Intraoperative monitoring of blood flow insufficiency in the anterior choroidal artery during aneurysm surgery

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Object. The lack of a specified intraoperative method for monitoring anterior choroidal artery (AChA) blood flow insufficiency (BFI) led the authors to devise a method for checking the BFI in this artery during aneurysm surgery. To this end, the authors relied on the intraoperative motor evoked potentials (MEPs) elicited by electrical stimulation of the hand motor cortex.

Methods. The study population consisted of 108 patients with internal carotid artery (ICA) aneurysms who underwent surgery via a standard frontotemporal craniotomy. After the dura mater had been opened, a grid electrode strip with 16 small electrodes was inserted subdurally into the hand motor cortex from the edge of the craniotomy. To check BFI in the AChA, the hand motor cortex was stimulated at an intensity level between 10 and 18 mA. The MEPs were successfully recorded from the contralateral thenar muscles in all 108 patients. There was no postoperative motor paresis in 88 patients in whom the MEPs remained unchanged during the performance of various surgical maneuvers. Among the other 20 patients, 19 manifested transient MEP changes, but 15 of those patients experienced no postoperative motor paresis. In four patients who exhibited transient MEP changes, either after aneurysm clipping or during temporary occlusion of the ICA and/or AChA, hemiparesis occurred postoperatively but disappeared within 24 hours. In one patient with an ICA—posterior communicating artery aneurysm, the MEP disappeared and did not reappear by the time of dural closure. Severe hemiplegia developed in this patient and a computerized tomography scan obtained postoperatively revealed a new low-density area in the internal capsule.

Conclusions. The findings of this study suggest that the monitoring method that is introduced here is safe and reliable for detecting intraoperative BFI in the AChA.

Article Information

Address reprint requests to: Kyouichi Suzuki, M.D., Department of Neurosurgery, Fukushima Medical University, 1 Hikarigaoka, Fukushima 960–1295, Japan. email: kyon@fmu.ac.jp.

© AANS, except where prohibited by US copyright law.

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Figures

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    Left: Schematic drawing showing the setup for monitoring MEPs. The central sulcus line is mapped and drawn on the scalp (dotted line). The point 70 mm lateral from the midline on the central sulcus line is marked (X) as the hand motor cortex. Center: After a standard frontotemporal craniotomy has been performed, the grid electrode is inserted into the subdural space at the site of the marked hand motor cortex. The cathode needle electrode is inserted at the frontal pole zero electrode location (Fpz). Right: Photograph showing the grid electrode used for electrical stimulation of the motor cortex. The strip contains 16 electrodes, each of which measures 3 mm in diameter. The distance between the electrodes is 2 mm.

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    Case 1. Preoperative 3D CT angiogram (superior view) revealing a left ICA—PCoA aneurysm (star).

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    Case 1. Intraoperative MEP findings. After a premature rupture of the aneurysm and a temporary occlusion of the left ICA, which lasted 17 minutes, the aneurysm was clipped. The MEP disappeared immediately after aneurysm rupture and did not reappear by the time of dural closure.

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    Case 1. Postoperative CT scan revealing a low-density area in the internal capsule, which is supplied by the AChA (arrowheads).

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    Case 3. Preoperative angiograms demonstrating a large left ICA—PCoA aneurysm and the AChA (arrowheads).

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    Case 3. Intraoperative MEP findings. The MEP remained unchanged until placement of the third clip, disappeared after placement of the fourth clip, and reappeared after all clips had been removed. The MEP decreased in amplitude after temporary clipping of the left ICA, the A1 segment of the left ACA, and the M1 segment of the left MCA. It recovered after release of the temporary clips. Finally, the aneurysm was occluded using six fenestrated clips and the amplitude of the MEP remained at the control level until dural closure.

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    Case 3. Postoperative angiograms clearly demonstrating the left AChA (arrowheads).

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    Case 19. Upper Left: A 3D CT angiogram (anteroposterior view) revealing a right ICA aneurysm. Upper Right: Drawing showing how the AChA was visualized using a micromirror. Lower Left: Drawing demonstrating how the aneurysm was clipped using two fenestrated clips. The proximal portion of the AChA was stenotic. Lower Right: Drawing showing repositioning of the second clip, which released the stenosis of the AChA. The artery was confirmed to be intact. AC = ACA; IC = ICA; MC = MCA; Op = optic nerve.

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    Case 19. Intraoperative MEP findings. The aneurysm was clipped using two fenestrated clips. The MEP amplitude decreased approximately 20 seconds after the second clip was placed and this decrease persisted for 2 minutes. Repositioning of the clip released the stenosis of the AChA. The amplitude of the MEP recovered to the control level within 40 seconds after repositioning of the clip and remained at the control level until dural closure.

References

  • 1.

