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Sasaki T, Murakami K, Saito A, Haryu S, Kameyama M, Takahashi Y, Takamuro S, Kato N, Endo T. Usefulness of Transcranial Motor Evoked Potential in Clipping Surgery for Cerebral Aneurysms-Introduction of a New Protocol for Stable Monitoring. Neurol Med Chir (Tokyo) 2023; 63:409-419. [PMID: 37380449 PMCID: PMC10556210 DOI: 10.2176/jns-nmc.2023-0007] [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: 01/21/2023] [Accepted: 04/17/2023] [Indexed: 06/30/2023] Open
Abstract
The usefulness of transcranial motor evoked potentials (Tc-MEPs) in clipping surgery has been reported. However, numerous false positive and false negative cases were reported. We report the usefulness of a new protocol compared with direct cortical MEP (Dc-MEP).Materials were 351 patients who underwent aneurysmal clipping under simultaneous monitoring of Tc- and Dc-MEPs. A total of 337 patients without hemiparesis and 14 with hemiparesis were separately analyzed. Intraoperative changes of Tc-MEP thresholds were examined in the first 50 patients without hemiparesis. The stimulation strength of Tc-MEP was set at +20% of the stimulation threshold. As thresholds changed intraoperatively, thresholds were examined every 10 min and changed stimulation strength.Stimulation thresholds of Tc-MEP were significantly decreased after craniotomy and significantly increased after CSF aspiration. The recording ratios of Tc- and Dc-MEPs were 98.8% and 90.5%, respectively. Out of 304 patients without MEP change, 5 patients developed transient or mild hemiparesis with infarction of the territory of the perforating artery arising from the posterior communicating artery. Out of 31 patients whose MEP transiently disappeared, 3 patients developed transient or mild hemiparesis. The other two patients without MEP recovery manifested persistent hemiparesis. In 14 patients with preoperative hemiparesis, 3 patients whose healthy/affected ratio of Tc-MEP was large developed severe persistent hemiparesis.We clarified the intraoperative changes of Tc-MEP thresholds for the first time. A new protocol of Tc-MEP that followed thresholds and changed stimulation strength to +20% of thresholds is useful for stable monitoring. The usefulness of Tc-MEP is the same as that or better than that of Dc-MEP.
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Affiliation(s)
- Tatsuya Sasaki
- Division of Neurosurgery, Tohoku Medical and Pharmaceutical University
| | | | | | - Shinya Haryu
- Division of Neurosurgery, Tohoku Medical and Pharmaceutical University
| | - Masayuki Kameyama
- Division of Neurosurgery, Tohoku Medical and Pharmaceutical University
| | | | - Satoru Takamuro
- School of Medicine, Tohoku Medical and Pharmaceutical University
| | - Nana Kato
- School of Medicine, Tohoku Medical and Pharmaceutical University
| | - Toshiki Endo
- Division of Neurosurgery, Tohoku Medical and Pharmaceutical University
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Szelényi A, Fernández-Conejero I, Kodama K. Surgery and intraoperative neurophysiologic monitoring for aneurysm clipping. HANDBOOK OF CLINICAL NEUROLOGY 2022; 186:375-393. [PMID: 35772896 DOI: 10.1016/b978-0-12-819826-1.00008-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
This chapter describes the feasibility, utilization, and value of intraoperative neurophysiologic monitoring (IONM) in cerebrovascular cases. Practical advice on the integration of these adjunct methods into the modern neurosurgical operating room is based on our own neurophysiologic and neurosurgical experience. Most IONM is done for anterior circulation aneurysms. Somatosensory and motor evoked potentials are the modalities of choice covering vascular territories of the internal, anterior, and middle cerebral arteries. While monitoring both hemispheres with the unoperated side as control, monitoring focus is laid upon those territories at risk and bearing the aneurysm. The specificity of IONM is close to 1, and sensitivity ranges from 0.2 to 1, depending on the categorization of transient changes. The overall likelihood of worsened neurologic outcome after any intraoperative signal deterioration (transient or permanent) is 0.4.
