Strategies and Pitfalls of Motor-Evoked Potential Monitoring during Supratentorial Aneurysm Surgery

Maruta, Yuichi; Fujii, Masami; Imoto, Hirochika; Nomura, Sadahiro; Tanaka, Nobuhiro; Inamura, Akinori; Sadahiro, Hirokazu; Oka, Fumiaki; Goto, Hisaharu; Shirao, Satoshi; Ideguchi, Makoto; Yanagawa, Hiroshi; Suehiro, Eiichi; Koizumi, Hiroyasu; Ishihara, Hideyuki; Suzuki, Michiyasu

doi:10.1016/j.jstrokecerebrovasdis.2015.10.025

Cited by 8 publications

(5 citation statements)

References 38 publications

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“…Bi-cranial stimulation is the most common configuration for cortical activation. It has become the standard of care for several procedures including intraoperative monitoring ( 14 , 15 , 31 ), and it is used extensively for low intensity DC and AC stimulations in research and clinical treatment. In this configuration, electrodes are placed on opposite sides of the scalp.…”

Section: Introductionmentioning

confidence: 99%

Sex and Electrode Configuration in Transcranial Electrical Stimulation

Russell¹,

Goodman

Visse³

et al. 2017

Front. Psychiatry

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Transcranial electrical stimulation (tES) can be an effective non-invasive neuromodulation procedure. Unfortunately, the considerable variation in reported treatment outcomes, both within and between studies, has made the procedure unreliable for many applications. To determine if individual differences in cranium morphology and tissue conductivity can account for some of this variation, the electrical density at two cortical locations (temporal and frontal) directly under scalp electrodes was modeled using a validated MRI modeling procedure in 23 subjects (12 males and 11 females). Three different electrode configurations (non-cephalic, bi-cranial, and ring) commonly used in tES were modeled at three current intensities (0.5, 1.0, and 2.0 mA). The aims were to assess the effects of configuration and current intensity on relative current received at a cortical brain target directly under the stimulating electrode and to characterize individual variation. The different electrode configurations resulted in up to a ninefold difference in mean current densities delivered to the brains. The ring configuration delivered the least current and the non-cephalic the most. Female subjects showed much less current to the brain than male subjects. Individual differences in the current received and differences in electrode configurations may account for significant variability in current delivered and, thus, potentially a significant portion of reported variation in clinical outcomes at two commonly targeted regions of the brain.

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Section: Introductionmentioning

confidence: 99%

Sex and Electrode Configuration in Transcranial Electrical Stimulation

Russell¹,

Goodman

Visse³

et al. 2017

Front. Psychiatry

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“…Therefore, even without MEP satisfying the warning criteria, IC can occur with abnormal SSEP findings only. Particularly, in the non-MCA territory, given the high likelihood of a false-negative MEP, care should be taken when interpreting the monitoring results (38,39). Although both the MEP and SSEP pathways are mainly distributed in the MCA territory, our risk factor analysis showed that UIA in the non-MCA territory was not a significant risk factor for IC.…”

Section: Discussionmentioning

confidence: 73%

Usefulness of Intraoperative Neurophysiological Monitoring During the Clipping of Unruptured Intracranial Aneurysm: Diagnostic Efficacy and Detailed Protocol

et al. 2021

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Background: Intraoperative neurophysiological monitoring (IONM) has been widely applied in brain vascular surgeries to reduce postoperative neurologic deficit (PND). This study aimed to investigate the effect of IONM during clipping of unruptured intracranial aneurysms (UIAs).Methods: Between January 2013 and August 2020, we enrolled 193 patients with 202 UIAs in the N group (clipping without IONM) and 319 patients with 343 UIAs in the M group (clipping with IONM). Patients in the M group were intraoperatively monitored for motor evoked potentials (MEPs) and somatosensory evoked potentials (SSEPs). Irreversible evoked potential (EP) change was defined as EP deterioration that did not recover until surgery completion. Sustained PND was defined as neurological symptoms lasting for more than one postoperative month.Results: Ten (3.1%) and 13 (6.7%) in the M and N groups, respectively, presented with PND. Compared with the N group, the M group had significantly lower occurrence rates of sustained PND [odds ratio (OR) = 0.36, 95% confidence interval (CI) = 0.13–0.98, p = 0.04], ischemic complications (OR = 0.39, 95% CI = 0.15–0.98, p = 0.04), and radiologic complications (OR = 0.40, 95% CI = 0.19–0.82, p = 0.01). Temporary clipping was an independent risk factor for ischemic complications (ICs) in the total patient group (OR = 6.18, 95% CI = 1.75–21.83, p = 0.005), but not in the M group (OR = 5.53, 95% CI = 0.76–41.92, p = 0.09). Regarding PND prediction, considering any EP changes (MEP and/or SSEP) showed the best diagnostic efficiency with a sensitivity of 0.900, specificity of 0.940, positive predictive value of 0.321, negative predictive value (NPV) of 0.997, and a negative likelihood ratio (LR) of 0.11.Conclusion: IONM application during UIA clipping can reduce PND and radiological complications. The diagnostic effectiveness of IONM, specifically the NPV and LR negative values, was optimal upon consideration of changes in any EP modality.

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“…None report on the occurrence of hyperexcitability as part of a reflex arc. One report mentions hyperexcitability occurring with cortical ischemia 6 and another during peripheral nerve compression over vascular loops, 7 suggesting that vascular ischemia can transiently increase the excitability of motor axons. It is possible that blood supply compromise during RLN dissection may have contributed to the observed transient hyperexcitability in the efferent LAR response, although this would be a novel concept in intraoperative reflex monitoring, where the final efferent motor response is the sum of the afferent and central components preceding it.…”

Section: Discussionmentioning

confidence: 99%

Laryngeal adductor reflex hyperexcitability may predict permanent vocal fold paralysis

Sinclair¹,

Téllez

Roldán

et al. 2019

The Laryngoscope

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Laryngeal adductor reflex-continuous intraoperative neuromonitoring (LAR-CIONM) is a novel method of continuous intraoperative neuromonitoring. In contrast to other vagal nerve monitoring techniques, which elicit a laryngeal compound muscle action potential, LAR-CIONM elicits a laryngeal reflex response (LAR). In 300 nerves at risk monitored with LAR-CIONM, two patients have had postoperative permanent vocal fold immobility (VFI). Both patients exhibited a significant LAR amplitude increase prior to complete loss of signal. No other patients have exhibited LAR hyperexcitability. If confirmed in a larger sample, this represents the first time that a vagal intraoperative neuromonitoring technique can distinguish transient from permanent VFI, which could improve patient outcomes.

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Strategies and Pitfalls of Motor-Evoked Potential Monitoring during Supratentorial Aneurysm Surgery

Cited by 8 publications

References 38 publications

Sex and Electrode Configuration in Transcranial Electrical Stimulation

Sex and Electrode Configuration in Transcranial Electrical Stimulation

Usefulness of Intraoperative Neurophysiological Monitoring During the Clipping of Unruptured Intracranial Aneurysm: Diagnostic Efficacy and Detailed Protocol

Laryngeal adductor reflex hyperexcitability may predict permanent vocal fold paralysis

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