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Mattogno PP, D'Alessandris QG, Rigante M, Granata G, Di Domenico M, Perotti V, Montano N, Giordano M, Chiloiro S, Doglietto F, Olivi A, Lauretti L. Reliability of intraoperative visual evoked potentials (iVEPs) in monitoring visual function during endoscopic transsphenoidal surgery. Acta Neurochir (Wien) 2023; 165:3421-3429. [PMID: 37733080 PMCID: PMC10624729 DOI: 10.1007/s00701-023-05778-1] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 08/23/2023] [Indexed: 09/22/2023]
Abstract
OBJECTIVE To refine a reliable and reproducible intraoperative visual evoked potentials (iVEPs) monitoring protocol during endoscopic transsphenoidal surgery. To assess the reliability of baseline iVEPs in predicting preoperative visual status and perioperative iVEP variation in predicting postoperative visual outcome. METHODS Sixty-four patients harboring tumors of the pituitary region were included. All patients underwent endoscopic endonasal approach (EEA) with iVEPs monitoring, using a totally intravenous anesthetic protocol. Ophthalmological evaluation included visual acuity and visual field studies. RESULTS Preoperatively, visual acuity was reduced in 86% and visual field in 76.5% of cases. Baseline iVEPs amplitude was significantly correlated with preoperative visual acuity and visual field (p = 0.001 and p = 0.0004, respectively), confirming the reliability of the neurophysiological/anesthetic protocol implemented. Importantly, perioperatively the variation in iVEPs amplitude was significantly correlated with the changes in visual acuity (p < 0.0001) and visual field (p = 0.0013). ROC analysis confirmed that iVEPs are an accurate predictor of perioperiative visual acuity improvement, with a 100% positive predictive value in patients with preoperative vision loss. CONCLUSIONS iVEPs during EEA is highly reliable in describing preoperative visual function and can accurately predict postoperative vision improvement. SIGNIFICANCE iVEPs represent a promising resource for carrying out a more effective and safe endoscopic transsphenoidal surgery.
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Affiliation(s)
- Pier Paolo Mattogno
- Institute of Neurosurgery, Fondazione Policlinico Gemelli IRCCS, Università Cattolica del Sacro Cuore - Roma, Largo A. Gemelli 8, 00168, Rome, Italy.
| | - Quintino Giorgio D'Alessandris
- Institute of Neurosurgery, Fondazione Policlinico Gemelli IRCCS, Università Cattolica del Sacro Cuore - Roma, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Mario Rigante
- Department of Otorhinolaryngology, Fondazione Policlinico Gemelli IRCCS, Università Cattolica del Sacro Cuore - Roma, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Giuseppe Granata
- Department of Neurology, Fondazione Policlinico Gemelli IRCCS, Università Cattolica del Sacro Cuore - Roma, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Michele Di Domenico
- Institute of Neurosurgery, Fondazione Policlinico Gemelli IRCCS, Università Cattolica del Sacro Cuore - Roma, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Valerio Perotti
- Department of Anesthesiology, Fondazione Policlinico Gemelli IRCCS, Università Cattolica del Sacro Cuore - Roma, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Nicola Montano
- Institute of Neurosurgery, Fondazione Policlinico Gemelli IRCCS, Università Cattolica del Sacro Cuore - Roma, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Martina Giordano
- Institute of Neurosurgery, Fondazione Policlinico Gemelli IRCCS, Università Cattolica del Sacro Cuore - Roma, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Sabrina Chiloiro
- Pituitary Unit, Department of Endocrinology and Metabolism, Fondazione Policlinico Gemelli IRCCS - Università Cattolica del Sacro Cuore - Roma, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Francesco Doglietto
- Institute of Neurosurgery, Fondazione Policlinico Gemelli IRCCS, Università Cattolica del Sacro Cuore - Roma, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Alessandro Olivi
- Institute of Neurosurgery, Fondazione Policlinico Gemelli IRCCS, Università Cattolica del Sacro Cuore - Roma, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Liverana Lauretti
- Institute of Neurosurgery, Fondazione Policlinico Gemelli IRCCS, Università Cattolica del Sacro Cuore - Roma, Largo A. Gemelli 8, 00168, Rome, Italy
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Olmsted ZT, Silverstein JW, Einstein EH, Sowulewski J, Nelson P, Boockvar JA, D'Amico RS. Evolution of flash visual evoked potentials to monitor visual pathway integrity during tumor resection: illustrative cases and literature review. Neurosurg Rev 2023; 46:46. [PMID: 36715828 DOI: 10.1007/s10143-023-01955-z] [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: 04/02/2022] [Revised: 12/21/2022] [Accepted: 01/23/2023] [Indexed: 01/31/2023]
Abstract
Flash visual evoked potentials (fVEPs) provide a means to interrogate visual system functioning intraoperatively during tumor resection in which the optic pathway is at risk for injury. Due to technical limitations, fVEPs have remained underutilized in the armamentarium of intraoperative neurophysiological monitoring (IONM) techniques. Here we review the evolution of fVEPs as an IONM technique with emphasis on the enabling technological and intraoperative improvements. A combined approach with electroretinography (ERG) has enhanced feasibility of fVEP neuromonitoring as a practical application to increase safety and reduce error during tumor resection near the prechiasmal optic pathway. The major advance has been towards differentiating true cases of damage from false findings. We use two illustrative neurosurgical cases in which fVEPs were monitored with and without ERG to discuss limitations and demonstrate how ERG data can clarify false-positive findings in the operating room. Standardization measures have focused on uniformity of photostimulation parameters for fVEP recordings between neurosurgical groups.