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Affiliation(s)
- Andrea Szelényi
- Department of Neurosurgery, University Hospital, Ludwig-Maximilians-University (LMU), Munich, Germany.
| | - Isabel Fernández-Conejero
- Unit of Intraoperative Neurophysiology, Department of Neurology, University Hospital of Bellvitge, Barcelona, Spain
| | - Kunihiko Kodama
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan
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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: 3.7] [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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Park D, Kim BH, Lee SE, Jeong E, Cho K, Park JK, Choi YJ, Jin S, Hong D, Kim MC. Usefulness of Intraoperative Neurophysiological Monitoring During the Clipping of Unruptured Intracranial Aneurysm: Diagnostic Efficacy and Detailed Protocol. Front Surg 2021; 8:631053. [PMID: 33718428 PMCID: PMC7952634 DOI: 10.3389/fsurg.2021.631053] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 01/20/2021] [Indexed: 12/21/2022] Open
Abstract
Background: Intraoperative neurophysiological monitoring (IONM) has been widely applied in brain vascular surgeries to reduce postoperative neurologic deficit (PND). This study aimed to investigate the effect of IONM during clipping of unruptured intracranial aneurysms (UIAs). Methods: Between January 2013 and August 2020, we enrolled 193 patients with 202 UIAs in the N group (clipping without IONM) and 319 patients with 343 UIAs in the M group (clipping with IONM). Patients in the M group were intraoperatively monitored for motor evoked potentials (MEPs) and somatosensory evoked potentials (SSEPs). Irreversible evoked potential (EP) change was defined as EP deterioration that did not recover until surgery completion. Sustained PND was defined as neurological symptoms lasting for more than one postoperative month. Results: Ten (3.1%) and 13 (6.7%) in the M and N groups, respectively, presented with PND. Compared with the N group, the M group had significantly lower occurrence rates of sustained PND [odds ratio (OR) = 0.36, 95% confidence interval (CI) = 0.13–0.98, p = 0.04], ischemic complications (OR = 0.39, 95% CI = 0.15–0.98, p = 0.04), and radiologic complications (OR = 0.40, 95% CI = 0.19–0.82, p = 0.01). Temporary clipping was an independent risk factor for ischemic complications (ICs) in the total patient group (OR = 6.18, 95% CI = 1.75–21.83, p = 0.005), but not in the M group (OR = 5.53, 95% CI = 0.76–41.92, p = 0.09). Regarding PND prediction, considering any EP changes (MEP and/or SSEP) showed the best diagnostic efficiency with a sensitivity of 0.900, specificity of 0.940, positive predictive value of 0.321, negative predictive value (NPV) of 0.997, and a negative likelihood ratio (LR) of 0.11. Conclusion: IONM application during UIA clipping can reduce PND and radiological complications. The diagnostic effectiveness of IONM, specifically the NPV and LR negative values, was optimal upon consideration of changes in any EP modality.
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Affiliation(s)
- Dougho Park
- Department of Rehabilitation Medicine, Pohang Stroke and Spine Hospital, Pohang-si, South Korea
| | - Byung Hee Kim
- Department of Rehabilitation Medicine, Pohang Stroke and Spine Hospital, Pohang-si, South Korea
| | - Sang-Eok Lee
- Department of Rehabilitation Medicine, Pohang Stroke and Spine Hospital, Pohang-si, South Korea
| | - Eunhwan Jeong
- Department of Neurology, Pohang Stroke and Spine Hospital, Pohang-si, South Korea
| | - Kwansang Cho
- Department of Anesthesiology, Pohang Stroke and Spine Hospital, Pohang-si, South Korea
| | - Ji Kang Park
- Department of Radiology, Pohang Stroke and Spine Hospital, Pohang-si, South Korea
| | - Yeon-Ju Choi
- Department of Neurosurgery, Pohang Stroke and Spine Hospital, Pohang-si, South Korea
| | - Suntak Jin
- Department of Neurosurgery, Pohang Stroke and Spine Hospital, Pohang-si, South Korea
| | - Daeyoung Hong
- Department of Neurosurgery, Pohang Stroke and Spine Hospital, Pohang-si, South Korea
| | - Mun-Chul Kim
- Department of Neurosurgery, Pohang Stroke and Spine Hospital, Pohang-si, South Korea
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Sinclair CF, Téllez MJ, Sánchez Roldán MA, Ulkatan S. Laryngeal adductor reflex hyperexcitability may predict permanent vocal fold paralysis. Laryngoscope 2019; 130:E625-E627. [PMID: 31854459 DOI: 10.1002/lary.28477] [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: 07/30/2019] [Revised: 11/01/2019] [Accepted: 11/20/2019] [Indexed: 11/07/2022]
Abstract
Laryngeal adductor reflex-continuous intraoperative neuromonitoring (LAR-CIONM) is a novel method of continuous intraoperative neuromonitoring. In contrast to other vagal nerve monitoring techniques, which elicit a laryngeal compound muscle action potential, LAR-CIONM elicits a laryngeal reflex response (LAR). In 300 nerves at risk monitored with LAR-CIONM, two patients have had postoperative permanent vocal fold immobility (VFI). Both patients exhibited a significant LAR amplitude increase prior to complete loss of signal. No other patients have exhibited LAR hyperexcitability. If confirmed in a larger sample, this represents the first time that a vagal intraoperative neuromonitoring technique can distinguish transient from permanent VFI, which could improve patient outcomes. Laryngoscope, 2019 Laryngoscope, 130:E625-E627, 2020.
