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

View More View Less
  • 1 Departments of Neurosurgery and
  • | 2 Neuroradiology, Ludwig-Maximilians-University, Campus Grosshadern, Munich, Germany
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00
Print or Print + Online

OBJECTIVE

Intraoperative 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.

METHODS

The 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.

RESULTS

There 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%.

CONCLUSIONS

The 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.

ABBREVIATIONS

ACA = anterior cerebral artery; ARR = absolute risk reduction; CI = confidence interval; CVRF = cardiovascular risk factor; DCS = direct cortical stimulation; DSA = digital subtraction angiography; ECUIA = elective microsurgical clipping of unruptured intracranial aneurysm; FP = false positive; FN = false negative; IAR = intraprocedural aneurysm rupture; ICA = internal carotid artery; ICG = indocyanine green; IOM = intraoperative neuromonitoring; MCA = middle cerebral artery; MD = micro-Doppler; MEP = motor-evoked potential; NNT = number needed to treat; PPV = positive predictive value; SAH = subarachnoid hemorrhage; SSEP = somatosensory-evoked potential; TC = temporary clipping; TES = transcranial electric stimulation; TN = true negative; TP = true positive; UIA = unruptured intracranial aneurysm.

Illustration from Duan et al. (pp 1174–1181).

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00

Contributor Notes

Correspondence Tobias Greve: Ludwig-Maximilians-University, Munich, Germany. greve.tobias@gmail.com.

INCLUDE WHEN CITING Published online March 29, 2019; DOI: 10.3171/2018.12.JNS182177.

Disclosures Franziska Dorn is consultant for Acandis, Germany. Jörg-Christian Tonn received consultant fees from BrainLAB, Germany.

  • 1

    Alshekhlee A, Mehta S, Edgell RC, Vora N, Feen E, Mohammadi A, et al. : Hospital mortality and complications of electively clipped or coiled unruptured intracranial aneurysm. Stroke 41:14711476, 2010

    • Search Google Scholar
    • Export Citation
  • 2

    Bacigaluppi S, Fontanella M, Manninen P, Ducati A, Tredici G, Gentili F: Monitoring techniques for prevention of procedure-related ischemic damage in aneurysm surgery. World Neurosurg 78:276288, 2012

    • Search Google Scholar
    • Export Citation
  • 3

    Barker FG II, Amin-Hanjani S, Butler WE, Ogilvy CS, Carter BS: In-hospital mortality and morbidity after surgical treatment of unruptured intracranial aneurysms in the United States, 1996–2000: the effect of hospital and surgeon volume. Neurosurgery 52:9951009, 2003

    • Search Google Scholar
    • Export Citation
  • 4

    Gerlach R, Beck J, Setzer M, Vatter H, Berkefeld J, Du Mesnil de Rochemont R, et al. : Treatment related morbidity of unruptured intracranial aneurysms: results of a prospective single centre series with an interdisciplinary approach over a 6 year period (1999–2005). J Neurol Neurosurg Psychiatry 78:864871, 2007

    • Search Google Scholar
    • Export Citation
  • 5

    Guo L, Gelb AW: The use of motor evoked potential monitoring during cerebral aneurysm surgery to predict pure motor deficits due to subcortical ischemia. Clin Neurophysiol 122:648655, 2011

    • Search Google Scholar
    • Export Citation
  • 6

    Horiuchi K, Suzuki K, Sasaki T, Matsumoto M, Sakuma J, Konno Y, et al. : Intraoperative monitoring of blood flow insufficiency during surgery of middle cerebral artery aneurysms. J Neurosurg 103:275283, 2005

    • Search Google Scholar
    • Export Citation
  • 7

    Irie T, Yoshitani K, Ohnishi Y, Shinzawa M, Miura N, Kusaka Y, et al. : The efficacy of motor-evoked potentials on cerebral aneurysm surgery and new-onset postoperative motor deficits. J Neurosurg Anesthesiol 22:247251, 2010

    • Search Google Scholar
    • Export Citation
  • 8

    Krieg SM, Shiban E, Droese D, Gempt J, Buchmann N, Pape H, et al. : Predictive value and safety of intraoperative neurophysiological monitoring with motor evoked potentials in glioma surgery. Neurosurgery 70:10601071, 2012

    • Search Google Scholar
    • Export Citation
  • 9

    Kunz M, Bakhshai Y, Zausinger S, Fesl G, Janssen H, Brückmann H, et al. : Interdisciplinary treatment of unruptured intracranial aneurysms: impact of intraprocedural rupture and ischemia in 563 aneurysms. J Neurol 260:13041313, 2013

    • Search Google Scholar
    • Export Citation
  • 10

    Kunz M, Dorn F, Greve T, Stoecklein V, Tonn JC, Brückmann H, et al. : Long-term functional outcome of symptomatic unruptured intracranial aneurysms in an interdisciplinary treatment concept. World Neurosurg 105:849856, 2017

    • Search Google Scholar
    • Export Citation
  • 11

    Malinova V, Schatlo B, Voit M, Suntheim P, Rohde V, Mielke D: The impact of temporary clipping during aneurysm surgery on the incidence of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. J Neurosurg 129:8490, 2018

