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Yuan F, Gong A, Gowda P, Khalil A, Farhan A, Hafezi-Nejad N, Bailey CR, Mitchell SE, Gutierrez-Hernandez S, Ritzl EK, Weiss CR. Intraoperative Neuromonitoring during Peripheral Arteriovenous Malformation Embolization. J Vasc Interv Radiol 2023; 34:1609-1617.e2. [PMID: 37187436 DOI: 10.1016/j.jvir.2023.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 04/27/2023] [Accepted: 05/07/2023] [Indexed: 05/17/2023] Open
Abstract
PURPOSE To evaluate whether intraoperative neuromonitoring (IONM), including pre-embolization lidocaine injection challenge ("provocative testing") is associated with reduced risk of irreversible nerve injury during embolization of peripheral arteriovenous malformations (AVMs). MATERIALS AND METHODS Medical records of patients with peripheral AVMs who underwent embolotherapy with IONM with provocative testing between 2012 and 2021 were reviewed retrospectively. Data collected included patient demographic characteristics, AVM location and size, embolic agent used, IONM signal changes after lidocaine and embolic agent injections, postprocedural adverse events, and clinical outcomes. Decisions regarding whether embolization would proceed at specific locations were based on IONM findings after the lidocaine challenge and as embolization proceeded. RESULTS A cohort of 17 patients (mean age, 27 years ± 19; 5 women) who underwent 59 image-guided embolization procedures with adequate IONM data was identified. No permanent neurologic deficits occurred. Transient neurologic deficits were observed in 3 patients (4 sessions), comprising skin numbness (2 patients), extremity weakness (1 patient), and extremity weakness and numbness (1 patient). All neurologic deficits resolved by postoperative day 4 without additional treatment. CONCLUSIONS IONM, including provocative testing, during AVM embolization may minimize potential nerve injury.
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Affiliation(s)
- Frank Yuan
- Division of Interventional Radiology, Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, Maryland. https://twitter.com/DrFrankYuan
| | - Anna Gong
- The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Prateek Gowda
- The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Adham Khalil
- Division of Interventional Radiology, Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ahmed Farhan
- The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nima Hafezi-Nejad
- Division of Interventional Radiology, Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christopher R Bailey
- Division of Interventional Radiology, Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sally E Mitchell
- Division of Interventional Radiology, Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Eva K Ritzl
- Divisions of Epilepsy and Neurocritical Care, Departments of Neurology and Anesthesia and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Clifford R Weiss
- Division of Interventional Radiology, Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
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Shima S, Tanaka Y, Sato S, Niimi Y. Spinal epidural arteriovenous fistula with improved sphincter impairment detected by intraoperative neurophysiological monitoring. Surg Neurol Int 2022; 13:384. [PMID: 36128103 PMCID: PMC9479640 DOI: 10.25259/sni_592_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 08/06/2022] [Indexed: 11/12/2022] Open
Abstract
Background: A spinal epidural arteriovenous fistula (SEAVF) is a rare type of arteriovenous shunt that occurs mainly in the thoracic or lumbar spine. Patients with SEAVF develop motor/sensory disturbances of the lower extremities and sphincter dysfunction. Among these symptoms, sphincter impairments show less improvement than others, and its relevance to neurophysiological monitoring has not been documented. Case Description: A 77-year-old woman presented with progressive motor weakness and numbness in the lower extremities and urinary and fecal incontinence. Spinal magnetic resonance imaging showed spinal cord edema in Th5-Th11 and enlarged perimedullary veins. We performed spinal angiography and endovascular treatment under intraoperative neurophysiological monitoring (IOM), including sensory evoked potential (SEP), motor evoked potential (MEP), and bulbocavernosus reflex (BCR) monitoring. Diagnostic angiography revealed a SEAVF with perimedullary venous drainage fed by the left L2 segmental artery. The shunt was completely embolized using N-butyl-2-cyanoacrylate. Although SEP and MEP of the lower legs were recordable during treatment, anal MEP and BCR were not observed. The sphincter symptoms improved 1.5 years after the treatment. Follow-up angiography revealed no shunt recurrence and improved venous congestion. Anal MEP and BCR were detected during angiography, indicating neurophysiological improvement in sphincter function. The prolonged latency of the monitoring suggested a pudendal nerve injury. Conclusion: This case report first described improvement of the IOM correlated with the functional recovery of sphincters after embolization of a SEAVF. Follow-up neurophysiological monitoring is important to assess the functional recovery of the sphincter.
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Affiliation(s)
- Shogo Shima
- Department of Neurosurgery and Neuroendovascular Therapy, St. Luke’s International Hospital, Tokyo, Japan
| | - Yasuko Tanaka
- Department of Clinical Laboratory and Intraoperative Neurophysiology, St. Luke’s International Hospital, Tokyo, Japan
| | - Shinsuke Sato
- Department of Neurosurgery and Neuroendovascular Therapy, St. Luke’s International Hospital, Tokyo, Japan
| | - Yasunari Niimi
- Department of Neurosurgery and Neuroendovascular Therapy, St. Luke’s International Hospital, Tokyo, Japan
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Bharadwaj S, Muthuchellappan R. Superselective Anesthesia Functional Examination of the Diaphragm during Endovascular Embolization of Spinal Cord Arteriovenous Malformation. Indian J Radiol Imaging 2022; 32:430-432. [PMID: 36177277 PMCID: PMC9514896 DOI: 10.1055/s-0042-1755244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Superselective anesthesia functional evaluation (SAFE) is an adjunct to the Wada test. It is performed to rule out unintentional positioning of the tip of the embolization catheter proximal to the origin of a normal artery supplying eloquent region of spinal cord. We report a case of a 36-year-old male with cervical intramedullary spinal cord arteriovenous malformation (SCAVM) at C3 level. In this patient, we monitored motor-evoked potentials (MEPs) of bilateral upper and lower limbs along with diaphragm. Electrodes for compound muscle action potential of diaphragm were placed under fluoroscopy guidance. Through this case, we want to emphasize that intraprocedural diaphragmatic MEPs enhance the safety margin during endovascular embolization of cervical intramedullary SCAVMs. Placement of electrodes under fluoroscopy guidance ensures proper positioning into the diaphragm muscle.