    Abbie AA: The clinical significance of the anterior choroidal artery. Brain 56:2332461933Abbie AA: The clinical significance of the anterior choroidal artery. Brain 56:233–246 1933

    • Search Google Scholar
    • Export Citation
  • 2.

    Anderson JE (ed): Grant's Atlas of Anatomyed 7. Baltimore: Williams & Wilkins1978Anderson JE (ed): Grant's Atlas of Anatomy ed 7. Baltimore: Williams & Wilkins 1978

    • Search Google Scholar
    • Export Citation
  • 3.

    Barrow DL: Intraoperative angiography in Loftus CMTraynelis VC (eds): Intraoperative Monitoring Techniques in Neurosurgery. New York: McGraw-Hill1994 pp 7794Barrow DL: Intraoperative angiography in Loftus CM Traynelis VC (eds): Intraoperative Monitoring Techniques in Neurosurgery. New York: McGraw-Hill 1994 pp 77–94

    • Search Google Scholar
    • Export Citation
  • 4.

    Boling WOlivier ABittar RGet al: Localization of hand motor activation in Broca's pli de passage moyen. J Neurosurg 91:9039101999Boling W Olivier A Bittar RG et al: Localization of hand motor activation in Broca's pli de passage moyen. J Neurosurg 91:903–910 1999

    • Search Google Scholar
    • Export Citation
  • 5.

    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
  • 6.

    Chiang VLGailloud PMurphy KJet al: Routine intraoperative angiography during aneurysm surgery. J Neurosurg 96:9889922002Chiang VL Gailloud P Murphy KJ et al: Routine intraoperative angiography during aneurysm surgery. J Neurosurg 96:988–992 2002

    • Search Google Scholar
    • Export Citation
  • 7.

    Cooper IS: Surgical alleviation of parkinsonism: effects of occlusion of the anterior choroidal artery. J Am Geriatrics Soc 2:6917181954Cooper IS: Surgical alleviation of parkinsonism: effects of occlusion of the anterior choroidal artery. J Am Geriatrics Soc 2:691–718 1954

    • Search Google Scholar
    • Export Citation
  • 8.

    Foix CChavany HHillemand Pet al: Obliteration de l'artere choroidienne anterieure: Ramollissement cerebral hemiplegia, hemianesthesie et hemianopsie. Soc Ophthalmol 27:2212231925 (Reference unverified)Foix C Chavany H Hillemand P et al: Obliteration de l'artere choroidienne anterieure: Ramollissement cerebral hemiplegia hemianesthesie et hemianopsie. Soc Ophthalmol 27:221–223 1925 (Reference unverified)

    • Search Google Scholar
    • Export Citation
  • 9.

    Friedman JAPichelmann MAPiepgras DGet al: Ischemic complications of surgery for anterior choroidal artery aneurysms. J Neurosurg 94:5655722001Friedman JA Pichelmann MA Piepgras DG et al: Ischemic complications of surgery for anterior choroidal artery aneurysms. J Neurosurg 94:565–572 2001

    • Search Google Scholar
    • Export Citation
  • 10.

    Jellish WSBrody MSawicki Ket al: Recovery from neuromuscular blockade after either bolus and prolonged infusions of cisatracurium or rocuronium using either isoflurane or propofolbased anesthetics. Anesth Analg 91:125012552000Jellish WS Brody M Sawicki K et al: Recovery from neuromuscular blockade after either bolus and prolonged infusions of cisatracurium or rocuronium using either isoflurane or propofolbased anesthetics. Anesth Analg 91:1250–1255 2000

    • Search Google Scholar
    • Export Citation
  • 11.

    Kalkman CJDrummond JCKennelly NAet al: Intraoperative monitoring of tibialis anterior muscle motor evoked responses to transcranial electrical stimulation during partial neuromuscular blockade. Anesth Analg 75:5845891992Kalkman CJ Drummond JC Kennelly NA et al: Intraoperative monitoring of tibialis anterior muscle motor evoked responses to transcranial electrical stimulation during partial neuromuscular blockade. Anesth Analg 75:584–589 1992

    • Search Google Scholar
    • Export Citation
  • 12.

    Katayama YTsubokawa TMaejima Set al: Corticospinal direct response in humans: identification of the motor cortex during intracranial surgery under general anesthesia. J Neurol Neurosurg Psychiatry 51:50591988Katayama Y Tsubokawa T Maejima S et al: Corticospinal direct response in humans: identification of the motor cortex during intracranial surgery under general anesthesia. J Neurol Neurosurg Psychiatry 51:50–59 1988

    • Search Google Scholar
    • Export Citation
  • 13.

    Lebeda MDWegrzynowicz ESWachtel RE: Propofol potentiates both pre- and postsynaptic effects of vecuronium in the rat hemidiaphragm. Br J Anaesth 68:2822851992Lebeda MD Wegrzynowicz ES Wachtel RE: Propofol potentiates both pre- and postsynaptic effects of vecuronium in the rat hemidiaphragm. Br J Anaesth 68:282–285 1992

    • Search Google Scholar
    • Export Citation
  • 14.

