Kubang Kerian, Kelantan, Malaysia.,Center for Neuroscience Services and Research, Health Campus, Universiti Sains Malaysia, Jalan Sultanah Zainab 2, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Wan Mohd Nazaruddin Wan Hassan
- Department of Anaesthesia, School of Medical Sciences, Universiti Sains Malaysia, Jalan Sultanah Zainab 2, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Mohd Erham Mat Hassan
- Department of Anaesthesia, School of Medical Sciences, Universiti Sains Malaysia, Jalan Sultanah Zainab 2, 16150 Kubang Kerian, Kelantan, Malaysia
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Abdulrauf SI, Urquiaga JF, Patel R, Albers JA, Sampat VB, Baumer M, Marvin E, Pierson M, Kragel R, Walsh J. Awake Microvascular Decompression for Trigeminal Neuralgia: Concept and Initial Results. World Neurosurg 2018; 113:e309-e313. [PMID: 29452326 DOI: 10.1016/j.wneu.2018.02.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 02/02/2018] [Accepted: 02/05/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND In this initial series, we evaluated the use of microvascular decompression (MVD) under an awake anesthesia protocol ("awake" MVD) to assess whether intraoperative pain evaluation can identify and mitigate insufficient decompression of the trigeminal nerve, improving surgical outcomes, and possibly expand the indications of MVD in patients with comorbidities that would preclude the use of general endotracheal anesthesia (GEA). METHODS An Institutional Review Board-approved prospective study of 10 consecutive adults who underwent MVD for trigeminal neuralgia (TN) was conducted. The primary outcome measure was postoperative TN pain quantified on the Barrow Neurological Institute (BNI) Pain Severity Scale. RESULTS The median patient age was 65.5 years, with a female:male ratio of 6:4. All 10 patients tolerated the procedure well and did not require GEA intraoperatively or postoperatively. Nine patients had a successful surgical outcome (BNI score I, n = 5; BNI score II, n = 4). One patient did not have pain relief (BNI score IV). This same patient also developed a pseudomeningocele, which was the sole surgical complication observed in this series. One patient experienced recurrence of pain at 11 months, with BNI score increasing from I to II. The median duration of follow-up was 16.5 months. Two patients did not experienced resolution of evoked pain during intraoperative awake testing following decompression. Further intraoperative exploration revealed secondary offending vessels that were subsequently decompressed, leading to resolution of pain. CONCLUSIONS Intraoperative awake testing for treatment efficacy may increase the success rate of MVD by rapidly identifying and mitigating insufficient cranial nerve V decompression.
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Affiliation(s)
- Saleem I Abdulrauf
- Department of Neurosurgery, Saint Louis University School of Medicine, St Louis, Missouri, USA.
| | - Jorge F Urquiaga
- Department of Neurosurgery, Saint Louis University School of Medicine, St Louis, Missouri, USA
| | - Ritesh Patel
- Department of Anesthesiology and Critical Care, Saint Louis University School of Medicine, St Louis, Missouri, USA
| | - J Andrew Albers
- Department of Neurosurgery, Saint Louis University School of Medicine, St Louis, Missouri, USA
| | - Varun B Sampat
- Department of Neurosurgery, Saint Louis University School of Medicine, St Louis, Missouri, USA
| | - Meghan Baumer
- Department of Neurosurgery, Saint Louis University School of Medicine, St Louis, Missouri, USA
| | - Eric Marvin
- Department of Neurosurgery, Saint Louis University School of Medicine, St Louis, Missouri, USA
| | - Matthew Pierson
- Department of Neurosurgery, Saint Louis University School of Medicine, St Louis, Missouri, USA
| | - Raquel Kragel
- Department of Neurosurgery, Saint Louis University School of Medicine, St Louis, Missouri, USA
| | - Jodi Walsh
- Department of Neurosurgery, Saint Louis University School of Medicine, St Louis, Missouri, USA
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21
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Komatsu K, Mikami T, Yokoyama R, Suzuki Y, Komura S, Enatsu R, Noshiro S, Miyata K, Akiyama Y, Mikuni N. Electrophysiological influence of temporal occlusion of the parent artery during aneurysm surgery. J Clin Neurosci 2017; 45:199-204. [PMID: 28673672 DOI: 10.1016/j.jocn.2017.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 06/09/2017] [Indexed: 11/17/2022]
Abstract