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Affiliation(s)
- Suparna Bharadwaj
- Department of Neuroanaesthesia and Neuro Critical Care, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
| | - Radhakrishnan Muthuchellappan
- Department of Neuroanaesthesia and Neuro Critical Care, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
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Tong X, Li X, Ye M, Hu P, Li G, Zhang P, Zhang H, Zhuang P. Pharmacologic Provocative Testing in Combination With Intraoperative Neurophysiologic Monitoring During Arteriovenous Malformation Embolization. World Neurosurg 2021; 154:e72-e81. [PMID: 34216836 DOI: 10.1016/j.wneu.2021.06.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 06/22/2021] [Accepted: 06/24/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To review our use of pharmacologic provocative testing (PT) and intraoperative neurophysiologic monitoring (IONM) during endovascular embolization for eloquent arteriovenous malformations (AVMs), and better define their clinical utility. METHODS This is a prospective study between 1 June 2018 and 1 June 2020. Prior to endovascular embolization, superselective PTs with propofol injection were performed. The PT results were assessed by IONM. The impact of different doses of propofol on PT results was compared. RESULTS Under general anesthesia, 111 PTs and 48 endovascular embolizations were performed in 22 patients. For the initial 48 PTs before planned embolization, 38 PTs with 5 mg propofol were negative and repeat PTs with 7 mg propofol were also negative. For the remaining 10 positive PTs, the microcatheter tip was adjusted to an alternative site until repeat PTs were negative to ensure a subsequent safe embolization. In comparison, 5-mg-propofol PT results were consistent with 7-mg-propofol PTs in larger-sized feeders, whereas for smaller-sized vessels, 3-mg-propofol PT results were consistent with 5-mg-propofol PTs. The negative predictive value of PTs was 97.9% (47 of 48), as only 1 of the 48 embolizations with negative PTs resulted in postoperative hemorrhage and none of the other 47 embolizations led to a postoperative neurologic deficit. CONCLUSIONS PTs and IONM are valuable techniques to predict neurologic deficits and improve procedure decision-making during AVM embolization under general anesthesia. A 5-mg dose of propofol may be sufficient for PTs in larger-sized feeders and a 3-mg dose may be sufficient in smaller-sized feeding branches.
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Affiliation(s)
- Xianzeng Tong
- Department of Neurosurgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Xiaoyu Li
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute (China-INI), Capital Medical University, Beijing, China
| | - Ming Ye
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute (China-INI), Capital Medical University, Beijing, China
| | - Peng Hu
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute (China-INI), Capital Medical University, Beijing, China
| | - Guilin Li
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute (China-INI), Capital Medical University, Beijing, China
| | - Peng Zhang
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute (China-INI), Capital Medical University, Beijing, China
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute (China-INI), Capital Medical University, Beijing, China.
| | - Ping Zhuang
- Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
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Feng AY, Sussman ES, Jin MC, Wong S, Lopez J, Pulli B, Heit JJ, Telischak N. Intraoperative Neuromonitoring for Cerebral Arteriovenous Malformation Embolization: A Propensity-Score Matched Retrospective Database Study. Cureus 2021; 13:e12946. [PMID: 33654622 PMCID: PMC7910512 DOI: 10.7759/cureus.12946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction The treatment of cerebral arteriovenous malformations (AVMs) may result in neurologic morbidity, particularly when an AVM is located in or adjacent to eloquent brain regions. Intraoperative neurophysiologic monitoring (IONM) may be utilized to reduce the risk of iatrogenic injury during endovascular AVM embolization; however, IONM for endovascular AVM embolization is not ubiquitously the standard of care. Methods Admissions for AVM embolization were assessed from the IBM MarketScan® Commercial and Medicare Supplemental databases (IBM Watson Health, Somers, NY). Inclusion criterion for patients was continuous enrollment six months before and after the index encounter. The use of IONM and presence of intracranial hemorrhage (ICH) were noted. Propensity-score matched cohorts with and without IONM were generated to minimize bias between treatment groups (adjusting for age, sex, and comorbidities). Results From 2007 to 2016, there were 16,279 patients diagnosed with cerebral AVM in the MarketScan database. Embolized patients were stratified into IONM and non-IONM cohorts; there were 357 patients in the IONM cohort and 1775 patients in the non-IONM cohort. Provider types were significantly different between cohorts (p<0.005). Unruptured AVMs were significantly more likely to be embolized with adjunctive IONM (17.7%) compared to ruptured AVMs (7.9%) (p<0.005). After balancing for baseline comorbidities, there were 266 patients in the IONM cohort, and 1347 patients in the non-IONM cohort. Among unruptured AVM patients, IONM was linked to a significantly shorter length of stay (2.72 versus 4.92 days; p<0.005), significantly lower rates of complications within 30 days of discharge (0.00% versus 1.88%; p=0.038), and significantly lower total payment ($40,179 versus $50,844; p<0.0001). Conclusion Endovascular embolization for unruptured AVMs performed with adjunctive IONM was associated with shorter length of stay, lower complication rates, and hospitalization costs.