    Lueders HLesser RPHahn Jet al: Cortical somatosensory evoked potentials in response to hand stimulation. J Neurosurg 58:8858941983Lueders H Lesser RP Hahn J et al: Cortical somatosensory evoked potentials in response to hand stimulation. J Neurosurg 58:885–894 1983

    • Search Google Scholar
    • Export Citation
  • 15.

    Markand ON: Continuous assessment of cerebral function with EEG and somatosensory evoked potential techniques during extracranial vascular reconstruction in Loftus CMTraynelis VC (eds): Intraoperative Monitoring Techniques in Neurosurgery. New York: McGraw-Hill1994 pp 1932Markand ON: Continuous assessment of cerebral function with EEG and somatosensory evoked potential techniques during extracranial vascular reconstruction in Loftus CM Traynelis VC (eds): Intraoperative Monitoring Techniques in Neurosurgery. New York: McGraw-Hill 1994 pp 19–32

    • Search Google Scholar
    • Export Citation
  • 16.

    McPherson RW: General anesthetic considerations in intraoperative monitoring: effects of anesthetic agents and neuromuscular blockade on evoked potentials, EEG, and cerebral blood flow in Loftus CMTraynelis VC (eds): Intraoperative Monitoring Techniques in Neurosurgery. New York: McGraw-Hill1994 pp 97106McPherson RW: General anesthetic considerations in intraoperative monitoring: effects of anesthetic agents and neuromuscular blockade on evoked potentials EEG and cerebral blood flow in Loftus CM Traynelis VC (eds): Intraoperative Monitoring Techniques in Neurosurgery. New York: McGraw-Hill 1994 pp 97–106

    • Search Google Scholar
    • Export Citation
  • 17.

    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
  • 18.

    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
  • 19.

    Rhoton AL JrFujii KFradd B: Microsurgical anatomy of the anterior choroidal artery. Surg Neurol 12:1711871979Rhoton AL Jr Fujii K Fradd B: Microsurgical anatomy of the anterior choroidal artery. Surg Neurol 12:171–187 1979

    • Search Google Scholar
    • Export Citation
  • 20.

    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
  • 21.

    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
  • 22.

    Tang GCawley CMDion JEet al: Intraoperative angiography during aneurysm surgery: a prospective evaluation of efficacy. J Neurosurg 96:9939992002Tang G Cawley CM Dion JE et al: Intraoperative angiography during aneurysm surgery: a prospective evaluation of efficacy. J Neurosurg 96:993–999 2002

    • Search Google Scholar
    • Export Citation
  • 23.

    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
  • 24.

    Taniguchi MNadstawek JLangenbach Uet al: Effects of four intravenous anesthetic agents on motor evoked potentials elicited by magnetic transcranial stimulation. Neurosurgery 33:4074151993Taniguchi M Nadstawek J Langenbach U et al: Effects of four intravenous anesthetic agents on motor evoked potentials elicited by magnetic transcranial stimulation. Neurosurgery 33:407–415 1993

    • Search Google Scholar
    • Export Citation
  • 25.

    Thompson PDDay BLCrockard HAet al: Intra-operative recording of motor tract potentials at the cervico-medullary junction following scalp electrical and magnetic stimulation of the motor cortex. J Neurol Neurosurg Psychiatry 54:6186231991Thompson PD Day BL Crockard HA et al: Intra-operative recording of motor tract potentials at the cervico-medullary junction following scalp electrical and magnetic stimulation of the motor cortex. J Neurol Neurosurg Psychiatry 54:618–623 1991

    • Search Google Scholar
    • Export Citation
  • 26.

    Yamamoto TXing JAKatayama Yet al: Spinal cord responses to feline transcranial brain stimulation: evidence for involvement of cerebellar pathways. J Neurotrauma 7:2472561990Yamamoto T Xing JA Katayama Y et al: Spinal cord responses to feline transcranial brain stimulation: evidence for involvement of cerebellar pathways. J Neurotrauma 7:247–256 1990

    • Search Google Scholar
    • Export Citation
  • 27.

    Yaşargil MGYonas HGasser JC: Anterior choroidal artery aneurysms: their anatomy and surgical significance. Surg Neurol 9:1291381978Yaşargil MG Yonas H Gasser JC: Anterior choroidal artery aneurysms: their anatomy and surgical significance. Surg Neurol 9:129–138 1978

    • Search Google Scholar
    • Export Citation
  • 28.

    Zentner JEbner A: Nitrous oxide suppresses the electromyographic response evoked by electrical stimulation of the motor cortex. Neurosurgery 24:60621989Zentner J Ebner A: Nitrous oxide suppresses the electromyographic response evoked by electrical stimulation of the motor cortex. Neurosurgery 24:60–62 1989

    • Search Google Scholar
    • Export Citation

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