Intraventricular monitoring for temporal lobe epilepsy: report on technique and initial results in eight patients.
Song J K,Abou-Khalil B,Konrad P E
Journal of neurology, neurosurgery, and psychiatry
OBJECTIVE AND IMPORTANCE:Resective surgery is an effective treatment for refractory temporal lobe epilepsy. In difficult cases, invasive monitoring may be needed to precisely lateralise and localise seizure foci of mesial temporal origin. The authors present a modified technique for image guided, endoscopic placement of an intraventricular electrode array (IVE) that abuts the amygdalo-hippocampal complex. METHODS:Eight patients with suspected mesial temporal lobe epilepsy had placement of an IVE in conjunction with other invasive electrodes. Seven of these patients also had subdural grid or strip electrodes and four had foramen ovale electrodes. Frameless image guidance was used to place a custom 10-contact depth electrode through a rigid neuroendoscope within the atrium of the lateral ventricle. Once proper orientation towards the temporal horn was confirmed, the IVE array was advanced into the temporal horn to the temporal tip. The endoscope was removed and electrode placement was confirmed through an intraoperative lateral skull radiograph and on visual inspection at the time of resection in two cases. RESULTS:The IVE was crucial for localisation in one patient and helped localisation in four others. Surgery was offered to seven patients. The only serious complication of IVE placement was a thalamic contusion presumably from an errant electrode tip. One electrode was inadvertently placed into the frontal horn. There were no deaths and no permanent morbidity associated with the procedure. CONCLUSION:Endoscopically placed temporal horn, intraventricular electrodes provide an alternative to transcortical depth electrode placement. The technique hopefully can avoid complications associated with multiple depth electrode placements, especially when bilateral amygdalo-hippocampal electrical recordings are desired, although there may be a steep learning curve.
Clinical significance of preoperative fibre-tracking to preserve the affected pyramidal tracts during resection of brain tumours in patients with preoperative motor weakness.
Mikuni Nobuhiro,Okada Tsutomu,Enatsu Rei,Miki Yukio,Urayama Shin-ichi,Takahashi Jun A,Nozaki Kazuhiko,Fukuyama Hidenao,Hashimoto Nobuo
Journal of neurology, neurosurgery, and psychiatry
OBJECTIVE:To clarify the clinical usefulness of preoperative fibre-tracking in affected pyramidal tracts for intraoperative monitoring during the removal of brain tumours from patients with motor weakness. METHODS:We operated on 10 patients with mild to moderate motor weakness caused by brain tumours located near the pyramidal tracts under local anaesthesia. Before surgery, we performed fibre-tracking imaging of the pyramidal tracts and then transferred this information to the neuronavigation system. During removal of the tumour, motor function was evaluated with motor evoked potentials elicited by cortical/subcortical electrical stimulation and with voluntary movement. RESULTS:In eight patients, the locations of the pyramidal tracts were estimated preoperatively by fibre-tracking; motor evoked potentials were elicited on the motor cortex and subcortex close to the predicted pyramidal tracts. In the remaining two patients, in which fibre-tracking of the pyramidal tracts revealed their disruption surrounding the tumour, cortical/subcortical electrical stimulation did not elicit responses clinically sufficient to monitor motor function. In all cases, voluntary movement with mild to moderate motor weakness was extensively evaluated during surgery and was successfully preserved postoperatively with appropriate tumour resection. CONCLUSIONS:Preoperative fibre-tracking could predict the clinical usefulness of intraoperative electrical stimulation of the motor cortex and subcortical fibres (ie, pyramidal tracts) to preserve affected motor function during removal of brain tumours. In patients for whom fibre-tracking failed preoperatively, awake surgery is more appropriate to evaluate and preserve moderately impaired muscle strength.
Carotid endarterectomy. Lessons from intraoperative monitoring--a decade of experience.