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Affiliation(s)
- Austin Y Feng
- Neurosurgery, Stanford University School of Medicine, Stanford, USA
| | - Eric S Sussman
- Neurosurgery, Stanford University School of Medicine, Stanford, USA
| | - Michael C Jin
- Neurosurgery, Stanford University School of Medicine, Stanford, USA
| | - Sandy Wong
- Neurosurgery, Stanford University School of Medicine, Stanford, USA
| | - Jaime Lopez
- Neurology, Stanford University School of Medicine, Stanford, USA
| | - Benjamin Pulli
- Radiology, Stanford University School of Medicine, Stanford, USA
| | - Jeremy J Heit
- Radiology, Stanford University School of Medicine, Stanford, USA
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Abstract
Spinal vascular malformations (SVM) are classified based on their location (intramedullary, perimedullary, radicular, extradural) and flow pattern (high-flow, low-flow, no arteriovenous shunt). High-flow SVMs are generally congenital lesions diagnosed in children and young patients without gender predominance. They present with hemodynamic disturbances, mass effect, or hemorrhages, but may also be discovered incidentally. Low-flow SVMs tend to be acquired lesions presenting in older men with progressive myelopathy caused by spinal venous hypertension. They are rarely associated with vascular syndromes but may accompany prothrombotic conditions. The sensitivity and specificity of conventional MRI are excellent for high-flow SVMs but poor for low-flow lesions, which are frequently diagnosed with extensive delays reducing the potential for favorable outcomes. The sensitivity of advanced MRI techniques remains unclear, notably for the detection of low-flow shunts without flow voids on conventional MRI. Catheter angiography remains the gold standard modality for the evaluation of the spinal vasculature and its disorders. SVMs can be treated by surgical or endovascular means. Initially plagued by high recurrence rates due to inadequate embolization material, endovascular techniques represent nowadays a valid alternative to surgery, thanks notably to the introduction of liquid embolic agents.
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Gopalakrishna KN, Menon P, Singh P, Pruthi N, Bharadwaj S. Multimodal Intraoperative Monitoring During Microsurgical Treatment of Spinal Dural Arteriovenous Fistula. Turk J Anaesthesiol Reanim 2020; 48:423-426. [PMID: 33103150 PMCID: PMC7556635 DOI: 10.5152/tjar.2020.88942] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 07/30/2019] [Indexed: 11/25/2022] Open
Abstract
We report here a case to illustrate the potential intraoperative multimodal monitoring options available for safe ligation of spinal dural arteriovenous fistula (DAVF). The success of microsurgical treatment depends on the correct identification of the arterial feeder and monitoring the functional integrity of the corticospinal tract.
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Affiliation(s)
| | - Prashanth Menon
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - Prashant Singh
- Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - Nupur Pruthi
- Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - Suparna Bharadwaj
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neuro Sciences, Bangalore, India
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8
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Taskiran E, Kemerdere R, Alizada O, Hancı M. Neurophysiological Monitoring in Spinal Dural Arteriovenous Fistula Surgery at the Thoracic Spine: A Case Report. Neurol India 2020; 67:1556-1558. [PMID: 31857562 DOI: 10.4103/0028-3886.273640] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Emine Taskiran
- Department of Neurology, Istanbul University-Cerrahpaşa, Cerrahpaşa Faculty of Medicine, Istanbul, Turkey
| | - Rahşan Kemerdere
- Department of Neurosurgery, Istanbul University-Cerrahpaşa, Cerrahpaşa Faculty of Medicine, Istanbul, Turkey
| | - Orkhan Alizada
- Department of Neurosurgery, Istanbul University-Cerrahpaşa, Cerrahpaşa Faculty of Medicine, Istanbul, Turkey
| | - Murat Hancı
- Department of Neurosurgery, Istanbul University-Cerrahpaşa, Cerrahpaşa Faculty of Medicine, Istanbul, Turkey
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Eichberg DG, Komotar RJ, Urakov TM. Commentary: Spinal Arteriovenous Fistula: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2020; 18:E227-E228. [PMID: 32243536 DOI: 10.1093/ons/opaa063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 02/02/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Daniel G Eichberg
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Ricardo J Komotar
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida.,Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Timur M Urakov
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
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Eichberg DG, Komotar RJ, Urakov TM. Commentary: Posterior C2-6 Laminoplasty for Resection of Arteriovenous Malformation: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2020; 18:E140-E141. [PMID: 32047933 DOI: 10.1093/ons/opaa006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 12/15/2019] [Indexed: 11/15/2022] Open
Affiliation(s)