    • Search Google Scholar
    • Export Citation
  • 12

    Moroi J, Hadeishi H, Suzuki A, Yasui N: Morbidity and mortality from surgical treatment of unruptured cerebral aneurysms at Research Institute for Brain and Blood Vessels-Akita. Neurosurgery 56:224231, 2005

    • Search Google Scholar
    • Export Citation
  • 13

    Neuloh G, Schramm J: Monitoring of motor evoked potentials compared with somatosensory evoked potentials and microvascular Doppler ultrasonography in cerebral aneurysm surgery. J Neurosurg 100:389399, 2004

    • Search Google Scholar
    • Export Citation
  • 14

    Pelosi L, Stevenson M, Hobbs GJ, Jardine A, Webb JK: Intraoperative motor evoked potentials to transcranial electrical stimulation during two anaesthetic regimens. Clin Neurophysiol 112:10761087, 2001

    • Search Google Scholar
    • Export Citation
  • 15

    Quiñones-Hinojosa A, Alam M, Lyon R, Yingling CD, Lawton MT: Transcranial motor evoked potentials during basilar artery aneurysm surgery: technique application for 30 consecutive patients. Neurosurgery 54:916924, 2004

    • Search Google Scholar
    • Export Citation
  • 16

    Raaymakers TW, Rinkel GJ, Limburg M, Algra A: Mortality and morbidity of surgery for unruptured intracranial aneurysms: a meta-analysis. Stroke 29:15311538, 1998

    • Search Google Scholar
    • Export Citation
  • 17

    Scibilia A, Terranova C, Rizzo V, Raffa G, Morelli A, Esposito F, et al. : Intraoperative neurophysiological mapping and monitoring in spinal tumor surgery: sirens or indispensable tools? Neurosurg Focus 41(2):E18, 2016

    • Search Google Scholar
    • Export Citation
  • 18

    Seidel K, Beck J, Stieglitz L, Schucht P, Raabe A: The warning-sign hierarchy between quantitative subcortical motor mapping and continuous motor evoked potential monitoring during resection of supratentorial brain tumors. J Neurosurg 118:287296, 2013

    • Search Google Scholar
    • Export Citation
  • 19

    Simon MV: Intraoperative neurophysiologic sensorimotor mapping and monitoring in supratentorial surgery. J Clin Neurophysiol 30:571590, 2013

    • Search Google Scholar
    • Export Citation
  • 20

    Slotty PJ, Abdulazim A, Kodama K, Javadi M, Hänggi D, Seifert V, et al. : Intraoperative neurophysiological monitoring during resection of infratentorial lesions: the surgeon’s view. J Neurosurg 126:281288, 2017

    • Search Google Scholar
    • Export Citation
  • 21

    Stoecklein VM, Faber F, Koch M, Mattmüller R, Schaper A, Rudolph F, et al. : Optional real-time display of intraoperative neurophysiological monitoring in the microscopic field of view: avoiding communication failures in the operating room. Acta Neurochir (Wien) 157:18431847, 2015

    • Search Google Scholar
    • Export Citation
  • 22

    Suzuki K, Kodama N, Sasaki T, Matsumoto M, Konno Y, Sakuma J, et al. : Intraoperative monitoring of blood flow insufficiency in the anterior choroidal artery during aneurysm surgery. J Neurosurg 98:507514, 2003

    • Search Google Scholar
    • Export Citation
  • 23

    Szelényi A, Kothbauer K, de Camargo AB, Langer D, Flamm ES, Deletis V: Motor evoked potential monitoring during cerebral aneurysm surgery: technical aspects and comparison of transcranial and direct cortical stimulation. Neurosurgery 57 (4 Suppl):331338, 2005

    • Search Google Scholar
    • Export Citation
  • 24

    Szelényi A, Langer D, Beck J, Raabe A, Flamm ES, Seifert V, et al. : Transcranial and direct cortical stimulation for motor evoked potential monitoring in intracerebral aneurysm surgery. Neurophysiol Clin 37:391398, 2007

    • Search Google Scholar
    • Export Citation
  • 25

    Szelényi A, Langer D, Kothbauer K, De Camargo AB, Flamm ES, Deletis V: Monitoring of muscle motor evoked potentials during cerebral aneurysm surgery: intraoperative changes and postoperative outcome. J Neurosurg 105:675681, 2006

    • Search Google Scholar
    • Export Citation
  • 26

    Thirumala PD, Crammond DJ, Loke YK, Cheng HL, Huang J, Balzer JR: Diagnostic accuracy of motor evoked potentials to detect neurological deficit during idiopathic scoliosis correction: a systematic review. J Neurosurg Spine 26:374383, 2017

    • Search Google Scholar
    • Export Citation
  • 27

    Wiebers DO, Whisnant JP, Huston J III, Meissner I, Brown RD Jr, Piepgras DG, et al. : Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet 362:103110, 2003

    • Search Google Scholar
    • Export Citation
  • 28

    Yue Q, Zhu W, Gu Y, Xu B, Lang L, Song J, et al. : Motor evoked potential monitoring during surgery of middle cerebral artery aneurysms: a cohort study. World Neurosurg 82:10911099, 2014

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 1122 824 70
Full Text Views 133 91 9
PDF Downloads 142 67 11
EPUB Downloads 0 0 0