Monitoring of motor evoked potentials compared with somatosensory evoked potentials and microvascular Doppler ultrasonography in cerebral aneurysm surgery

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Object. The aims of this study were to compare the efficiency of motor evoked potentials (MEPs), somatosensory evoked potentials (SSEPs), and microvascular Doppler ultrasonography (MDU) in the detection of impending motor impairment from subcortical ischemia in aneurysm surgery; to determine their sensitivity for specific intraoperative events; and to compare their impact on the surgical strategy used.

Methods. Motor evoked potentials, SSEPs, and MDU were monitored during 100 operations for 129 aneurysms in 95 patients. Intraoperative events, monitoring results, and clinical outcome were correlated in a prospective observational design.

Motor evoked potentials indicated inadequate temporary clipping, inadvertent occlusion, inadequate retraction, vasospasm, or compromise to perforating vessels in 21 of 33 instances and deteriorated despite stable SSEPs in 18 cases. Microvascular Doppler ultrasonography revealed inadvertent vessel occlusion in eight of 10 cases and insufficient clipping in four of four cases. Stable evoked potentials (EPs) allowed safe, permanent vessel occlusion or narrowing despite reduced flow on MDU in five cases. Two patients sustained permanent and 10 showed transient new weakness, which had been detected by SSEPs in two of 12 patients and MEPs in 10 of 11 monitored cases. The surgical strategy was directly altered in 33 instances: by MEPs in 16, SSEPs in four, and MDU in 13.

Conclusions. Monitoring of MEPs is superior to SSEP monitoring and MDU in detecting motor impairment, particularly that from subcortical ischemia. Microvascular Doppler ultrasonography is superior to EP monitoring in detecting inadvertent vessel occlusion, but cannot assess remote collateral flow. Motor evoked potentials are most sensitive to all other intraoperative conditions and have a direct influence on the course of surgery in the majority of events. A controlled study design is required to confirm the positive effect of monitoring on clinical outcome in aneurysm surgery.

Article Information

Contributor Notes

Address reprint requests to: Georg Neuloh, M.D., Neurochirurgische Universitätsklinik, 53105 Bonn, Germany. email: neuloh@ukb.uni-bonn.de.

© AANS, except where prohibited by US copyright law.

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References
  • 1.

    Bailes JETantuwaya LSFukushima Tet al: Intraoperative microvascular Doppler sonography in aneurysm surgery. Neurosurgery 40:9659721997Bailes JE Tantuwaya LS Fukushima T et al: Intraoperative microvascular Doppler sonography in aneurysm surgery. Neurosurgery 40:965–972 1997

    • Search Google Scholar
    • Export Citation
  • 2.

    British Medical Research Council: Aids to the examination of the peripheral nervous system. Memorandum No. 45Her Majesty's Stationery OfficeLondon1976British Medical Research Council: Aids to the examination of the peripheral nervous system. Memorandum No. 45 Her Majesty's Stationery Office London 1976

    • Search Google Scholar
    • Export Citation
  • 3.

    Buchthal ABelopavlovic MMooij JJ: Evoked potential monitoring and temporary clipping in cerebral aneurysm surgery. Acta Neurochir 93:28361988Buchthal A Belopavlovic M Mooij JJ: Evoked potential monitoring and temporary clipping in cerebral aneurysm surgery. Acta Neurochir 93:28–36 1988

    • Search Google Scholar
    • Export Citation
  • 4.

    Cedzich CTaniguchi MSchafer Set al: Somatosensory evoked potential phase reversal and direct motor cortex stimulation during surgery in and around the central region. Neurosurgery 38:9629701996Cedzich C Taniguchi M Schafer S et al: Somatosensory evoked potential phase reversal and direct motor cortex stimulation during surgery in and around the central region. Neurosurgery 38:962–970 1996

    • Search Google Scholar
    • Export Citation
  • 5.

    Charbel FTGonzales-Portillo GHoffman WEet al: Quantitative assessment of vessel flow integrity for aneurysm surgery. Technical note. J Neurosurg 91:105010541999Charbel FT Gonzales-Portillo G Hoffman WE et al: Quantitative assessment of vessel flow integrity for aneurysm surgery. Technical note. J Neurosurg 91:1050–1054 1999

    • Search Google Scholar
    • Export Citation
  • 6.