- Daniel G Eichberg
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Ricardo J Komotar
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
- Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Timur M Urakov
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
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Bican O, Cho C, Suarez-Roman A, Nguyen V, Lee L, Le S, Heit J, Dodd R, López J. Superselective methohexital challenge prior to intracranial endovascular embolization. J Clin Neurosci 2019; 63:68-71. [DOI: 10.1016/j.jocn.2019.01.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 01/30/2019] [Indexed: 10/27/2022]
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Affiliation(s)
- M. W. Hayman
- Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Visiting Specialist Anaesthestist
| | - M. S. Paleologos
- Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Staff Specialist Anaesthetist, Director of Services
| | - P. C. A. Kam
- Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Nuffield Professor and Head, Departments of Anaesthetics, University of Sydney and Royal Prince Alfred Hospital
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Lee S, Kim DY, Kim SB, Kim W, Kang MR, Kim HJ, Lee KH, Yoo M, Choi BS, Kim JS, Lee SI, Kim HY, Jin SC. Predictive value of neurophysiologic monitoring during neurovascular intervention for postoperative new neurologic deficits. Neuroradiology 2018; 61:207-215. [PMID: 30334091 DOI: 10.1007/s00234-018-2115-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 10/08/2018] [Indexed: 12/20/2022]
Abstract
PURPOSE Forms of intraoperative neurophysiologic monitoring (IONM), including somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs), have been widely used in the field of neurosurgery. This study aimed to evaluate the diagnostic efficacy of IONM in identifying intraoperative events and predicting postoperative neurologic deficits in neurovascular intervention. METHODS From January 2013 to December 2016, we retrospectively reviewed patients who underwent neurovascular intervention under general anesthesia with the use of IONM. Associations between significant changes in MEPs or SSEPs which were defined as a decrease more than 50% in amplitude and/or an increase more than 10% in latency and any identifiable intraoperative events and/or postoperative neurologic deficits were determined. The sensitivity and specificity values for both MEPs and SSEPs were calculated. RESULTS In total, 578 patients (175 men and 403 women) were included. Their mean age was 59.5 years. SSEP changes occurred in 1% (n = 6), and MEP changes occurred in 1.2% (n = 7). Four patients suffered postoperative neurologic deficits, and identifiable intraoperative events were observed in seven patients. Both SSEP and MEP changes were significantly associated with identifiable intraoperative events and/or postoperative neurologic deficits (p < 0.001, Fisher's exact test). The calculated sensitivity and specificity of MEP monitoring were 50 and 99.5%, respectively. The sensitivity and specificity of SSEP monitoring were both 100%. CONCLUSION Intraoperative SSEP monitoring might be a reliable and sensitive method to surveil neurologic complications during neurovascular intervention. Intraoperative MEP monitoring appears to be feasible. However, it is unclear whether MEP monitoring has any additive benefit over SSEP monitoring.
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Affiliation(s)
- Sungjoon Lee
- Department of Neurosurgery, Inje University Haeundae Paik Hospital, 875 Haeundae-ro, Haeundae-gu, Busan, 48108, Republic of Korea
| | - Doo Young Kim
- Department of Neurosurgery, Inje University Haeundae Paik Hospital, 875 Haeundae-ro, Haeundae-gu, Busan, 48108, Republic of Korea
| | - Su Bin Kim
- Department of Neurosurgery, Inje University Haeundae Paik Hospital, 875 Haeundae-ro, Haeundae-gu, Busan, 48108, Republic of Korea
| | - Woojin Kim
- Department of Physical Medicine, Inje University Haeundae Paik Hospital, Busan, Republic of Korea
| | - Mi-Ri Kang
- Department of Neurology, Busan Paik Hospital, Busan, Republic of Korea
| | - Hye-Jin Kim
- Department of Neurology, BHS Hanseo Hospital, Busan, Republic of Korea
| | - Ki Hwa Lee
- Department of Anesthesiology, Inje University Haeundae Paik Hospital, Busan, Republic of Korea
| | - Minwook Yoo
- Department of Neurosurgery, Inje University Haeundae Paik Hospital, 875 Haeundae-ro, Haeundae-gu, Busan, 48108, Republic of Korea
| | - Byung-Sam Choi
- Department of Neurosurgery, Inje University Haeundae Paik Hospital, 875 Haeundae-ro, Haeundae-gu, Busan, 48108, Republic of Korea
| | - Jung Soo Kim
- Department of Neurosurgery, Inje University Haeundae Paik Hospital, 875 Haeundae-ro, Haeundae-gu, Busan, 48108, Republic of Korea
| | - Sun-Il Lee
- Department of Neurosurgery, Inje University Haeundae Paik Hospital, 875 Haeundae-ro, Haeundae-gu, Busan, 48108, Republic of Korea
| | - Hae Yu Kim
- Department of Neurosurgery, Inje University Haeundae Paik Hospital, 875 Haeundae-ro, Haeundae-gu, Busan, 48108, Republic of Korea
| | - Sung-Chul Jin
- Department of Neurosurgery, Inje University Haeundae Paik Hospital, 875 Haeundae-ro, Haeundae-gu, Busan, 48108, Republic of Korea.
