Conjunct SEP and MEP monitoring in resection of infratentorial lesions: lessons learned in a cohort of 210 patients

2014 ◽  
Vol 121 (6) ◽  
pp. 1453-1461 ◽  
Author(s):  
Kunihiko Kodama ◽  
Mani Javadi ◽  
Volker Seifert ◽  
Andrea Szelényi
Keyword(s):  
Evoked Potentials ◽  
Negative Predictive Value ◽  
Predictive Value ◽  
Motor Evoked Potentials ◽  
Intraoperative Neuromonitoring ◽  
Lessons Learned ◽  
Surgical Removal ◽  
Medial Lemniscus ◽  
Brainstem Lesion ◽  
Lesion Location

Object During the surgical removal of infratentorial lesions, intraoperative neuromonitoring is mostly focused on cranial nerve assessment and brainstem auditory potentials. Despite the known risk of perforating vessel injury during microdissection within the vicinity of the brainstem, there are few reports about intraoperative neuromonitoring with somatosensory evoked potentials (SEPs) and motor evoked potentials (MEPs) assessing the medial lemniscus and corticospinal tract. This study analyses the occurrence of intraoperative changes in MEPs and SEPs with regard to lesion location and postoperative neurological outcome. Methods The authors analyzed 210 cases in which patients (mean age 49 ± 13 years, 109 female) underwent surgeries involving the skull base (n = 104), cerebellum (n = 63), fourth ventricle (n = 28), brainstem (n = 12), and foramen magnum (n = 3). Results Of 210 surgeries, 171 (81.4%) were uneventful with respect to long-tract monitoring. Nine (23%) of the 39 SEP and/or MEP alterations were transient and were only followed by a slight permanent deficit in 1 case. Permanent deterioration only was seen in 19 (49%) of 39 cases; the deterioration was related to tumor dissection in 4 of these cases, and permanent deficit (moderate-severe) was seen in only 1 of these 4 cases. Eleven patients (28%) had losses of at least 1 modality, and in 9 of these 11 cases, the loss was related to surgical microdissection within the vicinity of the brainstem. Four of these 9 patients suffered a moderate-to-severe long-term deficit. For permanent changes, the positive predictive value for neuromonitoring of the long tracts was 0.467, the negative predictive value was 0.989, the sensitivity was 0.875, and the specificity 0.918. Twenty-eight (72%) of 39 SEP and MEP alterations occurred in 66 cases involving intrinsic brainstem tumors or tumors adjacent to the brainstem. Lesion location and alterations in intraoperative neuromonitoring significantly correlated with patients' outcome (p < 0.001, chi-square test). Conclusions In summary, long-tract monitoring with SEPs and MEPs in infratentorial surgeries has a high sensitivity and negative predictive value with respect to postoperative neurological status. It is recommended especially in those surgeries in which microdissection within and in the vicinity of the brainstem might lead to injury of the brainstem parenchyma or perforating vessels and a subsequent perfusion deficit within the brainstem.

scholarly journals Sensitivity and Negative Predictive Value of Motor Evoked Potentials of the Facial Nerve

2021 ◽  
Author(s):  
Nicolas Bovo ◽  
Shahan Momjian ◽  
Renato Gondar ◽  
Philippe Bijlenga ◽  
Karl Schaller ◽  
...  
Keyword(s):  
Facial Nerve ◽  
Evoked Potentials ◽  
Negative Predictive Value ◽  
Patient Group ◽  
Vestibular Schwannoma ◽  
Predictive Value ◽  
Cerebellopontine Angle ◽  
Motor Evoked Potentials ◽  
Vestibular Schwannomas ◽  
Predictive Values