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Affiliation(s)
- Zachary T Olmsted
- Department of Neurological Surgery, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra, Northwell Health, New York, NY, USA.
| | - Justin W Silverstein
- Department of Neurology, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra, Northwell Health, New York, NY, USA
- Neuro Protective Solutions, New York, NY, USA
| | - Evan H Einstein
- Department of Neurological Surgery, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra, Northwell Health, New York, NY, USA
| | | | - Priscilla Nelson
- Department of Anesthesiology, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra, Northwell Health, New York, NY, USA
| | - John A Boockvar
- Department of Neurological Surgery, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra, Northwell Health, New York, NY, USA
| | - Randy S D'Amico
- Department of Neurological Surgery, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra, Northwell Health, New York, NY, USA
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Yamada S, Hayamizu K, Akiyama Y, Kimura Y, Hashimoto S, Mikuni N, Yamakage M. Effect of remimazolam on intraoperative neurophysiology monitoring of visual-evoked potential: a case series. J Anesth 2023; 37:311-314. [PMID: 36602625 DOI: 10.1007/s00540-022-03159-z] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 12/18/2022] [Indexed: 01/06/2023]
Abstract
There are very few reports on the effects of benzodiazepines such as midazolam and diazepam on intraoperative visual-evoked potential (VEP), and there is no report on the effect of remimazolam at all. Five patients underwent neurosurgery using VEP monitoring for avoiding surgical injury to the optic nerve. In all cases, drug administration was based on actual body weight. General anesthesia was induced with propofol and remifentanil, and then maintained with propofol at target concentrations of 2.7-3.5 µg/ml for maintaining bispectral index (BIS) between 40 and 60. After resection of the tumor under stable VEP, we discontinued propofol immediately followed by infusion of remimazolam at 12 mg/kg/h for a few seconds, then reduced to 1 mg/kg/h. After a time, when blood levels of remimazolam appeared to be stable, VEP was monitored again and compared to controls. In all cases, we were able to confirm that there was reproducibility. Remimazolam may provide a comparable quality of anesthesia to that of existing drugs for VEP in neurosurgery.
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Affiliation(s)
- Shoto Yamada
- Division of Clinical Engineering, Sapporo Medical University Hospital, South 1, West 16, Chuo-Ku, Sapporo-Shi, Hokkaido, 060-8543, Japan
| | - Kengo Hayamizu
- Department of Anesthesiology, Sapporo Medical University, South 1, West 16, Chuo-Ku, Sapporo-Shi, Hokkaido, 060-8543, Japan.
| | - Yukinori Akiyama
- Department of Neurosurgery, Sapporo Medical University, South 1, West 16, Chuo-Ku, Sapporo-Shi, Hokkaido, 060-8543, Japan
| | - Yusuke Kimura
- Department of Neurosurgery, Sapporo Medical University, South 1, West 16, Chuo-Ku, Sapporo-Shi, Hokkaido, 060-8543, Japan
| | - Shuichi Hashimoto
- Division of Clinical Engineering, Sapporo Medical University Hospital, South 1, West 16, Chuo-Ku, Sapporo-Shi, Hokkaido, 060-8543, Japan
| | - Nobuhiro Mikuni
- Department of Neurosurgery, Sapporo Medical University, South 1, West 16, Chuo-Ku, Sapporo-Shi, Hokkaido, 060-8543, Japan
| | - Michiaki Yamakage
- Department of Anesthesiology, Sapporo Medical University, South 1, West 16, Chuo-Ku, Sapporo-Shi, Hokkaido, 060-8543, Japan
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Chang S, Zwueste D, Ambros B, Norton J, Leis ML. Comparison of the effect of sedation and general anesthesia on pattern and flash visual evoked potentials in normal dogs. BMC Vet Res 2022; 18:272. [PMID: 35831819 PMCID: PMC9277965 DOI: 10.1186/s12917-022-03375-5] [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] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 06/30/2022] [Indexed: 11/12/2022] Open
Abstract
Background Visual evoked potentials (VEPs) can provide objective functional assessment of the post-retinal visual pathway. This study compared the effects of sedation (butorphanol and dexmedetomidine) and general anesthesia (propofol and sevoflurane) on pattern and flash VEPs. Dogs (n = 13) underwent sedation or anesthesia and VEPs were obtained from 3 subcutaneous recording electrodes placed on the head (O1, Oz, O2). Results Pattern VEPs could only be recorded under sedation and a maximum of 3 peaks were identified (N75, P100, N135). Flash VEPs could be recorded under both sedation and anesthesia and a maximum of 5 peaks were identified (N1, P1, N2, P2, N3). The latency of the N1 peak and the baseline-N1 amplitude were significantly longer under general anesthesia. Conclusion Visual evoked potentials should be preferentially recorded in dogs sedated with dexmedetomidine and butorphanol, regardless of the stimulus. Supplementary Information The online version contains supplementary material available at 10.1186/s12917-022-03375-5.