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Ghadirpour R, Nasi D, Iaccarino C, Romano A, Motti L, Farneti M, Pascarella R, Servadei F. Intraoperative Neurophysiological Monitoring in Surgical Treatment of Spinal Dural Arteriovenous Fistulas: Technique and Results. Asian J Neurosurg 2018; 13:595-606. [PMID: 30283511 PMCID: PMC6159052 DOI: 10.4103/ajns.ajns_209_16] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objective and Background: Data on intraoperative neurophysiological monitoring (IOM) during surgery of spinal dural arteriovenous fistulas (SDAVFs) are lacking. The purpose of this study was to evaluate the role of IOM during microsurgery for SDAVFs. Materials and Methods: From March 2007 to March 2013, 12 patients had microsurgery with IOM for SDAVFs. The IOM included somatosensory-evoked potentials, motor-evoked potentials (MEPs), and – in selected cases – D-Waves. All patients were evaluated at admission and at follow-up (6, 12, and 24 months) with Aminoff–Logue Disability Scale for Gait-Aminoff–Logue Disability Scale (G-ALS) and Micturition-Aminoff–Logue Disability Scale (M-ALS). Statistical Analysis Used: Logistic regression was used for detecting the clinical risk factors influencing neurological functions after the treatment. Results: During surgery, we registered the absence of significant modifications of evoked potentials in nine cases (75%), while improvement of MEPs occurred in three cases (25%). No false-negative case was registered, and IOM predicted the absence of new postoperative neurological deficit in all patients. At 24-month follow-up, nine patients improved their overall neurological status, while three patients remained stable. At univariate analysis, Aminoff–Logue Disability Scales for Gait and Micturition (G + M-ALS) score at 24-month follow-up was directly associated with the duration of symptom before the surgery (P = 0.024), preoperative G-ALS (P = 0.02), M-ALS (P = 0.022), and G + M-ALS scores (P = 0.045), and improvement of IOM after occlusion of the fistula (P = 0.025). Conclusions: In our series, no significant worsening of evoked potentials occurred and subsequently the surgical strategy was not changed by IOM. However, no false-negative case was registered, and IOM predicted the absence of new postoperative neurological deficit in all patients. Patients with improvement of IOM parameters after occlusion of the fistula had greater chances of postsurgical improvement at the univariate analysis.
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Affiliation(s)
- Reza Ghadirpour
- Department of Neurosurgery-Neurotraumatology, A.O.U. Parma, Parma, Italy.,Parma Department of Neurosurgery-Neurotraumatology, Arcispedale Santa Maria Nuova, Italy
| | - Davide Nasi
- Department of Neurosurgery-Neurotraumatology, A.O.U. Parma, Parma, Italy.,Parma Department of Neurosurgery-Neurotraumatology, Arcispedale Santa Maria Nuova, Italy
| | - Corrado Iaccarino
- Department of Neurosurgery-Neurotraumatology, A.O.U. Parma, Parma, Italy.,Parma Department of Neurosurgery-Neurotraumatology, Arcispedale Santa Maria Nuova, Italy
| | - Antonio Romano
- Department of Neurosurgery-Neurotraumatology, A.O.U. Parma, Parma, Italy.,Parma Department of Neurosurgery-Neurotraumatology, Arcispedale Santa Maria Nuova, Italy
| | - Luisa Motti
- Department of Neurophysiology, IRCCS "Arcispedale Santa Maria Nuova," Reggio Emilia, Italy
| | - Marco Farneti
- Department of Neurosurgery, "S. Anna" University Hospital, Ferrara, Italy
| | - Rosario Pascarella
- Department of Neuroradiology, IRCCS "Arcispedale Santa Maria Nuova," Reggio Emilia, Italy
| | - Franco Servadei
- Department of Neurosurgery-Neurotraumatology, A.O.U. Parma, Parma, Italy.,Parma Department of Neurosurgery-Neurotraumatology, Arcispedale Santa Maria Nuova, Italy
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Bican O, Cho C, Lee L, Nguyen V, Le S, Heit J, Lopez J. Positive pharmacologic provocative testing with methohexital during cerebral arteriovenous malformation embolization. Clin Imaging 2018; 51:155-159. [DOI: 10.1016/j.clinimag.2018.02.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 08/29/2017] [Accepted: 02/16/2018] [Indexed: 11/28/2022]
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Abstract
Spinal dural arteriovenous fistulas (dAVF) are the most common subset of the larger group of spinal vascular malformations. In this chapter, we discuss the definition, epidemiology, clinical presentation, diagnosis, treatment, and outcomes of spinal dAVF. Special attention is given to clinical approach, imaging, and diagnosis with discussion of newer spinal magnetic resonance angiographic techniques. Endovascular management techniques are discussed, including technical and safety considerations for the performance of spinal angiography and various methods of embolization. Embolization media, including liquid embolics, particles, and coils, are introduced. Finally, clinical and imaging outcomes are discussed with attention to the clinical and imaging findings of dAVF recurrence.
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Affiliation(s)
| | - Ali R Zomorodi
- Department of Neurosurgery, Duke University, Durham, NC, USA
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17
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Abstract
Spinal arteriovenous malformations (AVMs) are a rare but treatable cause of myelopathy and spinal cord hemorrhage. The clinical presentation and ideal treatment of these lesions vary widely, primarily due to differences in anatomic and angioarchitectural features. Six well-defined types of fistula have been defined: (1) intradural dorsal AVM; (2) intramedullary AVM; (3) extradural-intradural AVM; (4) intradural ventral AVF; (5) extradural/epidural AVF; and (6) conus medullaris AVM. Each of these lesions have unique clinical presentations and variable natural histories and endovascular treatment options. The principles of endovascular treatment include: (1) a complete understanding of the angioarchitecture and anatomic features of the lesion, including identification of radiculomedullary arteries; (2) careful spinal angiography; (3) identification of treatment goals prior to the procedure (i.e., complete occlusion versus partial occlusion aimed at altering natural history); (4) selection of proper embolic agent; and (5) careful follow-up in both the immediate postoperative setting and long term.