Abstract Objective The objective of this study was to determine the performance of the standard alarm criterion of motor evoked potentials (MEPs) of the facial nerve in surgeries performed for resections of vestibular schwannomas or of other lesions of the cerebellopontine angle. Methods This retrospective study included 33 patients (16 with vestibular schwannomas and 17 with other lesions) who underwent the resection surgery with transcranial MEPs of the facial nerve. A reproducible 50% decrease in MEP amplitude, resistant to a 10% increase in stimulation intensity, was applied as the alarm criterion during surgery. Facial muscular function was clinically evaluated with the House–Brackmann score (HBS), pre- and postsurgery at 3 months. Results In the patient group with vestibular schwannoma, postoperatively, the highest sensitivity and negative predictive values were found for a 30% decrease in MEP amplitude, that is, a criterion stricter than the 50% decrease in MEP amplitude criterion, prone to trigger more warnings, used intraoperatively. With this new criterion, the sensitivity would be 88.9% and the negative predictive value would be 85.7%. In the patient group with other lesions of the cerebellopontine angle, the highest sensitivity and negative predictive values were found equally for 50, 60, or 70% decrease in MEP amplitude. With these criteria, the sensitivities and the negative predictive values would be 100.0%. Conclusion Different alarm criteria were found for surgeries for vestibular schwannomas and for other lesions of the cerebellopontine angle. The study consolidates the stricter alarm criterion, that is, a criterion prone to trigger early warnings, as found previously by others for vestibular schwannoma surgeries (30% decrease in MEP amplitude).

scholarly journals Intraoperative neuromonitoring in spine deformity surgery: modalities, advantages, limitations, medicolegal issues – surgeons’ views

2020 ◽  
Vol 5 (1) ◽  
pp. 9-16 ◽  
Author(s):  
Mirza Biscevic ◽  
Aida Sehic ◽  
Ferid Krupic
Keyword(s):  
Spinal Cord ◽  
Evoked Potentials ◽  
Motor Evoked Potentials ◽  
Dorsal Column ◽  
Intraoperative Neuromonitoring ◽  
Spine Deformity ◽  
Medial Lemniscus ◽  
Motor Pathways ◽  
Sensory Pathways ◽  
Permanent Neurological Deficit

In spine deformity surgery, iatrogenic neurologic injuries might occur due to the mechanical force applied to the spinal cord from implants, instruments, and bony structures, or due to ischemic changes from vessel ligation during exposure and cord distraction/compression during corrective manoeuvres. Prompt reaction within the reversible phase (reducing of compressive/distractive forces) usually restores functionality of the spinal cord, but if those forces continue to persist, a permanent neurological deficit might be expected. With monitoring of sensory pathways (dorsal column–medial lemniscus) by somatosensory-evoked potentials (SSEPs), such events are detected with a sensitivity of up to 92%, and a specificity of up to 100%. The monitoring of motor pathways by transcranial electric motor-evoked potentials (TceMEPs) has a sensitivity and a specificity of up to 100%, but it requires avoidance of halogenated anaesthetics and neuromuscular blockades. Different modalities of intraoperative neuromonitoring (IONM: SSEP, TceMEP, or combined) can be performed by the neurophysiologist, the technician or the surgeon. Combined SSEP/TceMEP performed by the neurophysiologist in the operating room is the preferable method of IONM, but it might be impractical or unaffordable in many institutions. Still, many spine deformity surgeries worldwide are performed without any type of IONM. Medicolegal aspects of IONM are different worldwide and in many cases some vagueness remains. The type of IONM that a spinal surgeon employs should be reliable, affordable, practical, and recognized by the medicolegal guidelines. Cite this article: EFORT Open Rev 2020;5:9-16. DOI: 10.1302/2058-5241.5.180032

Introduction of intraoperative neuromonitoring does not necessarily improve overall long-term outcome in elective aneurysm clipping

2020 ◽  
Vol 132 (4) ◽  
pp. 1188-1196 ◽  
Author(s):  
Tobias Greve ◽  
Veit M. Stoecklein ◽  
Franziska Dorn ◽  
Sophia Laskowski ◽  
Niklas Thon ◽  
...  
Keyword(s):  
Evoked Potentials ◽  
Predictive Value ◽  
Neurological Outcome ◽  
Positive Impact ◽  
Case Series ◽  
Intraoperative Neuromonitoring ◽  
Neurosurgical Procedures ◽  
Long Term Outcome ◽  
Unruptured Intracranial Aneurysms ◽  
Significant Difference