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Affiliation(s)
- Stephanie Chang
- Department of Small Animal Clinical Sciences, Western College of Veterinary Medicine, University of Saskatchewan, 52 Campus Drive, Saskatoon, SK, S7N 5B4, Canada
| | - Danielle Zwueste
- Department of Small Animal Clinical Sciences, Western College of Veterinary Medicine, University of Saskatchewan, 52 Campus Drive, Saskatoon, SK, S7N 5B4, Canada
| | - Barbara Ambros
- Department of Small Animal Clinical Sciences, Western College of Veterinary Medicine, University of Saskatchewan, 52 Campus Drive, Saskatoon, SK, S7N 5B4, Canada
| | - Jonathan Norton
- Department of Surgery, College of Medicine, University of Saskatchewan, Saskatoon, SK, S7N 5E5, Canada
| | - Marina L Leis
- Department of Small Animal Clinical Sciences, Western College of Veterinary Medicine, University of Saskatchewan, 52 Campus Drive, Saskatoon, SK, S7N 5B4, Canada.
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Jashek-Ahmed F, Cabrilo I, Bal J, Sanders B, Grieve J, Dorward NL, Marcus HJ. Intraoperative monitoring of visual evoked potentials in patients undergoing transsphenoidal surgery for pituitary adenoma: a systematic review. BMC Neurol 2021; 21:287. [PMID: 34301198 PMCID: PMC8299587 DOI: 10.1186/s12883-021-02315-4] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 07/01/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Transsphenoidal surgery is the gold standard for pituitary adenoma resection. Although rare, a serious complication of surgery is worsened vision post-operatively. OBJECTIVE To determine whether, in patients undergoing transsphenoidal surgery for pituitary adenoma, intraoperative monitoring of visual evoked potentials (VEP) is a safe, reproducible, and effective technological adjunct in predicting postoperative visual function. METHODS The PubMed and OVID platforms were searched between January 1993 and December 2020 to identify publications that (1) featured patients undergoing transsphenoidal surgery for pituitary adenoma, (2) used intraoperative optic nerve monitoring with VEP and (3) reported on safety or effectiveness. Reference lists were cross-checked and expert opinion sought to identify further publications. RESULTS Eleven studies were included comprising ten case series and one prospective cohort study. All employed techniques to improve reliability. No safety issues were reported. The only comparative study included described a statistically significant improvement in post-operative visual field testing when VEP monitoring was used. The remaining case-series varied in conclusion. In nine studies, surgical manipulation was halted in the event of a VEP amplitude decrease suggesting a widespread consensus that this is a warning sign of injury to the anterior optic apparatus. CONCLUSIONS Despite limited and low-quality published evidence regarding intra-operative VEP monitoring, our review suggests that it is a safe, reproducible, and increasingly effective technique of predicting postoperative visual deficits. Further studies specific to transsphenoidal surgery are required to determine its utility in protecting visual function in the resection of complex pituitary tumours.
