Cheran Elangovan, Supriya Palwinder Singh, Paul Gardner, Carl Snyderman, Elizabeth C. Tyler-Kabara, Miguel Habeych, Donald Crammond, Jeffrey Balzer and Parthasarathy D. Thirumala
The aim of this study was to evaluate the value of intraoperative neurophysiological monitoring (IONM) using electromyography (EMG), brainstem auditory evoked potentials (BAEPs), and somatosensory evoked potentials (SSEPs) to predict and/or prevent postoperative neurological deficits in pediatric patients undergoing endoscopic endonasal surgery (EES) for skull base tumors.
All consecutive pediatric patients with skull base tumors who underwent EES with at least 1 modality of IONM (BAEP, SSEP, and/or EMG) at our institution between 1999 and 2013 were retrospectively reviewed. Staged procedures and repeat procedures were identified and analyzed separately. To evaluate the diagnostic accuracy of significant free-run EMG activity, the prevalence of cranial nerve (CN) deficits and the sensitivity, specificity, and positive and negative predictive values were calculated.
A total of 129 patients underwent 159 procedures; 6 patients had a total of 9 CN deficits. The incidences of CN deficits based on the total number of nerves monitored in the groups with and without significant free-run EMG activity were 9% and 1.5%, respectively. The incidences of CN deficits in the groups with 1 staged and more than 1 staged EES were 1.5% and 29%, respectively. The sensitivity, specificity, and negative predictive values (with 95% confidence intervals) of significant EMG to detect CN deficits in repeat procedures were 0.55 (0.22–0.84), 0.86 (0.79–0.9), and 0.97 (0.92–0.99), respectively. Two patients had significant changes in their BAEPs that were reversible with an increase in mean arterial pressure.
IONM can be applied effectively and reliably during EES in children. EMG monitoring is specific for detecting CN deficits and can be an effective guide for dissecting these procedures. Triggered EMG should be elicited intraoperatively to check the integrity of the CNs during and after tumor resection. Given the anatomical complexity of pediatric EES and the unique challenges encountered, multimodal IONM can be a valuable adjunct to these procedures.
Parthasarathy Thirumala, Kristin Meigh, Navya Dasyam, Preethi Shankar, Kanika R. K. Sarma, Deepika R. K. Sarma, Miguel Habeych, Donald Crammond and Jeffrey Balzer
The primary aim of this study was to evaluate the incidence and discuss the pathogenesis of high-frequency hearing loss (HFHL) after microvascular decompression (MVD) for trigeminal neuralgia (TGN), glossopharyngeal neuralgia (GPN), or geniculate neuralgia (GN).
The authors analyzed preoperative and postoperative audiogram data and brainstem auditory evoked potentials (BAEPs) from 93 patients with TGN, 6 patients with GPN, and 8 patients with GN who underwent MVD. Differences in pure tone audiometry > 10 dB at frequencies of 0.25, 0.5, 1, 2, 4, and 8 kHz were calculated preoperatively and postoperatively for both the ipsilateral and the contralateral sides. Intraoperative monitoring records were analyzed and compared with the incidence of HFHL, which was defined as a change in pure tone audiometry > 10 dB at frequencies of 4 and 8 kHz.
The incidence of HFHL was 30.84% on the side ipsilateral to the surgery and 20.56% on the contralateral side. Of the 47 patients with HFHL, 20 had conductive hearing loss, and 2 experienced nonserviceable hearing loss after the surgery. The incidences of HFHL on the ipsilateral side at 4 and 8 kHz were 17.76% and 25.23%, respectively, and 8.41% and 15.89%, respectively, on the contralateral side. As the audiometric frequency increased, the number of patients with hearing loss increased. No significant postoperative difference was found between patients with and without HFHL in intraoperative BAEP waveforms. Sex, age, and affected side were not associated with an increase in the incidence of hearing loss.
High-frequency hearing loss occurred after MVD for TGN, GPN, or GN, and the greatest incidence occurred on the ipsilateral side. This hearing loss may be a result of drill-induced noise and/or transient loss of cerebrospinal fluid during the course of the procedure. Changes in intraoperative BAEP waveforms were not useful in predicting HFHL after MVD. Repeated postoperative audiological examinations may be useful in assessing the prognosis of HFHL.
Parthasarathy Thirumala, Andrew M. Frederickson, Jeffrey Balzer, Donald Crammond, Miguel E. Habeych, Yue-Fang Chang and Raymond F. Sekula Jr.
Microvascular decompression is a safe and effective procedure to treat hemifacial spasm, but the operation poses some risk to the patient’s hearing. While severe sensorineural hearing loss across all frequencies occurs at a low rate in experienced hands, a recent study suggests that as many as one-half of patients who undergo this procedure may experience ipsilateral high-frequency hearing loss (HFHL), and as many as one-quarter may experience contralateral HFHL. While it has been suggested that drill-related noise may account for this finding, this study was designed to examine the effect of a number of techniques designed to protect the vestibulocochlear nerve from operative manipulation on the incidence of HFHL.