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18
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Adhikari RB, Takeda M, Kolakshyapati M, Sakamoto S, Morishige M, Kiura Y, Okazaki T, Shinagawa K, Ichinose N, Yamaguchi S, Kurisu K. Somatosensory evoked potentials in carotid artery stenting: Effectiveness in ascertaining cerebral ischemic events. J Clin Neurosci 2016; 30:71-76. [PMID: 27291465 DOI: 10.1016/j.jocn.2016.01.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [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: 12/11/2015] [Revised: 01/04/2016] [Accepted: 01/17/2016] [Indexed: 11/16/2022]
Abstract
Somatosensory evoked potentials (SSEP) have been used in various endovascular procedures and carotid endarterectomy, but to our knowledge no literature deals exclusively with the utility of SSEP in carotid artery stenting (CAS). The purpose of this study was to evaluate the efficacy of SSEP in detecting cerebral ischemic events during CAS. We conducted a prospective study in 35 CAS procedures in 31 patients during an 18month period. Thirty-three patients without near occlusion underwent stenting using dual protection (simultaneous flow reversal and distal filter) combined with blood aspiration, while two patients with near occlusion underwent stenting without dual protection. All 35 patients underwent SSEP monitoring. SSEP were generated by stimulating median and/or tibial nerves and recorded by scalp electrodes. During the aspiration phase post-dilation, seven patients (20%) exhibited SSEP changes with a mean duration of 11.3±8.5minutes (range: 3-25minutes), three of whom later developed minor stroke/transient ischemic attack. Diffusion-weighted imaging showed new lesions in 10 patients (28.6%). Change in SSEP exhibited mean sensitivity of 100% (95% confidence interval, 0.29-1.0) and specificity of 88% (95% confidence interval, 0.71-0.96) in predicting clinical stroke post-CAS. Intra-procedural SSEP change was predictive of post-procedural complications (p=0.005, Fisher's exact test). Longer span of SSEP change was positively correlated with complications (p=0.032, Mann-Whitney test). Intra-procedural SSEP changes are highly sensitive in predicting neurological outcome following CAS. Chances of complications are increased with prolongation of such changes. SSEP allows for prompt intra-procedural ischemia prevention measures and stratification to pursue an aggressive peri-procedural protocol for high risk patients to mitigate neurological deficits.
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Affiliation(s)
- Rupendra Bahadur Adhikari
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan.
| | - Masaaki Takeda
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan
| | - Manish Kolakshyapati
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan
| | - Shigeyuki Sakamoto
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan
| | - Mizuki Morishige
- Clinical Engineer Section, Clinical Support Department, Hiroshima University Hospital, Hiroshima, Japan
| | - Yoshihiro Kiura
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan
| | - Takahito Okazaki
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan
| | - Katsuhiro Shinagawa
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan
| | - Nobuhiko Ichinose
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan
| | - Satoshi Yamaguchi
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan
| | - Kaoru Kurisu
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan
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Deshaies EM, Singla A, Allott G, Villwock MR, Li F, Gorji R. Multimodality intraoperative neurophysiological monitoring during Onyx embolization of cerebrovascular malformations. Neurodiagn J 2015; 55:12-24. [PMID: 26036117 DOI: 10.1080/21646821.2015.1012450] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
General anesthesia prohibits neurological examination during embolization of cerebrovascular malformations when provocative testing prior to pedicle occlusion is needed. Intraoperative neurophysiological monitoring (IONM) has the potential to fill this gap but remains relatively unexplored. We conduct a retrospective review of consecutive patients with cerebrovascular malformations treated with Onyx (ethylene vinyl alcohol copolymer, dissolved in dimethyl sulfoxide) embolization under general anesthesia with IONM from 2009 to 2012. Somatosensory evoked potentials (SSEPs), transcranial motor evoked potentials (TcMEPs), visual evoked potential (VEPs), auditory brainstem response (ABR), and electroencephalography (EEG) were used selectively in all patients depending on the location of the malformation. Provocative testing combined with IONM was performed in 28 patients over 75 sessions. Three patients demonstrated changes in TcMEPs or ABR during provocative testing, which halted the planned embolization. Two patients demonstrated changes in baseline SSEPs after embolization, despite normal IONM during provocative testing, correlating with postprocedural contralateral weakness. Six patients developed visual deficits after arterial occlusion despite unchanged VEPs and occipital EEG during provocative testing and embolization. We therefore conclude that the sensitivity of TcMEPs and SSEPs is preferable to EEG, and we strongly caution against relying on occipital recorded VEPs to predict visual deficits.
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Martinez Piñeiro A, Cubells C, Garcia P, Castaño C, Dávalos A, Coll-Canti J. Implementation of Intraoperative Neurophysiological Monitoring during Endovascular Procedures in the Central Nervous System. Interv Neurol 2015; 3:85-100. [PMID: 26019712 DOI: 10.1159/000371453] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND OBJECTIVE Intraoperative monitoring (IOM) has been used in different surgical disciplines since the 1980s. Nonetheless, regular routine use of IOM in interventional neuroradiology units has only been reported in a few centers. The aim of this study is to report our experience, 1 year after deciding to implement standardized IOM during endovascular treatment of vascular abnormalities of the central nervous system. METHODS Basic recordings included somatosensory-evoked potentials (SEPs) and motor-evoked potentials (MEPs). Corticobulbar motor-evoked potentials and flash-visual-evoked potentials were also recorded depending on the topography of the lesion. Intra-arterial provocative tests (PTs) with amobarbital and lidocaine were also performed. All patients except 1 were under total intravenous anesthesia. Clinical outcome was assessed prospectively and correlated with IOM events. RESULTS Twelve patients and 15 procedures were monitored during the inclusion period. Significant IOM events were detected during 3 of the 15 procedures (20%). We observed temporary MEP changes in 2 cases which resolved after interruption of the embolization or application of corrective measures, leaving no postoperative neurological deficits. In 1 case, persistent SEP and MEP deterioration was detected secondary to a frontal hematoma, resulting in mild sensory-motor deficit in the right upper extremity after the procedure. Overall, 12 PTs (4 spinal cord and 8 brain abnormalities) were performed using lidocaine and sodium amytal injections. One positive result occurred after the injection of lidocaine. No false negatives were detected. CONCLUSIONS IOM may provide continuous real-time data about the functional status of eloquent areas and pathways of the central nervous system in patients under general anesthesia. It therefore allows us to detect early neurological damage in time to perform specific actions that may prevent irreversible neurological deficits.