McCarthy W J,Park A E,Koushanpour E,Pearce W H,Yao J S
Annals of surgery
OBJECTIVE:The authors analyzed a single institution's 10-year experience with intraoperative monitoring during 709 primary carotid endarterectomies and investigated the impact of contralateral internal carotid artery stenosis on carotid artery stump pressure (SP). SUMMARY BACKGROUND DATA:Stump pressure reflects the combination of contralateral carotid artery anatomy, collateral intracranial vasculature, and systemic blood pressure. By controlling for blood pressure with a stump index (SI) (SI = [SP/mean arterial pressure] x 100), a correlation between pressure and contralateral carotid artery anatomy can be demonstrated. Although the use of SP has long been advocated as an indicator of adequate cerebral perfusion, its correlation with perioperative complications while using an intraluminal shunt has not been evaluated completely. METHODS:From a series of 886 primary carotid endarterectomy cases, SP and mean arterial pressure were measured prospectively in 709 procedures. Temporary intraluminal shunts were used in cases with demonstrated contralateral carotid occlusion, prior cerebrovascular accident (CVA), or SPs less than 35 mmHg. Ipsilateral and contralateral angiographic degree of carotid stenosis was recorded at the time of the operation. Neurologic status was recorded prospectively for all 709 procedures. Operative electroencephalogram (EEG) changes and SP then were compared with the neurologic status of the patient in the perioperative period. RESULTS:The mean SP for the group (n = 709) was 46.7 +/- 15.3 mmHg (mean +/- standard deviation [SD]) with a mean SI of 54.9 +/- 22.6. The distribution for the SI is a more gaussian curve than that for SP. There were 19 ipsilateral CVAs (2.7%). The mean SP in the nonstroke group was 47.1 +/- 15.2 mmHg (mean SI = 54.7 +/- 16.5) compared with 31.9 +/- 13.2 mmHg (mean SI = 38.8 +/- 18.2) in the stroke group (P < 0.0001). Stroke rate for SP < or = 35 mmHg was 7% (13/185) versus 1.1% (6/524) for SP > 35 (p < 0.0001). Stump index and SP are related to contralateral carotid artery stenosis. The pattern of SI or SP versus contralateral stenosis is biphasic, with an increase at 75%. If SI is < or = 40, the mean contralateral stenosis is 55.1%; if SI is > 40, the mean contralateral stenosis is 35.1% (p < 0.05). Continuous EEG monitoring was completed for the 549 most recent operations. Patients who had a perioperative stroke had EEG changes observed during the procedure in only 6 of 12 cases (50% sensitivity), with 76% specificity. Using SP < or = 35 mmHg, sensitivity was 68% and specificity was 75%.
Predictive value of transcranial evoked potentials during mechanical endovascular therapy for acute ischaemic stroke: a feasibility study.
Shiban Ehab,Wunderlich Silke,Kreiser Kornelia,Lehmberg Jens,Hemmer Bernhard,Prothmann Sascha,Zimmer Claus,Meyer Bernhard,Ringel Florian
Journal of neurology, neurosurgery, and psychiatry
BACKGROUND AND PURPOSE:Mechanical endovascular therapy (MET) is a promising adjuvant or stand-alone therapy for acute ischaemic stroke caused by occlusion of a large vessel. Real-time monitoring of recanalisation success with regard to functional outcome is usually not possible because these procedures are mainly performed under general anaesthesia. We present a novel application for evoked potential monitoring for real-time evaluation of reperfusion success with respect to functional outcome during MET for acute ischaemic stroke. METHODS:Prospective observational study from March 2012 to April 2013 of patients presenting with acute ischaemic stroke who were eligible for MET. Transcranial motor evoked potentials (MEPs) and somatosensory evoked potentials (SSEPs) were measured bilaterally during MET throughout the intervention. The electrophysiological data of the contralateral side served as control. Neurological outcome was assessed by the modified Rankin Scale and National Institutes of Health Stroke Scale at 0, 7 and 90 days following intervention. RESULTS:20 patients were examined. MEPs and SSEPs were technically successful in 19 (95%) and 9 (45%) cases, respectively. Successful reperfusion was achieved in 16 cases. Functional recovery was observed in 14 patients. MEPs and SSEPs recovery status was a better predictor of functional recovery than successful reperfusion with a positive predictive value of 92%, 83% and 75% for MEPs, SSEPs and reperfusion, respectively. CONCLUSIONS:MEPs and SSEPs are safe and feasible methods of real-time monitoring of reperfusion success with respect to functional outcome during MET for acute ischaemic stroke.
Application of time-frequency analysis to somatosensory evoked potential for intraoperative spinal cord monitoring.
Hu Y,Luk K D K,Lu W W,Leong J C Y
Journal of neurology, neurosurgery, and psychiatry
OBJECTIVE:To investigate the improvement in the reliability of intraoperative spinal cord monitoring by applying time-frequency analysis to somatosensory evoked potentials (SEP). METHODS:34 patients undergoing scoliosis surgery were studied. SEP were recorded during different stages of scoliosis surgery. Averaged SEP signals were analysed intraoperatively by short time Fourier transform (STFT). The time-frequency characteristics of SEP were observed during surgery. The main peak in the time-frequency interpretation of SEP was measured in peak time, peak frequency, and peak power. The changes in these variables were compared with the changes in latency and amplitude during different surgical stages. RESULTS:During different surgical stages, changes in peak times and peak powers were found to correlate with the changes in latency and amplitude, respectively. Peak time showed more variability than latency (p < 0.01), while peak power showed less variability than amplitude (p < 0.01). The peak frequency of SEP appeared to be unchanged during surgery. SEP signals were found to have specific time-frequency characteristics, with the time-frequency distribution of the signals being located in a particular time-frequency space. CONCLUSIONS:Time-frequency analysis of SEP waveforms reveals stable and easily identifiable characteristics. Peak power is recommended as a more reliable monitoring parameter than amplitude, while peak time monitoring was not superior to latency measurement. Applying time-frequency analysis to SEP can improve the reliability of intraoperative spinal cord monitoring.