OBJECTIVEIntraoperative neuromonitoring (IOM), particularly of somatosensory-evoked potentials (SSEPs) and motor-evoked potentials (MEPs), evolved as standard of care in a variety of neurosurgical procedures. Case series report a positive impact of IOM for elective microsurgical clipping of unruptured intracranial aneurysms (ECUIA), whereas systematic evaluation of its predictive value is lacking. Therefore, the authors analyzed the neurological outcome of patients undergoing ECUIA before and after IOM introduction to this procedure.METHODSThe dates of inclusion in the study were 2007–2014. In this period, ECUIA procedures before (n = 136, NIOM-group; 2007–2010) and after introduction of IOM (n = 138, IOM-group; 2011–2014) were included. The cutoff value for SSEP/MEP abnormality was chosen as an amplitude reduction ≥ 50%. SSEP/MEP changes were correlated with neurological outcome. IOM-undetectable deficits (bulbar, vision, ataxia) were not included in risk stratification.RESULTSThere was no significant difference in sex distribution, follow-up period, subarachnoid hemorrhage risk factors, aneurysm diameter, complexity, and location. Age was higher in the IOM-group (57 vs 54 years, p = 0.012). In the IOM group, there were 18 new postoperative deficits (13.0%, 5.8% permanent), 9 hemisyndromes, 2 comas, 4 bulbar symptoms, and 3 visual deficits. In the NIOM group there were 18 new deficits (13.2%; 7.3% permanent, including 7 hemisyndromes). The groups did not significantly differ in the number or nature of postoperative deficits, nor in their recovery rate. In the IOM group, SSEPs and MEPs were available in 99% of cases. Significant changes were noted in 18 cases, 4 of which exhibited postoperative hemisyndrome, and 1 suffered from prolonged comatose state (5 true-positive cases). Twelve patients showed no new detectable deficits (false positives), however 2 of these cases showed asymptomatic infarction. Five patients with new hemisyndrome and 1 comatose patient did not show significant SSEP/MEP alterations (false negatives). Overall sensitivity of SSEP/MEP monitoring was 45.5%, specificity 89.8%, positive predictive value 27.8%, and negative predictive value 95.0%.CONCLUSIONSThe assumed positive impact of introducing SSEP/MEP monitoring on overall neurological outcome in ECUIA did not reach significance. This study suggests that from a medicolegal point of view, IOM is not stringently required in all neurovascular procedures. However, future studies should carefully address high-risk patients with complex procedures who might benefit more clearly from IOM than others.

Influence of lesion location on the accuracy of CT derived FFR: head-to-head comparison with invasive FFR

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
M Moshage ◽  
S Smolka ◽  
S Achenbach ◽  
F Ammon ◽  
P Ferstl ◽  
...  
Keyword(s):  
Coronary Angiography ◽  
Positive Predictive Value ◽  
Diagnostic Accuracy ◽  
Negative Predictive Value ◽  
Predictive Value ◽  
Invasive Coronary Angiography ◽  
Roc Curve Analysis ◽  
Jude Medical ◽  
Lesion Location ◽  
Distal Vessel