    Ducati ALandi ACenzato Met al: Monitoring of brain function by means of evoked potentials in cerebral aneurysm surgery. Acta Neurochir Suppl 42:8131988Ducati A Landi A Cenzato M et al: Monitoring of brain function by means of evoked potentials in cerebral aneurysm surgery. Acta Neurochir Suppl 42:8–13 1988

    • Search Google Scholar
    • Export Citation
  • 7.

    Firsching RSynowitz HJHanebeck J: Practicability of intraoperative microvascular Doppler sonography in aneurysm surgery. Minim Invasive Neurosurg 43:1441482000Firsching R Synowitz HJ Hanebeck J: Practicability of intraoperative microvascular Doppler sonography in aneurysm surgery. Minim Invasive Neurosurg 43:144–148 2000

    • Search Google Scholar
    • Export Citation
  • 8.

    Friedman WAChadwick GMVerhoeven FJet al: Monitoring of Evoked potentials monitoring and ultrasonography in aneurysm surgery somatosensory evoked potentials during surgery for middle cerebral artery aneurysms. Neurosurgery 29:83881991Friedman WA Chadwick GM Verhoeven FJ et al: Monitoring of Evoked potentials monitoring and ultrasonography in aneurysm surgery somatosensory evoked potentials during surgery for middle cerebral artery aneurysms. Neurosurgery 29:83–88 1991

    • Search Google Scholar
    • Export Citation
  • 9.

    Gilsbach JMHassler WE: Intraoperative Doppler and real time sonography in neurosurgery. Neurosurg Rev 7:1992081984Gilsbach JM Hassler WE: Intraoperative Doppler and real time sonography in neurosurgery. Neurosurg Rev 7:199–208 1984

    • Search Google Scholar
    • Export Citation
  • 10.

    Grundy BLNelson PBLina Aet al: Monitoring of cortical somatosensory evoked potentials to determine the safety of sacrificing the anterior cerebral artery. Neurosurgery 11:64671982Grundy BL Nelson PB Lina A et al: Monitoring of cortical somatosensory evoked potentials to determine the safety of sacrificing the anterior cerebral artery. Neurosurgery 11:64–67 1982

    • Search Google Scholar
    • Export Citation
  • 11.

    Holland NR: Subcortical strokes from intracranial aneurysm surgery: implications for intraoperative neuromonitoring. J Clin Neurophysiol 15:4394461998Holland NR: Subcortical strokes from intracranial aneurysm surgery: implications for intraoperative neuromonitoring. J Clin Neurophysiol 15:439–446 1998

    • Search Google Scholar
    • Export Citation
  • 12.

    Hunt WEHess RM: Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg 28:14201968Hunt WE Hess RM: Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg 28:14–20 1968

    • Search Google Scholar
    • Export Citation
  • 13.

    Kassell NFTorner JCJane JAet al: The International Cooperative Study on the Timing of Aneurysm Surgery. Part 2: Surgical Results. J Neurosurg 73:37471990Kassell NF Torner JC Jane JA et al: The International Cooperative Study on the Timing of Aneurysm Surgery. Part 2: Surgical Results. J Neurosurg 73:37–47 1990

    • Search Google Scholar
    • Export Citation
  • 14.

    Kombos TSuess OCiklatekerlio Oet al: Monitoring of intraoperative motor evoked potentials to increase the safety of surgery in and around the motor cortex. J Neurosurg 95:6086142001Kombos T Suess O Ciklatekerlio O et al: Monitoring of intraoperative motor evoked potentials to increase the safety of surgery in and around the motor cortex. J Neurosurg 95:608–614 2001

    • Search Google Scholar
    • Export Citation
  • 15.

    Krieger DAdams HPAlbert Fet al: Pure motor hemiparesis with stable somatosensory evoked potential monitoring during aneurysm surgery: case report. Neurosurgery 31:1451501992Krieger D Adams HP Albert F et al: Pure motor hemiparesis with stable somatosensory evoked potential monitoring during aneurysm surgery: case report. Neurosurgery 31:145–150 1992

    • Search Google Scholar
    • Export Citation
  • 16.