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Affiliation(s)
- Alicia Martinez Piñeiro
- Service of Neurology and Section of Interventional Neuroradiology, Department of Neurosciences, Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Spain
| | - Carles Cubells
- Department of Anesthesiology, Germans Trias i Pujol University Hospital, Barcelona, Spain
| | - Pablo Garcia
- Service of Neurology and Section of Interventional Neuroradiology, Department of Neurosciences, Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Spain
| | - Carlos Castaño
- Service of Neurology and Section of Interventional Neuroradiology, Department of Neurosciences, Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Spain
| | - Antonio Dávalos
- Service of Neurology and Section of Interventional Neuroradiology, Department of Neurosciences, Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Spain
| | - Jaume Coll-Canti
- Service of Neurology and Section of Interventional Neuroradiology, Department of Neurosciences, Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Spain
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21
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Dhakal LP, Díaz-Gómez JL, Freeman WD. Role of anesthesia for endovascular treatment of ischemic stroke: do we need neurophysiological monitoring? Stroke 2015; 46:1748-54. [PMID: 25953376 DOI: 10.1161/strokeaha.115.008223] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 04/09/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Laxmi P Dhakal
- From the Departments of Neurology (L.P.D., W.D.F.), Critical Care (L.P.D., J.L.D.-G., W.D.F.), Anesthesiology (J.L.D.-G.), and Neurosurgery (J.L.D.-G., W.D. F.), Mayo Clinic, Jacksonville, FL
| | - José L Díaz-Gómez
- From the Departments of Neurology (L.P.D., W.D.F.), Critical Care (L.P.D., J.L.D.-G., W.D.F.), Anesthesiology (J.L.D.-G.), and Neurosurgery (J.L.D.-G., W.D. F.), Mayo Clinic, Jacksonville, FL
| | - William D Freeman
- From the Departments of Neurology (L.P.D., W.D.F.), Critical Care (L.P.D., J.L.D.-G., W.D.F.), Anesthesiology (J.L.D.-G.), and Neurosurgery (J.L.D.-G., W.D. F.), Mayo Clinic, Jacksonville, FL.
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Romanini CV, Ferreira EDF, Soares LM, Santiago AN, Milani H, de Oliveira RMW. 4-hydroxy-3-methoxy-acetophenone-mediated long-lasting memory recovery, hippocampal neuroprotection, and reduction of glial cell activation after transient global cerebral ischemia in rats. J Neurosci Res 2015; 93:1240-9. [DOI: 10.1002/jnr.23575] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Revised: 12/31/2014] [Accepted: 01/22/2015] [Indexed: 12/17/2022]
Affiliation(s)
- Cássia Valério Romanini
- Department of Pharmacology and Therapeutics; State University of Maringá; Maringá Paraná Brazil
| | | | - Lígia Mendes Soares
- Department of Pharmacology and Therapeutics; State University of Maringá; Maringá Paraná Brazil
| | - Amanda Nunes Santiago
- Department of Pharmacology and Therapeutics; State University of Maringá; Maringá Paraná Brazil
| | - Humberto Milani
- Department of Pharmacology and Therapeutics; State University of Maringá; Maringá Paraná Brazil
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Retraction notice to: Long-term assay of off-pump atrial septal defect closure using vena caval inflow occlusion and minimally invasive approaches in 130 cases. Eur J Cardiothorac Surg 2015; 47:1114. [PMID: 25326016 DOI: 10.1093/ejcts/ezu405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Abstract
PURPOSE To evaluate whether intraoperative neurophysiologic monitoring (IONM) with combined muscle motor evoked potentials (mMEPs) and somatosensory evoked potentials is useful for more aggressive and safe resection in intramedullary spinal cord tumour (IMSCT) surgery. MATERIALS AND METHODS We reviewed data from consecutive patients who underwent surgery for IMSCT between 1998 and April 2012. The patients were divided into two groups based on whether or not IONM was applied. In the monitored group, the procedures were performed under IONM using 75% muscle amplitude decline weaning criteria. The control group was comprised of patients who underwent IMSCT surgery without IONM. The primary outcome was the rate of gross total excision of the tumour on magnetic resonance imaging at one week after surgery. The secondary outcome was the neurologic outcome based on the McCormick Grade scale. RESULTS The two groups had similar demographics. The total gross removal tended to increase when intraoperative neurophysiologic monitoring was used, but this tendency did not reach statistical significance (76% versus 58%; univariate analysis, p=0.049; multivariate regression model, p=0.119). The serial McCormick scale score was similar between the two groups (based on repeated measure ANOVA). CONCLUSION Our study evaluated combined IONM of trans-cranial electrical (Tce)-mMEPs and SEPs for IMSCT. During IMSCT surgery, combined Tce-mMEPs and SEPs using 75% muscle amplitude weaning criteria did not result in significant improvement in the rate of gross total excision of the tumour or neurologic outcome.