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Affiliation(s)
- Farizeh Jashek-Ahmed
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, UK.
| | - Ivan Cabrilo
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Jarnail Bal
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Brett Sanders
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Joan Grieve
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Neil L Dorward
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Hani J Marcus
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, UK
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Houlden DA, Turgeon CA, Amyot NS, Edem I, Sinclair J, Agbi C, Polis T, Alkherayf F. Intraoperative Flash Visual Evoked Potential Recording and Relationship to Visual Outcome. Can J Neurol Sci 2019; 46:295-302. [PMID: 30867080 DOI: 10.1017/cjn.2019.4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To determine the relationship between intraoperative flash visual evoked potential (FVEP) monitoring and visual function. METHODS Intraoperative FVEPs were recorded from electrodes placed in the scalp overlying the visual cortex (Oz) after flashing red light stimulation delivered by Cadwell LED stimulating goggles in 89 patients. Restrictive filtering (typically 10-100 Hz), optimal reject window settings, mastoid reference site, total intravenous anesthetic (TIVA), and stable retinal stimulation (ensured by concomitant electroretinogram [ERG] recording) were used to enhance FVEP reproducibility. RESULTS The relationship between FVEP amplitude change and visual outcome was determined from 179 eyes. One eye had a permanent intraoperative FVEP loss despite stable ERG, and this eye had new, severe postoperative visual dysfunction. Seven eyes had transient significant FVEP change (>50% amplitude decrease that recovered by the end of surgery), but only one of those had a decrease in postoperative visual acuity. FVEP changes in all eight eyes (one permanent FVEP loss plus seven transient FVEP changes) were related to surgical manipulation. In each case the surgeon was promptly informed of the FVEP deterioration and took remedial action. The other eyes did not have FVEP changes, and none of those eyes had new postoperative visual deficits. CONCLUSIONS Our FVEP findings relate to visual outcome with a sensitivity and specificity of 1.0. New methods for rapidly acquiring reproducible FVEP waveforms allowed for timely reporting of significant FVEP change resulting in prompt surgical action. This may have accounted for the low postoperative visual deficit rate (1%) in this series.
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Soffin EM, Emerson RG, Cheng J, Mercado K, Smith K, Beckman JD. A pilot study to record visual evoked potentials during prone spine surgery using the SightSaver™ photic visual stimulator. J Clin Monit Comput 2017; 32:889-895. [DOI: 10.1007/s10877-017-0092-1] [Citation(s) in RCA: 6] [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: 05/11/2017] [Accepted: 12/13/2017] [Indexed: 11/29/2022]
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Abstract
AIM To evaluate the efficacy of neuromonitoring methods in prevention of postoperative neurological complications and estimation of predictive power of intraoperative changes in monitored characteristics. MATERIAL AND METHODS Retrospective study examined 240 patients, operated in the years 2014-2015 using intraoperative neurophysiological monitoring. One hundred and seventy-three patients suffered from hemispheric lesions and 67 had lesions located in or near the brainstem. Somatosensory evoked potentials (SSEP) were monitored in 152 cases, visual in 32, brainstem acoustic in 22, transcranial motor in 36; stimulation mapping of motor cortex was performed in 69 surgeries, and cranial nerves identification in 27. EEG was recorded in 7 patients, and 3 of them were woke up during the surgery for speech mapping. RESULTS The sensitivity of the SSEP in motor dysfunction detection was low (33%), while the specificity was relatively high (82%). These characteristics for visual and motor evoked potentials were close to 100% provided that the parameters of anesthesia met the corresponding requirements. The most effective methods in respect of prevention of postoperative dysfunctions were the stimulation mapping of functionally significant areas (motor and speech) and motor pathways mapping. CONCLUSION Intraoperative neuromonitoring reduces a number of neurological complications after neurosurgical operations. The SSEP method is not sensitive enough in surgeries that could affect motor centers and/or pathways, and multimodal monitoring combining SSEP and motor responses recording during transcranial and/or direct electrical brain stimulation. Successful monitoring requires highly coordinated actions between neurophysiologists, neurosurgeons and anesthesiologists.
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Affiliation(s)
- A G Vasyatkina
- Center of Angioneurology and Neurosurgery, Novosibirsk Research Institute of Circulation Pathology, Ministry of Health Care of Russian Federation, Novosibirsk, Russia
| | - E A Levin
- Center of Angioneurology and Neurosurgery, Novosibirsk Research Institute of Circulation Pathology, Ministry of Health Care of Russian Federation, Novosibirsk, Russia
| | - K Yu Orlov
- Center of Angioneurology and Neurosurgery, Novosibirsk Research Institute of Circulation Pathology, Ministry of Health Care of Russian Federation, Novosibirsk, Russia
| | - V V Kobozev
- Center of Angioneurology and Neurosurgery, Novosibirsk Research Institute of Circulation Pathology, Ministry of Health Care of Russian Federation, Novosibirsk, Russia
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Huberfeld G, Trébuchon A, Capelle L, Badier JM, Chen S, Lefaucheur JP, Gavaret M. Preoperative and intraoperative neurophysiological investigations for surgical resections in functional areas. Neurochirurgie 2017; 63:142-149. [DOI: 10.1016/j.neuchi.2016.10.008] [Citation(s) in RCA: 12] [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: 04/30/2016] [Revised: 10/17/2016] [Accepted: 10/31/2016] [Indexed: 01/23/2023]
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