Intraoperative monitoring of the motor evoked potential (MEP) during cerebral aneurysm surgery has been widely used to confirm surgical safety. In this study, we retrospectively analyzed the influence of the MEP amplitude resulting from temporal occlusion of the parent artery, and appropriate judgement in the surgery was discussed. Ten patients underwent temporal occlusion of the parent artery during aneurysm surgery, and five of these patients showed a decrease in the MEP amplitude following temporal arterial occlusion. Clinical factors in patients with and without MEP decrease were compared. The time gap between the surgical procedure and the MEP change and recovery was then investigated. A decrease in the MEP amplitude caused by temporal occlusion had a significantly higher occurrence compared with permanent clip failure. The time from the release procedure to MEP amplitude recovery was relatively longer than the time from the occlusion procedure to the decrease in MEP amplitude. The time from release procedure to MEP amplitude recovery showed a weak correlation with the parent artery occlusion time. There is a time gap between releasing the temporal arterial occlusion and MEP recovery that is similar to temporal parent arterial occlusion and the MEP decrease. The cause of MEP amplitude should be judged carefully, and influence of parent artery temporal occlusion should be taken into consideration during aneurysm clipping.
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Affiliation(s)
- Katsuya Komatsu
- Department of Neurosurgery, Sapporo Medical University, Japan
| | - Takeshi Mikami
- Department of Neurosurgery, Sapporo Medical University, Japan.
| | | | - Yuto Suzuki
- Department of Neurosurgery, Sapporo Medical University, Japan
| | - Shoichi Komura
- Department of Neurosurgery, Sapporo Medical University, Japan
| | - Rei Enatsu
- Department of Neurosurgery, Sapporo Medical University, Japan
| | - Shouhei Noshiro
- Department of Neurosurgery, Sapporo Medical University, Japan
| | - Kei Miyata
- Department of Neurosurgery, Sapporo Medical University, Japan
| | | | - Nobuhiro Mikuni
- Department of Neurosurgery, Sapporo Medical University, Japan
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22
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Awake High-Flow Extracranial to Intracranial Bypass for Complex Cerebral Aneurysms: Institutional Clinical Trial Results. World Neurosurg 2017; 105:557-567. [PMID: 28416411 DOI: 10.1016/j.wneu.2017.04.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 04/01/2017] [Accepted: 04/05/2017] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Assess the potential added benefit to patient outcomes of "awake" neurological testing when compared with standard neurophysiologic testing performed under general endotracheal anesthesia. METHODS Prospective study of 30 consecutive adult patients who underwent awake high flow extracranial to intracranial (HFEC-IC) bypass. Clinical neurological and neurophysiologic findings were recorded. Primary outcome measures were the incidence of stroke/cerebrovascular accident (CVA), length of stay, discharge to rehabilitation, 30-day modified Rankin scale score, and death. An analysis was also performed of a retrospective control cohort (n = 110 patients who underwent HFEC-IC for internal carotid artery (ICA) aneurysms under standard general endotracheal anesthesia). RESULTS Five patients (16.6%) developed clinical awake neurological changes (4, contralateral hemiparesis; 1, ipsilateral visual changes) during the 10-minute ICA occlusion test. These patients had 2 kinks in the graft, 1 vasospasm, 1 requiring reconstruction of the distal anastomosis, and 1 developed blurring of vision that reversed after the removal of the distal permanent clip on the ICA. Three of these 5 patients had asynchronous clinical "awake" neurological and neurophysiologic changes. Two patients (7%) developed CVA. Median length of stay was 4 days. Twenty-eight of 30 patients were discharged to home. Median modified Rankin scale score was 1. There were no deaths in this series. Absolute risk reduction in the awake craniotomy group (n = 30) relative to control retrospective group (n = 110) was 7% for CVA, 9% for discharge to rehabilitation, and 10% for graft patency. CONCLUSIONS Temporary ICA occlusion during HFEC-IC bypass for ICA aneurysms in conjunction with awake intraoperative clinical testing was effective in detecting a subset of patients (n = 3, 10%) in whom neurological deficit was not detected by neurophysiologic monitoring alone.