    Lagalla GCeravolo MGProvinciali Let al: Transcranial Doppler sonographic monitoring during cerebral aneurysm embolization: a preliminary report. AJNR 19:154915531998Lagalla G Ceravolo MG Provinciali L et al: Transcranial Doppler sonographic monitoring during cerebral aneurysm embolization: a preliminary report. AJNR 19:1549–1553 1998

    • Search Google Scholar
    • Export Citation
  • 17.

    Little JRLesser RPLuders H: Electrophysiological monitoring during basilar aneurysm operation. Neurosurgery 20:4214271987Little JR Lesser RP Luders H: Electrophysiological monitoring during basilar aneurysm operation. Neurosurgery 20:421–427 1987

    • Search Google Scholar
    • Export Citation
  • 18.

    Ljunggren BSaveland HBrandt L: Causes of unfavorable outcome after early aneurysm operation. Neurosurgery 13:6296331983Ljunggren B Saveland H Brandt L: Causes of unfavorable outcome after early aneurysm operation. Neurosurgery 13:629–633 1983

    • Search Google Scholar
    • Export Citation
  • 19.

    Lopez JRChang SDSteinberg GK: The use of electrophysiological monitoring in the intraoperative management of intracranial aneurysms. J Neurol Neurosurg Psychiatry 66:1891961999Lopez JR Chang SD Steinberg GK: The use of electrophysiological monitoring in the intraoperative management of intracranial aneurysms. J Neurol Neurosurg Psychiatry 66:189–196 1999

    • Search Google Scholar
    • Export Citation
  • 20.

    Matsuda MKidooka MNakazawa Tet al: Intraoperative monitoring of somatosensory evoked potentials in patients with cerebral aneurysm—correlation between central conduction time and postoperative neurological status. Neurol Med Chir 31:13171991Matsuda M Kidooka M Nakazawa T et al: Intraoperative monitoring of somatosensory evoked potentials in patients with cerebral aneurysm—correlation between central conduction time and postoperative neurological status. Neurol Med Chir 31:13–17 1991

    • Search Google Scholar
    • Export Citation
  • 21.

    Min KTKim JHShin YSet al: The monitoring of somatosensory evoked potentials and neurologic complications in aneurysm surgery. Yonsei Med J 42:2272322001Min KT Kim JH Shin YS et al: The monitoring of somatosensory evoked potentials and neurologic complications in aneurysm surgery. Yonsei Med J 42:227–232 2001

    • Search Google Scholar
    • Export Citation
  • 22.

    Mizoi KYoshimoto T: Permissible temporary occlusion time in aneurysm surgery as evaluated by evoked potential monitoring. Neurosurgery 33:4344401993Mizoi K Yoshimoto T: Permissible temporary occlusion time in aneurysm surgery as evaluated by evoked potential monitoring. Neurosurgery 33:434–440 1993

    • Search Google Scholar
    • Export Citation
  • 23.

    Molyneux AKerr RStratton Iet al: International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet 360:126712742002Molyneux A Kerr R Stratton I et al: International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet 360:1267–1274 2002

    • Search Google Scholar
    • Export Citation
  • 24.

    Momma FWang ADSymon L: Effects of temporary arterial occlusion on somatosensory evoked responses in aneurysm surgery. Surg Neurol 27:3433521987Momma F Wang AD Symon L: Effects of temporary arterial occlusion on somatosensory evoked responses in aneurysm surgery. Surg Neurol 27:343–352 1987

    • Search Google Scholar
    • Export Citation
  • 25.

    Mooij JJBuchthal ABelopavlovic M: Somatosensory evoked potential monitoring of temporary middle cerebral artery occlusion during aneurysm operation. Neurosurgery 21:4924961987Mooij JJ Buchthal A Belopavlovic M: Somatosensory evoked potential monitoring of temporary middle cerebral artery occlusion during aneurysm operation. Neurosurgery 21:492–496 1987

    • Search Google Scholar
    • Export Citation
  • 26.