Efficacy of Intraoperative Neuro-Monitoring to Localize the External Branch of the Superior Laryngeal Nerve.
Hurtado-López Luis-Mauricio,Díaz-Hernández Pastor Israel,Basurto-Kuba Erich,Zaldívar-Ramírez Felipe Rafael,Pulido-Cejudo Abraham
Thyroid : official journal of the American Thyroid Association
BACKGROUND:This study investigated whether visual localization of the external branch of the superior laryngeal nerve (EBSLN) coincides with its localization via intraoperative neuro-monitoring (IONM) during thyroidectomy and whether its use influences the frequency of injuries. METHODS:A prospective, comparative, cross-sectional, observational study was performed in 240 superior thyroid poles. The metrics were visual identification of the EBSLN and its corroboration with IONM. The frequency of EBSLN injuries was also determined. Statistical analysis was achieved via kappa and chi-square tests, as well as odds ratios (OR). RESULTS:Of the 240 superior thyroid poles, IONM identified 234 (97.5%) EBSLN, whereas 190 (79.1%) were identified visually: OR = 10.35 [CI 4.37-24.65] p < 0.0001. Of the 190 EBSLN identified visually, 150 were confirmed through IONM. Indeed, their structure corresponded to an EBSLN to yield a kappa with a linear weighting value of 0.362. The standard error was 0.0467 [CI 0.2686-0.4554], indicating a fair agreement between the visual and IONM classification. CONCLUSION:IONM identified 97.5% of EBSLN cases. It was higher than the visual identification. There were no injuries to EBSLN identified through IONM.
Effect of Electroencephalography-Guided Anesthetic Administration on Postoperative Delirium Among Older Adults Undergoing Major Surgery: The ENGAGES Randomized Clinical Trial.
Wildes Troy S,Mickle Angela M,Ben Abdallah Arbi,Maybrier Hannah R,Oberhaus Jordan,Budelier Thaddeus P,Kronzer Alex,McKinnon Sherry L,Park Daniel,Torres Brian A,Graetz Thomas J,Emmert Daniel A,Palanca Ben J,Goswami Shreya,Jordan Katherine,Lin Nan,Fritz Bradley A,Stevens Tracey W,Jacobsohn Eric,Schmitt Eva M,Inouye Sharon K,Stark Susan,Lenze Eric J,Avidan Michael S,
Importance:Intraoperative electroencephalogram (EEG) waveform suppression, often suggesting excessive general anesthesia, has been associated with postoperative delirium. Objective:To assess whether EEG-guided anesthetic administration decreases the incidence of postoperative delirium. Design, Setting, and Participants:Randomized clinical trial of 1232 adults aged 60 years and older undergoing major surgery and receiving general anesthesia at Barnes-Jewish Hospital in St Louis. Recruitment was from January 2015 to May 2018, with follow-up until July 2018. Interventions:Patients were randomized 1:1 (stratified by cardiac vs noncardiac surgery and positive vs negative recent fall history) to receive EEG-guided anesthetic administration (n = 614) or usual anesthetic care (n = 618). Main Outcomes and Measures:The primary outcome was incident delirium during postoperative days 1 through 5. Intraoperative measures included anesthetic concentration, EEG suppression, and hypotension. Adverse events included undesirable intraoperative movement, intraoperative awareness with recall, postoperative nausea and vomiting, medical complications, and death. Results:Of the 1232 randomized patients (median age, 69 years [range, 60 to 95]; 563 women [45.7%]), 1213 (98.5%) were assessed for the primary outcome. Delirium during postoperative days 1 to 5 occurred in 157 of 604 patients (26.0%) in the guided group and 140 of 609 patients (23.0%) in the usual care group (difference, 3.0% [95% CI, -2.0% to 8.0%]; P = .22). Median end-tidal volatile anesthetic concentration was significantly lower in the guided group than the usual care group (0.69 vs 0.80 minimum alveolar concentration; difference, -0.11 [95% CI, -0.13 to -0.10), and median cumulative time with EEG suppression was significantly less (7 vs 13 minutes; difference, -6.0 [95% CI, -9.9 to -2.1]). There was no significant difference between groups in the median cumulative time with mean arterial pressure below 60 mm Hg (7 vs 7 minutes; difference, 0.0 [95% CI, -1.7 to 1.7]). Undesirable movement occurred in 137 patients (22.3%) in the guided and 95 (15.4%) in the usual care group. No patients reported intraoperative awareness. Postoperative nausea and vomiting was reported in 48 patients (7.8%) in the guided and 55 patients (8.9%) in the usual care group. Serious adverse events were reported in 124 patients (20.2%) in the guided and 130 (21.0%) in the usual care group. Within 30 days of surgery, 4 patients (0.65%) in the guided group and 19 (3.07%) in the usual care group died. Conclusions and Relevance:Among older adults undergoing major surgery, EEG-guided anesthetic administration, compared with usual care, did not decrease the incidence of postoperative delirium. This finding does not support the use of EEG-guided anesthetic administration for this indication. Trial Registration:ClinicalTrials.gov Identifier: NCT02241655.