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23
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Yamada Y, Kato Y, Nouri M, Ganaha T, Oheda M, Ishihara K, Moriya S, Sadato A, Inamasu J, Hirose Y. Predictive Value of Motor Evoked Potential Monitoring during Surgery of Unruptured Anterior Circulation Cerebral Aneurysms. Asian J Neurosurg 2017; 12:644-647. [PMID: 29114276 PMCID: PMC5652088 DOI: 10.4103/ajns.ajns_135_14] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective and Background: Surgery of unruptured aneurysms is always a great challenge to neurovascular surgeons because no postoperative neurological deficits should be expected postoperatively as the patients are fully asymptomatic before the surgery. Here, we present our experience with selective motor evoked potential (MEP) monitoring of our patients in a 2-year time window. Patients and Methods: From 2012 to 2014, 27 patients with unruptured intracranial aneurysms were operated in our institute with the help of MEP monitoring. All patients underwent endoscope-assisted microsurgery with pre- and post-clipping indocyanine green angiography. Results: In this period, no mortality was observed, but 18.5% of the patients developed postoperative deficits which showed good recovery in all cases. Overall, MEP showed about 90% accuracy in predicting postoperative deficits. Conclusions: MEP as a part of multimodality monitoring of aneurysm surgeries is a valuable tool to improve the outcome. However, we should know its limitations as its results are not always consistent with the outcome.
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Affiliation(s)
- Yasuhiro Yamada
- Department of Neurosurgery, Fujita Health University Hospital, Toyoake, Aichi, Japan
| | - Yoko Kato
- Department of Neurosurgery, Fujita Health University Hospital, Toyoake, Aichi, Japan
| | - Mohsen Nouri
- Department of Neurosurgery, Fujita Health University Hospital, Toyoake, Aichi, Japan
| | - Tsukasa Ganaha
- Department of Neurosurgery, Fujita Health University Hospital, Toyoake, Aichi, Japan
| | - Motoki Oheda
- Department of Neurosurgery, Fujita Health University Hospital, Toyoake, Aichi, Japan
| | - Kohei Ishihara
- Department of Neurosurgery, Fujita Health University Hospital, Toyoake, Aichi, Japan
| | - Shigeta Moriya
- Department of Neurosurgery, Fujita Health University Hospital, Toyoake, Aichi, Japan
| | - Akiyo Sadato
- Department of Neurosurgery, Fujita Health University Hospital, Toyoake, Aichi, Japan
| | - Joji Inamasu
- Department of Neurosurgery, Fujita Health University Hospital, Toyoake, Aichi, Japan
| | - Yuichi Hirose
- Department of Neurosurgery, Fujita Health University Hospital, Toyoake, Aichi, Japan
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Awake surgery for hemispheric low-grade gliomas: oncological, functional and methodological differences between pediatric and adult populations. Childs Nerv Syst 2016; 32:1861-74. [PMID: 27659829 DOI: 10.1007/s00381-016-3069-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 03/14/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Brain mapping through a direct cortical and subcortical electrical stimulation during an awake craniotomy has gained an increasing popularity as a powerful tool to prevent neurological deficit while increasing extent of resection of hemispheric diffuse low-grade gliomas in adults. However, few case reports or very limited series of awake surgery in children are currently available in the literature. METHODS In this paper, we review the oncological and functional differences between pediatric and adult populations, and the methodological specificities that may limit the use of awake mapping in pediatric low-grade glioma surgery. RESULTS This could be explained by the fact that pediatric low-grade gliomas have a different epidemiology and biologic behavior in comparison to adults, with pilocytic astrocytomas (WHO grade I glioma) as the most frequent histotype, and with WHO grade II gliomas less prone to anaplastic transformation than their adult counterparts. In addition, aside from the issue of poor collaboration of younger children under 10 years of age, some anatomical and functional peculiarities of children developing brain (cortical and subcortical myelination, maturation of neural networks and of specialized cortical areas) can influence direct electrical stimulation methodology and sensitivity, limiting its use in children. CONCLUSIONS Therefore, even though awake procedure with cortical and axonal stimulation mapping can be adapted in a specific subgroup of children with a diffuse glioma from the age of 10 years, only few pediatric patients are nonetheless candidates for awake brain surgery.