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Affiliation(s)
- Catherine F Sinclair
- Department of Otolaryngology-Head and Neck Surgery, Mount Sinai West Hospital, New York, New York, U.S.A
| | - Maria J Téllez
- Department of Intraoperative Neurophysiology, Mount Sinai West Hospital, New York, New York, U.S.A
| | - M Angeles Sánchez Roldán
- Department of Intraoperative Neurophysiology, Mount Sinai West Hospital, New York, New York, U.S.A
| | - Sedat Ulkatan
- Department of Intraoperative Neurophysiology, Mount Sinai West Hospital, New York, New York, U.S.A
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Koo DL, Lee WG, Hong SC, Seo DW. Clinical Usefulness of Intraoperative Motor-Evoked Potential Monitoring during Temporal Lobe Epilepsy Surgery. J Clin Neurol 2019; 15:285-291. [PMID: 31286698 PMCID: PMC6620456 DOI: 10.3988/jcn.2019.15.3.285] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 12/12/2018] [Accepted: 12/17/2018] [Indexed: 11/17/2022] Open
Abstract
Background and Purpose We aimed to determine the effectiveness of intraoperative neurophysiological monitoring focused on the transcranial motor-evoked potential (MEP) in patients with medically refractory temporal lobe epilepsy (TLE). Methods We compared postoperative neurological deficits in patients who underwent TLE surgery with or without transcranial MEPs combined with somatosensory evoked potential (SSEP) monitoring between January 1995 and June 2018. Transcranial motor stimulation was performed using subdermal electrodes, and MEP responses were recorded in the four extremity muscles. A decrease of more than 50% in the MEP or the SSEP amplitudes compared with baseline was used as a warning criterion. Results In the TLE surgery group without MEP monitoring, postoperative permanent motor deficits newly developed in 7 of 613 patients. In contrast, no permanent motor deficit occurred in 279 patients who received transcranial MEP and SSEP monitoring. Ten patients who exhibited decreases of more than 50% in the MEP amplitude recovered completely, although two cases showed transient motor deficits that recovered within 3 months postoperatively. Conclusions Intraoperative transcranial MEP monitoring during TLE surgery allowed the prompt detection and appropriate correction of injuries to the motor nervous system or ischemic stroke. Intraoperative transcranial MEP monitoring is a reliable modality for minimizing motor deficits in TLE surgery.