    Nanda AVannemreddy P: Management of intracranial aneurysms: factors that influence clinical grade and surgical outcome. South Med J 96:2592632003Nanda A Vannemreddy P: Management of intracranial aneurysms: factors that influence clinical grade and surgical outcome. South Med J 96:259–263 2003

    • Search Google Scholar
    • Export Citation
  • 27.

    Neuloh GSchramm J: Intraoperative neurophysiological mapping and monitoring for supratentorial procedures in Deletis VShilsJL (eds): Neurophysiology in Neurosurgery. A Modern Intraoperative Approach. Amsterdam: Academic Press2002 pp 339401Neuloh G Schramm J: Intraoperative neurophysiological mapping and monitoring for supratentorial procedures in Deletis V Shils JL (eds): Neurophysiology in Neurosurgery. A Modern Intraoperative Approach. Amsterdam: Academic Press 2002 pp 339–401

    • Search Google Scholar
    • Export Citation
  • 28.

    Neuloh GSchramm J: Motor evoked potential monitoring compared with SEP and micro Doppler in cerebral aneurysm surgery. Clin Neurophysiol 113:S452002 (Abstract)Neuloh G Schramm J: Motor evoked potential monitoring compared with SEP and micro Doppler in cerebral aneurysm surgery. Clin Neurophysiol 113:S45 2002 (Abstract)

    • Search Google Scholar
    • Export Citation
  • 29.

    Pechstein UCedzich CNadstawek Jet al: Transcranial high-frequency repetitive electrical stimulation for recording myogenic motor evoked potentials with the patient under general anesthesia. Neurosurgery 39:3353441996Pechstein U Cedzich C Nadstawek J et al: Transcranial high-frequency repetitive electrical stimulation for recording myogenic motor evoked potentials with the patient under general anesthesia. Neurosurgery 39:335–344 1996

    • Search Google Scholar
    • Export Citation
  • 30.

    Raabe ASeifert VSchmiedek Pet al: Empfehlungen zum Management nicht rupturierter intrakranieller Aneurysmen. Zentralbl Neurochir 63:70762002Raabe A Seifert V Schmiedek P et al: Empfehlungen zum Management nicht rupturierter intrakranieller Aneurysmen. Zentralbl Neurochir 63:70–76 2002

    • Search Google Scholar
    • Export Citation
  • 31.

    Rohde VWill BEHahn Get al: Motorisch evozierte Potentiale während der Embolisation arteriovenöser Malformationen zur Erfassung ischämischer Komplikationen. Zentralbl Neurochir 60:74801999Rohde V Will BE Hahn G et al: Motorisch evozierte Potentiale während der Embolisation arteriovenöser Malformationen zur Erfassung ischämischer Komplikationen. Zentralbl Neurochir 60:74–80 1999

    • Search Google Scholar
    • Export Citation
  • 32.

    Sako KNakaiHKawataYet al: Temporary arterial occlusion during anterior communicating or anterior cerebral artery aneurysm operation under tibial nerve somatosensory evoked potential monitoring. Surg Neurol 49:3163231998Sako K Nakai H Kawata Y et al: Temporary arterial occlusion during anterior communicating or anterior cerebral artery aneurysm operation under tibial nerve somatosensory evoked potential monitoring. Surg Neurol 49:316–323 1998

    • Search Google Scholar
    • Export Citation
  • 33.

    Sala FNiimi YBerenstein Aet al: Neuroprotective role of neurophysiological monitoring during endovascular procedures in the spinal cord. Ann NY Acad Sci 939:1261362001Sala F Niimi Y Berenstein A et al: Neuroprotective role of neurophysiological monitoring during endovascular procedures in the spinal cord. Ann NY Acad Sci 939:126–136 2001

    • Search Google Scholar
    • Export Citation
  • 34.