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Grossauer S, Koeck K, Kraschl J, Olipitz O, Hausegger KA, Vince GH. Detection of Cerebral Vasospasm Following Aneurysmal Subarachnoid Hemorrhage Using Motor Evoked Potentials. Neurosurgery 2016; 78:265-73. [PMID: 26421589 DOI: 10.1227/neu.0000000000001040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Early detection of vasospasm (VS) following aneurysmal subarachnoid hemorrhage (aSAH) is vital to trigger therapy and to prevent infarction and subsequent permanent neurological deficit. Although motor evoked potentials (MEPs) are a well-established method for intraoperative detection of cerebral VS and cerebral ischemia during aneurysm surgery, there are no studies investigating the diagnostic value of MEPs for detecting delayed VS following aSAH in an intensive care unit. OBJECTIVE A prospective study was conceived to assess the diagnostic accuracy of MEPs in comparison with digital subtraction angiography. METHODS MEP threshold changes were determined in patients both with and without angiographic VS following high-grade aSAHs. Sensitivity, specificity, and the positive and negative predictive values of significant MEP threshold increases, which indicate angiographic VS, were calculated. RESULTS In all patients experiencing VS of the arteries supplying cerebral motor areas, a minimal MEP threshold increase of 50 mA (mean 66.25 mA) was observed, whereas a maximum MEP threshold increase of 30 mA was observed in patients without VS. Therefore, an increase from a baseline of ≥50 mA was considered significant and resulted in a sensitivity of 0.83, a specificity of 0.92, a positive predictive value of 0.83, and a negative predictive value of 0.92. CONCLUSION VS following aSAH can be detected accurately by using MEPs. MEPs are a feasible bedside tool for online VS detection in an intensive care unit and, therefore, may complement existing diagnostic tools.
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Affiliation(s)
- Stefan Grossauer
- ‡Department of Neurosurgery, General Hospital of Klagenfurt, Klagenfurt, Austria; §Institute of Human Biology, Karl-Franzens University Graz, Graz, Austria; ¶Department of Interventional and Diagnostic Radiology, General Hospital of Klagenfurt, Klagenfurt, Austria
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Mikuni N. Japanese Congress of Neurological Surgeons Presidential Address. Neurosurgery 2016; 63 Suppl 1:83-84. [DOI: 10.1227/neu.0000000000001278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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The sensory-motor profile awake-A new tool for pre-, intra-, and postoperative assessment of sensory-motor function. Clin Neurol Neurosurg 2016; 147:39-45. [PMID: 27276340 DOI: 10.1016/j.clineuro.2016.05.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 05/17/2016] [Accepted: 05/22/2016] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Awake craniotomy is a well-established procedure in surgery of intracranial tumors in eloquent areas. However, sufficiently standardized instruments for the assessment of sensory-motor function before, during and after the operation are currently lacking, despite their importance for evaluation of operative outcome. PATIENTS AND METHODS To address this issue, we designed a standardized assessment tool (the "sensory-motor profile awake scale"; SMP-a). The final scale consists of three motor sections (face, arm and leg) assessing both gross and fine motor skills and one sensory section. It differentiates between six grades of impairment and its tasks are applicable for intraoperative continuous monitoring of sensory-motor functions and supporting processes. We analyzed the data of 17 patients with intracranial tumors eligible for awake craniotomy who were preoperatively assessed with the SMP-a. In addition, we present an exemplary case. RESULTS Our data support the assumption that the SMP-a is feasible in patients eligible for awake craniotomy, even in patients with symptoms of mild aphasia or more severe sensory-motor deficits caused by tumor recurrence. The exemplary case demonstrates the feasibility of repeated measures with the SMP-a in a tumor patient, including the adaption of tasks to the individual requirements of an intraoperative setting. CONCLUSION This exploratory study suggests that the SMP-a might be a feasible rating scale in patients with intracranial tumors. The flexibility of the scale enables individual adaption, but preserves the standardized scoring system to allow comparison between assessment dates, patients and, hopefully in the future, institutions. However, future studies are mandatory to provide data on the instrument's diagnostic properties with respect to feasibility, objectivity, validity and reliability.