Lessons from brain mapping in surgery for low-grade glioma: insights into associations between tumour and brain plasticity.
The Lancet. Neurology
Surgical treatment of low-grade gliomas (LGGs) aims to maximise the amount of tumour tissue resected, while minimising the risk of functional sequelae. In this review I address the issue of how to reconcile these two conflicting goals. First, I review the natural history of LGG-growth, invasion, and anaplastic transformation. Second, I discuss the contribution of new techniques, such as functional mapping, to our understanding of brain reorganisation in response to progressive growth of LGG. Third, I consider the clinical implications of interactions between tumour progression and brain plasticity. In particular, I show how longitudinal studies (preoperative, intraoperative, and postoperative) could allow us to optimise the surgical risk-to-benefit ratios. I will also discuss controversial issues such as defining surgical indications for LGGs, predicting the risk of postoperative deficit, aspects of operative surgical neuro-oncology (eg, preoperative planning and preservation of functional areas and tracts), and postoperative functional recovery.
Diagnostic value of somatosensory evoked potential changes during carotid endarterectomy: a systematic review and meta-analysis.
Nwachuku Enyinna L,Balzer Jeffrey R,Yabes Jonathan G,Habeych Miguel E,Crammond Donald J,Thirumala Parthasarathy D
IMPORTANCE:Perioperative stroke is a persistent complication of carotid endarterectomy (CEA) for patients with symptomatic carotid stenosis (CS). OBJECTIVE:To evaluate whether changes in somatosensory evoked potential (SSEP) during CEA are diagnostic of perioperative stroke in patients with symptomatic CS. DESIGN, SETTING, AND PARTICIPANTS:We searched PubMed and the World Science Database for reference lists of retrieved studies and/or experiments on SSEP use in postoperative outcomes following CEA in patients with symptomatic CS from January 1, 1950, through January 1, 2013. We independently screened all titles and abstracts to identify studies that met the inclusion criteria and extracted relevant articles in a uniform manner. Inclusion criteria included randomized clinical trials, prospective studies, or retrospective cohort reviews; population of symptomatic CS; use of intraoperative SSEP monitoring during CEA; immediate postoperative assessment and/or as long as a 3-month follow-up; a total sample size of 50 or more patients; studies with adult humans 18 years or older; and studies published in English. MAIN OUTCOME AND MEASURE:Whether intraoperative SSEP changes were diagnostic of perioperative stroke indicated by postoperative neurological examination. RESULTS:Four-hundred sixty-four articles were retrieved, and 15 prospective and retrospective cohort studies were included in the data analysis. A 4557-patient cohort composed the total sample population for all the studies, 3899 of whom had symptomatic CS. A change in SSEP exhibited a strong pooled mean specificity of 91% (95% CI, 86-94) but a weaker pooled mean sensitivity of 58% (95% CI, 49-68). A pooled diagnostic odds ratio for individual studies of patients with neurological deficit with changes in SSEPs was 14.39 (95% CI, 8.34-24.82), indicating that the odds of observing an SSEP change among those with neurologic deficits were 14 times higher than in individuals without neurologic deficit. CONCLUSIONS AND RELEVANCE:Intraoperative SSEP is a highly specific test in predicting neurological outcome following CEA. Patients with perioperative neurological deficits are 14 times more likely to have had changes in SSEPs during the procedure. The use of SSEPs to design prevention strategies is valuable in reducing perioperative cerebral infarctions during CEA.
Neurophysiological Changes Measured Using Somatosensory Evoked Potentials.
Macerollo Antonella,Brown Matt J N,Kilner James M,Chen Robert
Trends in neurosciences
Measurements of somatosensory evoked potentials (SEPs), recorded using electroencephalography during different phases of movement, have been fundamental in understanding the neurophysiological changes related to motor control. SEP recordings have also been used to investigate adaptive plasticity changes in somatosensory processing related to active and observational motor learning tasks. Combining noninvasive brain stimulation with SEP recordings and intracranial SEP depth recordings, including recordings from deep brain stimulation electrodes, has been critical in identifying neural areas involved in specific temporal stages of somatosensory processing. Consequently, this fundamental information has furthered our understanding of the maladaptive plasticity changes related to pathophysiology of diseases characterized by abnormal movements, such as Parkinson's disease, dystonia, and functional movement disorders.