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Affiliation(s)
- Il Choi
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung-Jae Hyun
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Joong-Koo Kang
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung-Chul Rhim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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26
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Abstract
This article focuses on the application of neurophysiologic monitoring in uniquely neurosurgical procedures. Neurophysiologic monitoring provides functional testing and mapping to identify neural structures. Once identified, the functionality of the central and peripheral nervous system areas at risk for neurosurgical injury can be monitored. It discusses the use of motor-evoked potentials, sensory evoked potentials, electromyography and electroencephalography to assess neurologic change.
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Affiliation(s)
- Leslie C Jameson
- Department of Anesthesiology, University of Colorado, Anschutz Medical Campus, 12401 East 17th Avenue, Aurora, CO 80045, USA.
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27
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Nitzschke R, Hansen-Algenstaedt N, Regelsberger J, Goetz AE, Goepfert MS. [Intraoperative electrophysiological monitoring with evoked potentials]. Anaesthesist 2012; 61:320-35. [PMID: 22526743 DOI: 10.1007/s00101-012-2015-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
During the last 30 years intraoperative electrophysiological monitoring (IOEM) has gained increasing importance in monitoring the function of neuronal structures and the intraoperative detection of impending new neurological deficits. The use of IOEM could reduce the incidence of postoperative neurological deficits after various surgical procedures. Motor evoked potentials (MEP) seem to be superior to other methods for many indications regarding monitoring of the central nervous system. During the application of IOEM general anesthesia should be provided by total intravenous anesthesia with propofol with an emphasis on a continuous high opioid dosage. When intraoperative MEP or electromyography guidance is planned, muscle relaxation must be either completely omitted or maintained in a titrated dose range in a steady state. The IOEM can be performed by surgeons, neurologists and neurophysiologists or increasingly more by anesthesiologists. However, to guarantee a safe application and interpretation, sufficient knowledge of the effects of the surgical procedure and pharmacological and physiological influences on the neurophysiological findings are indispensable.
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Abstract
Pial arteriovenous malformations (AVMs) and dural arteriovenous fistulas (DAVFs) are high-flow vascular lesions with abnormal communications between the arterial and venous system. AVMs are congenital lesions, whereas DAVFs are considered acquired lesions. Both can cause significant morbidity and mortality if they rupture and result in intracranial hemorrhage. The primary goal of treatment is to eliminate the risk of bleeding or at least decrease it. Because the epidemiology, clinical presentation, and classification of AVMs and DAVFs have been covered in previous articles in this issue, the authors only briefly touch on these subjects as they relate to endovascular treatment.
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Affiliation(s)
- Martin G Radvany
- Division of Interventional Neuroradiology, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD 21287, USA.
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29
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Machado C, Estévez M, Rodríguez R, Carrick FR, Melillo R, Leisman G. Bilateral N20 absence in post-anoxic coma: do you pay attention? Clin Neurophysiol 2011; 123:1264-6. [PMID: 22209660 DOI: 10.1016/j.clinph.2011.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Revised: 11/10/2011] [Accepted: 11/11/2011] [Indexed: 11/28/2022]
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Neuloh G, Bien CG, Clusmann H, von Lehe M, Schramm J. Continuous motor monitoring enhances functional preservation and seizure-free outcome in surgery for intractable focal epilepsy. Acta Neurochir (Wien) 2010; 152:1307-14. [PMID: 20437060 DOI: 10.1007/s00701-010-0675-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2010] [Accepted: 04/21/2010] [Indexed: 10/19/2022]
Abstract
PURPOSE Complete yet safe resection close to motor areas in medically intractable epilepsy requires functional information. New deficit may occur despite preservation of motor cortex, e.g., through vascular compromise. Here, we explore for the first time the feasibility, safety, and the clinical value of continuous motor-evoked potential (MEP) monitoring in focal epilepsy surgery. METHODS High-frequency stimulation for MEP monitoring was performed during 100 consecutive lesionectomies critically related to motor areas and pathways. Extraoperative motor cortex mapping was performed in 27 of these cases via chronically implanted subdural grid electrodes. MEP monitoring results, postoperative motor outcome, and seizure control were correlated in a prospective observational design. RESULTS Reliable MEP monitoring was achieved in 86 cases. Young age was the only discernible cause of unsuccessful recordings. Seizures from cortex stimulation did not occur. MEP changes (36%) predicted new motor deficit (17%) in all cases except purely cortical lesions. MEP changes predicted occurrence and permanence of new pareses. New deficit was significantly more frequent without (as compared with) successful monitoring (43% vs. 17%); permanently severe pareses from ischemia occurred only without MEPs (21% vs. 0%). Complete seizure control was significantly more frequent in successfully monitored cases (60% vs. 31%). Even with extraoperative motor mapping, severe paresis occurred only among cases with unsuccessful MEPs. CONCLUSIONS Continuous MEP monitoring in epilepsy surgery is feasible and safe. It reflects motor function complementarily to the localizing motor mapping results. Successful MEP monitoring correlates with unimpaired motor outcome and full seizure control.
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Chen L, Spetzler RF, Mcdougall CG, Albuquerque FC, Xu B. Detection of ischemia in endovascular therapy of cerebral aneurysms: a perspective in the era of neurophysiological monitoring. Neurosurg Rev 2011; 34:69-75. [DOI: 10.1007/s10143-010-0276-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2009] [Revised: 03/14/2010] [Accepted: 04/25/2010] [Indexed: 10/19/2022]
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