Abstract Background The accuracy of CT-derived FFR (FFRCT) has been repeatedly reported. However, the influence of lesion location on accuracy is unknown. Therefore, we evaluated the diagnostic accuracy of FFRCT to detect lesion-specific ischemia and determined the influence of lesion location (proximal vs. distal vessel segments) compared to invasively measured FFR in patients with suspected CAD. Methods A total of 136 vessels in which “Dual-Source”-CT coronary angiography had been performed due to suspected CAD and who were further referred for invasive coronary angiography with invasive FFR measurement within three months of the index CT examination were retrospectively identified and screened for inclusion in this analysis. Patients with either left main coronary artery stenoses, bifurcation or ostial stenoses were excluded. Invasive FFR was measured using a pressure wire (CERTUS®, St. Jude Medical, Minnesota, USA or Verrata®, Volcano, San Diego, USA). FFRCT was calculated using an on-site prototype (cFFR Version 3.0, Siemens Healthineers, Forchheim, Germany). All vessels were analyzed by an experienced observer blinded to the results of invasive FFR. Stenoses with invasively measured FFR ≤0.80 were classified as hemodynamically significant. We evaluated the diagnostic accuracy of FFRCT in proximal vs. non-proximal vessel segments. Proximal lesions included stenoses located in segment one, six, eleven and twelve. All other stenoses were categorized as distal lesions. Results Out of 136 coronary stenoses, 47 (35%) were located in proximal segments and 89 (65%) lesions were located in distal segments. Compared to invasive FFR, the sensitivity of FFRCT to correctly identify/exclude hemodynamically significant stenoses in proximal vessel segments was 93% (95% CI: 68–99.8%) and the specificity was 100% (95% CI: 89–100%), compared to a sensitivity of 72% (95% CI: 46.5–90%) and a specificity of 87% (95% CI: 77–94%) for FFRCT in distal lesions. The positive predictive value was 100% and the negative predictive value was 97% (95% CI: 82.8–99.5%) compared to a positive predictive value of 59% (95% CI: 42–93.9%) and a negative predictive value of 93% (95% CI: 85.4–96.3%) for proximal vs. distal vessel segment, respectively. This corresponds to an accuracy of 98% vs. 84%, respectively (p=0.02). ROC-Curve analysis showed a slightly higher – albeit non-significant – area under the curve for FFRCT to detect hemodynamic relevance in proximal lesions compared to distal lesions (AUC 0.95, p&lt;0.001 vs. AUC: 0.86, p&lt;0.001, respectively, p=0.2). Conclusion FFRCT obtained using an on-site prototype shows overall a high diagnostic accuracy for detecting lesions causing ischemia as compared to invasive FFR with a trend towards better diagnostic performance in proximal vessel segments. Funding Acknowledgement Type of funding source: None

Predicting Hand Motor Recovery in Severe Stroke: The Role of Motor Evoked Potentials in Relation to Early Clinical Assessment

2008 ◽  
Vol 23 (1) ◽  
pp. 45-51 ◽  
Author(s):  
Annette A. van Kuijk ◽  
Jaco W. Pasman ◽  
Henk T. Hendricks ◽  
Machiel J. Zwarts ◽  
Alexander C. H. Geurts
Keyword(s):  
Lower Extremity ◽  
Evoked Potentials ◽  
Upper Extremity ◽  
Clinical Assessment ◽  
Predictive Value ◽  
Motor Evoked Potentials ◽  
Motor Recovery ◽  
Stroke Patients ◽  
Abductor Digiti Minimi

Objective. The primary aim of this study was to compare the predictive value of motor evoked potentials (MEPs) and early clinical assessment with regard to long-term hand motor recovery in patients with profound hemiplegia after stroke. Methods. The sample was an inception cohort of 39 stroke patients with an acute, ischemic, supratentorial stroke and an initial upper-extremity paralysis admitted to an academic hospital. Hand motor function recovery was defined at 26 weeks poststroke as a Fugl–Meyer Motor Assessment (FMA) hand score >3 points. The following prognostic factors were compared at week 1 and week 3 poststroke: motor functions as assessed by the FMA upper-extremity and lower-extremity subscores, and the presence of an MEP in the abductor digiti minimi and biceps brachii muscle. Results. Both the presence of an abductor digiti minimi–MEP and any motor recovery in the FMA upper-extremity subscore showed a positive predictive value of 1.00 at weeks 1 and 3. The FMA lower-extremity subscore showed the best negative predictive value (0.90; 95% CI 0.78-1.00 at week 1 and 0.95; 95% CI 0.87-1.00 at week 3). Conclusions. In stroke patients with an initial paralysis of the upper extremity the presence or absence of an MEP has similar predictive value compared with early clinical assessment with regard to long-term hand motor recovery.