    Sala FNiimi YKrzan MJet al: Embolization of a spinal arteriovenous malformation: correlation between motor evoked potentials and angiographic findings: technical case report. Neurosurgery 45:9329381999Sala F Niimi Y Krzan MJ et al: Embolization of a spinal arteriovenous malformation: correlation between motor evoked potentials and angiographic findings: technical case report. Neurosurgery 45:932–938 1999

    • Search Google Scholar
    • Export Citation
  • 35.

    Schramm JKoht ASchmidt Get al: Surgical and electrophysiological observations during clipping of 134 aneurysms with evoked potential monitoring. Neurosurgery 26:61701990Schramm J Koht A Schmidt G et al: Surgical and electrophysiological observations during clipping of 134 aneurysms with evoked potential monitoring. Neurosurgery 26:61–70 1990

    • Search Google Scholar
    • Export Citation
  • 36.

    Schramm JZentner JPechstein U: Intraoperative SEP monitoring in aneurysm surgery. Neurol Res 16:20221994Schramm J Zentner J Pechstein U: Intraoperative SEP monitoring in aneurysm surgery. Neurol Res 16:20–22 1994

    • Search Google Scholar
    • Export Citation
  • 37.

    Shibata YFujita SKawaguchi Tet al: Use of microvascular Doppler sonography in aneurysm surgery on the anterior choroidal artery. Neurol Med Chir 40:30372000Shibata Y Fujita S Kawaguchi T et al: Use of microvascular Doppler sonography in aneurysm surgery on the anterior choroidal artery. Neurol Med Chir 40:30–37 2000

    • Search Google Scholar
    • Export Citation
  • 38.

    Stendel RPietila TAl Hassan AAet al: Intraoperative microvascular Doppler ultrasonography in cerebral aneurysm surgery. J Neurol Neurosurg Psychiatry 68:29352000Stendel R Pietila T Al Hassan AA et al: Intraoperative microvascular Doppler ultrasonography in cerebral aneurysm surgery. J Neurol Neurosurg Psychiatry 68:29–35 2000

    • Search Google Scholar
    • Export Citation
  • 39.

    Suzuki HFujita KEhara Ket al: Anterior choroidal artery syndrome after surgery for internal carotid artery aneurysms. Neurosurgery 31:1321361992Suzuki H Fujita K Ehara K et al: Anterior choroidal artery syndrome after surgery for internal carotid artery aneurysms. Neurosurgery 31:132–136 1992

    • Search Google Scholar
    • Export Citation
  • 40.

    Suzuki KKodama NSasaki Tet al: Intraoperative monitoring of blood flow insufficiency in the anterior choroidal artery during aneurysm surgery. J Neurosurg 98:5075142003Suzuki K Kodama N Sasaki T et al: Intraoperative monitoring of blood flow insufficiency in the anterior choroidal artery during aneurysm surgery. J Neurosurg 98:507–514 2003

    • Search Google Scholar
    • Export Citation
  • 41.

    Szelenyi ALangerDKothbauerKet al: Intraoperative motor evoked potential monitoring in cerebral aneurysm surgery. J Neurosurg 96:174A2002 (Abstract)Szelenyi A Langer D Kothbauer K et al: Intraoperative motor evoked potential monitoring in cerebral aneurysm surgery. J Neurosurg 96:174A 2002 (Abstract)

    • Search Google Scholar
    • Export Citation
  • 42.

    Taniguchi MCedzich CSchramm J: Modification of cortical stimulation for motor evoked potentials under general anesthesia: technical description. Neurosurgery 32:2192261993Taniguchi M Cedzich C Schramm J: Modification of cortical stimulation for motor evoked potentials under general anesthesia: technical description. Neurosurgery 32:219–226 1993

    • Search Google Scholar
    • Export Citation
  • 43.

    Yaşargil G: Microneurosurgery. New York: Thieme1987Yaşargil G: Microneurosurgery. New York: Thieme 1987

  • 44.

    Zhou HHKelly PJ: Transcranial electrical motor evoked potential monitoring for brain tumor resection. Neurosurgery 48:107510812001Zhou HH Kelly PJ: Transcranial electrical motor evoked potential monitoring for brain tumor resection. Neurosurgery 48:1075–1081 2001

    • Search Google Scholar
    • Export Citation
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