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Park W, Ahn JS, Lee SH, Park JC, Kwun BD. Results of re-exploration because of compromised distal blood flow after clipping unruptured intracranial aneurysms. Acta Neurochir (Wien) 2015; 157:1015-24; discussion 1024. [PMID: 25845552 DOI: 10.1007/s00701-015-2408-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 03/18/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND One of the major causes for performing unplanned re-exploration of a craniotomy after microsurgery for unruptured intracranial aneurysms (UIAs) is compromised distal blood flow after clipping. Therefore, it is important to identify the causes of compromised distal blood flow after clipping and the factors that influence the prognosis for re-exploration in order to decrease ischemic complications related to clipping UIAs. METHOD Between January 2007 and December 2013, 1954 patients underwent microsurgery for UIAs. In this cohort, 20 patients (1.0%) required unplanned re-exploration of the craniotomy for several reasons, and 11 patients (0.6%) underwent unplanned re-exploration with clip repositioning or changing of the previous clip because of compromised distal blood flow after clipping. Patient characteristics, aneurysm properties, intraoperative findings, annual incidence and prognosis were analyzed in these 11 patients. RESULTS The annual incidence of re-exploration has gradually decreased since the introduction of several intraoperative monitoring techniques. In total, 3.0% of UIAs in the M1 trunk, 0.8% of UIAs at the origin of the anterior choroidal artery (AchA) and 0.5% of UIAs at the bifurcation of the middle cerebral artery (MCA) required re-exploration. Here, all 11 UIAs had broad necks, and atherosclerosis was identified around 10 UIAs. Six patients with compromised MCA flow demonstrated relatively better outcomes following re-exploration than five patients with a compromised lenticulostriate artery (LSA) or AchA flow. Four patients with delayed ischemic symptoms demonstrated relatively better outcomes than the seven patients who developed ischemic symptoms immediately postoperatively. CONCLUSION Clinicians need to be more careful not to compromise distal blood flow when clipping UIAs at the MCA and AchA origin. Various intraoperative monitoring techniques can help reduce the incidence of compromised distal blood flow after clipping.
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Affiliation(s)
- Wonhyoung Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736 l, South Korea
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Saito T, Muragaki Y, Maruyama T, Tamura M, Nitta M, Okada Y. Intraoperative functional mapping and monitoring during glioma surgery. Neurol Med Chir (Tokyo) 2014; 55:1-13. [PMID: 25744346 PMCID: PMC4533401 DOI: 10.2176/nmc.ra.2014-0215] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Glioma surgery represents a significant advance with respect to improving resection rates using new surgical techniques, including intraoperative functional mapping, monitoring, and imaging. Functional mapping under awake craniotomy can be used to detect individual eloquent tissues of speech and/or motor functions in order to prevent unexpected deficits and promote extensive resection. In addition, monitoring the patient’s neurological findings during resection is also very useful for maximizing the removal rate and minimizing deficits by alarming that the touched area is close to eloquent regions and fibers. Assessing several types of evoked potentials, including motor evoked potentials (MEPs), sensory evoked potentials (SEPs) and visual evoked potentials (VEPs), is also helpful for performing surgical monitoring in patients under general anesthesia (GA). We herein review the utility of intraoperative mapping and monitoring the assessment of neurological findings, with a particular focus on speech and the motor function, in patients undergoing glioma surgery.
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Affiliation(s)
- Taiichi Saito
- Department of Neurosurgery, Institute of Advanced Biomedical Engineering and Science, Tokyo Women' Medical University; Department of Neurosurgery, Tokyo Rosai Hospital
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