Neurophysiologic Monitoring

2019 ◽  
Author(s):  
Scott Vaughan ◽  
Chadron Vassar ◽  
Nitin Kumar ◽  
Kerolos Yousef
Keyword(s):  
Nervous System ◽  
Evoked Potentials ◽  
Predictive Value ◽  
Auditory Evoked Potentials ◽  
Motor Evoked Potentials ◽  
Neurophysiologic Monitoring ◽  
High Positive Predictive Value ◽  
Sensory Evoked Potentials ◽  
Sensory Evoked ◽  
Bispectral Index Monitor

Neurophysiologic monitoring is a diverse group of instruments that are used to monitor the central and peripheral nervous system during surgical procedures. Some are used to monitor anesthetic depth, whereas others are used by neurologists to monitor the integrity of the nervous system during surgical procedure. The goal of neurophysiologic monitoring is to have reliable, reproducible, and predictive monitors that can identify impending compromise to the neurologic system (or anesthetic) with minimal false predictive value and high positive predictive value. This allows for the identification of neurologic tissues by location and type that are at risk of compromise by vascular and/or mechanical injury. This review contains 3 figures, 8 tables, and  34 references. Key Words: auditory evoked potentials, bispectral index monitor, electrocorticography, electroencephalography, electromyographic monitoring, M-ENTROPY, motor evoked potentials, narcotrend index, sensory evoked potentials, spectral analysis

Intraoperative Neuromonitoring of Motor-Evoked Potentials in Infants Undergoing Surgery of the Spine and Spinal Cord

2019 ◽  
Vol 36 (1) ◽  
pp. 60-66 ◽  
Author(s):  
Elif Ilgaz Aydinlar ◽  
Pinar Yalinay Dikmen ◽  
Muge Kocak ◽  
Nigar Baykan ◽  
Nogayhan Seymen ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Evoked Potentials ◽  
Motor Evoked Potentials ◽  
Intraoperative Neuromonitoring

Predictive Value and Safety of Intraoperative Neurophysiological Monitoring With Motor Evoked Potentials in Glioma Surgery

Neurosurgery ◽  
2011 ◽  
Vol 70 (5) ◽  
pp. 1060-1071 ◽  
Author(s):  
Sandro M. Krieg ◽  
Ehab Shiban ◽  
Doris Droese ◽  
Jens Gempt ◽  
Niels Buchmann ◽  
...  
Keyword(s):  
Evoked Potentials ◽  
Predictive Value ◽  
Motor System ◽  
Motor Evoked Potentials ◽  
False Negative ◽  
Motor Deficit ◽  
Neurophysiological Monitoring ◽  
Glioma Surgery ◽  
Supratentorial Gliomas

Abstract BACKGROUND: Resection of gliomas in or adjacent to the motor system is widely performed with intraoperative neuromonitoring (IOM). Despite the fact that data on the safety of IOM are available, the significance and predictive value of the procedure are still under discussion. Moreover, cases of false-negative monitoring affect the surgeon's confidence in IOM. OBJECTIVE: To examine cases of false-negative IOM to reveal structural explanations. METHODS: Between 2007 and 2010, we resected 115 consecutive supratentorial gliomas in or close to eloquent motor areas using direct cortical stimulation for monitoring of motor evoked potentials (MEPs). The monitoring data were reviewed and related to new postoperative motor deficit and postoperative imaging. Clinical outcomes were assessed during follow-up. RESULTS: Monitoring of MEPs was successful in 112 cases (97.4%). Postoperatively, 30.3% of patients had a new motor deficit, which remained permanent in 12.5%. Progression-free follow-up was 9.7 months (range, 2 weeks-40.6 months). In 65.2% of all cases, MEPs were stable throughout the operation, but 8.9% showed a new temporary motor deficit, whereas 4.5% (5 patients) presented with permanently deteriorated motor function representing false-negative monitoring at first glance. However, these cases were caused by secondary hemorrhage, ischemia, or resection of the supplementary motor area. CONCLUSION: Continuous MEP monitoring provides reliable monitoring of the motor system, influences the course of operation in some cases, and has to be regarded as the standard for IOM of the motor system. In our series, we found no false-negative MEP results.

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