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Affiliation(s)
- Dae Lim Koo
- Department of Neurology, Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Won Gu Lee
- Department of Neurology, Kosin University College of Medicine, Busan, Korea
| | - Seung-Chyul Hong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dae-Won Seo
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Russell MJ, Goodman TA, Visse JM, Beckett L, Saito N, Lyeth BG, Recanzone GH. Sex and Electrode Configuration in Transcranial Electrical Stimulation. Front Psychiatry 2017; 8:147. [PMID: 28855877 PMCID: PMC5558260 DOI: 10.3389/fpsyt.2017.00147] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 07/28/2017] [Indexed: 02/04/2023] Open
Abstract
Transcranial electrical stimulation (tES) can be an effective non-invasive neuromodulation procedure. Unfortunately, the considerable variation in reported treatment outcomes, both within and between studies, has made the procedure unreliable for many applications. To determine if individual differences in cranium morphology and tissue conductivity can account for some of this variation, the electrical density at two cortical locations (temporal and frontal) directly under scalp electrodes was modeled using a validated MRI modeling procedure in 23 subjects (12 males and 11 females). Three different electrode configurations (non-cephalic, bi-cranial, and ring) commonly used in tES were modeled at three current intensities (0.5, 1.0, and 2.0 mA). The aims were to assess the effects of configuration and current intensity on relative current received at a cortical brain target directly under the stimulating electrode and to characterize individual variation. The different electrode configurations resulted in up to a ninefold difference in mean current densities delivered to the brains. The ring configuration delivered the least current and the non-cephalic the most. Female subjects showed much less current to the brain than male subjects. Individual differences in the current received and differences in electrode configurations may account for significant variability in current delivered and, thus, potentially a significant portion of reported variation in clinical outcomes at two commonly targeted regions of the brain.
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Affiliation(s)
| | | | | | - Laurel Beckett
- Division of Biostatistics, Davis School of Medicine, University of California, Davis, Davis, CA, United States
| | - Naomi Saito
- Division of Biostatistics, Davis School of Medicine, University of California, Davis, Davis, CA, United States
| | - Bruce G Lyeth
- Department of Neurological Surgery, University of California, Davis, Davis, CA, United States
| | - Gregg H Recanzone
- Center for Neuroscience, University of California, Davis, Davis, CA, United States.,Department of Neurobiology, Physiology and Behavior, University of California, Davis, Davis, CA, United States
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Singh H, Vogel RW, Lober RM, Doan AT, Matsumoto CI, Kenning TJ, Evans JJ. Intraoperative Neurophysiological Monitoring for Endoscopic Endonasal Approaches to the Skull Base: A Technical Guide. SCIENTIFICA 2016; 2016:1751245. [PMID: 27293965 PMCID: PMC4886091 DOI: 10.1155/2016/1751245] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 04/04/2016] [Accepted: 04/11/2016] [Indexed: 06/06/2023]
Abstract
Intraoperative neurophysiological monitoring during endoscopic, endonasal approaches to the skull base is both feasible and safe. Numerous reports have recently emerged from the literature evaluating the efficacy of different neuromonitoring tests during endonasal procedures, making them relatively well-studied. The authors report on a comprehensive, multimodality approach to monitoring the functional integrity of at risk nervous system structures, including the cerebral cortex, brainstem, cranial nerves, corticospinal tract, corticobulbar tract, and the thalamocortical somatosensory system during endonasal surgery of the skull base. The modalities employed include electroencephalography, somatosensory evoked potentials, free-running and electrically triggered electromyography, transcranial electric motor evoked potentials, and auditory evoked potentials. Methodological considerations as well as benefits and limitations are discussed. The authors argue that, while individual modalities have their limitations, multimodality neuromonitoring provides a real-time, comprehensive assessment of nervous system function and allows for safer, more aggressive management of skull base tumors via the endonasal route.
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Affiliation(s)
- Harminder Singh
- Stanford Hospitals and Clinics, Department of Neurosurgery, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Richard W. Vogel
- Safe Passage Neuromonitoring, 915 Broadway, Suite 1200, New York, NY 10010, USA
| | - Robert M. Lober
- Stanford Hospitals and Clinics, Department of Neurosurgery, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Adam T. Doan
- Safe Passage Neuromonitoring, 915 Broadway, Suite 1200, New York, NY 10010, USA
| | - Craig I. Matsumoto
- Sentient Medical Systems, 11011 McCormick Road, Suite 200, Hunt Valley, MD 21031, USA
| | - Tyler J. Kenning
- Department of Neurosurgery, Albany Medical Center, Physicians Pavilion, First Floor, 47 New Scotland Avenue, MC 10, Albany, NY 12208, USA
| | - James J. Evans
- Thomas Jefferson University Hospital, Department of Neurosurgery, 909 Walnut Street, Third Floor, Philadelphia, PA 19107, USA
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