Pure-tone audiometry was performed both preoperatively and postoperatively on 67 patients who underwent microvascular decompression for hemifacial spasm during the study period. A change of greater than 10 dB at either 4 kHz or 8 kHz was considered to be HFHL. Additionally, the authors analyzed intraoperative brainstem auditory evoked potentials from this patient cohort.
The incidence of ipsilateral HFHL in this cohort was 7.4%, while the incidence of contralateral HFHL was 4.5%. One patient (1.5%; also included in the HFHL group) experienced an ipsilateral nonserviceable hearing loss.
The reduced incidence of HFHL in this study suggests that technical modifications including performing the procedure without the use of fixed retraction may greatly reduce, but not eliminate, the occurrence of HFHL following microvascular decompression for hemifacial spasm.
Tingting Ying, Parthasarathy Thirumala, Aalap Shah, Tara Nikonow, Kelley Wichman, Maura Holmes, Barry Hirsch, Yuefang Chang, Paul Gardner, Miguel Habeych, Donald J. Crammond, Lois Burkhart, Michael Horowitz and Jeffrey Balzer
The primary aim of this study was to evaluate the incidence and discuss the pathogenesis of high-frequency hearing loss (HFHL) after microvascular decompression (MVD) for hemifacial spasm (HFS).
Preoperative and postoperative audiogram data and brainstem auditory evoked potentials (BAEPs) from 94 patients who underwent MVD for HFS were analyzed. Pure tone audiometry at 0.25–2 kHz, 4 kHz, and 8 kHz was calculated for all individuals pre- and postoperatively ipsilateral and contralaterally. Intraoperative neurophysiological data were reviewed independently. An HFHL was defined as a change in pure tone audiometry of more than 10 dB at frequencies of 4 and 8 kHz.
The incidence of HFHL was 50.00% and 25.53% ipsilateral and contralateral to the side of surgery, respectively. The incidence of HFHL adjusted for conductive and nonserviceable hearing loss was 26.6% ipsilaterally. The incidence of HFHL at 4 and 8 kHz on the ipsilateral side was 37.23% and 45.74%, respectively, and it was 10.64% and 25.53%, respectively, on the contralateral side. Maximal change in interpeak latency Waves I–V compared with baseline was the only variable significantly different between groups (p < 0.05). Sex, age, and side did not increase the risk of HFHL. Stepwise logistic regression analysis did not find any changes in intraoperative BAEPs to increase the risk of HFHL.
High-frequency hearing loss occurs in a significant number of patients following MVD surgery for HFS. Drill-induced noise and transient loss of CSF during surgery may impair hearing in the high-frequency ranges on both the ipsilateral and contralateral sides, with the ipsilateral side being more affected. Changes in intraoperative BAEPs during MVD for HFS were not useful in predicting HFHL. Follow-up studies and repeat audiological examinations may be helpful in evaluating the time course and prognosis of HFHL. Prospective studies focusing on decreasing intraoperative noise exposure, as well as auditory shielding devices, will establish causation and allow the team to intervene appropriately to decrease the risk of HFHL.
Parthasarathy D. Thirumala, Preethi Ilangovan, Miguel Habeych, Donald J. Crammond and Jeffrey Balzer
Microvascular decompression (MVD) of the facial nerve is an effective treatment for patients with hemifacial spasm. Intraoperative monitoring of brainstem auditory evoked potentials (BAEPs) during MVD can reduce the incidence of hearing loss. In this study the authors' goal was to evaluate changes in interpeak latencies (IPLs) of Waves I–V, Waves III–V, and Waves I–III of BAEP Waveforms I, III, and V during MVD and correlate them with postoperative hearing loss. To date, no such study has been performed. Hearing loss is defined as nonuseful hearing (Class C/D), which is a pure tone average of more than 50 dB and/or speech discrimination score of less than 50%.
The authors performed a retrospective analysis of IPLs of BAEPs in 93 patients who underwent intraoperative BAEP monitoring during MVD. Patients who did not have hearing loss were in Class A/B and those who had hearing loss were in Class C/D.
Binary logistic regression analysis of independent IPL variables was performed. A maximum change in IPLs of Waves I–III and Waves I–V and on-skin change in IPLs of Waves I–V increases the odds of hearing loss. However, on adjusting the same variables for loss of response, change in IPLs did not increase the odds of hearing loss.
Changes in IPL measurements did not increase the odds of postoperative hearing loss. This information might be helpful in evaluating the value of IPLs as alarm criteria during MVD to prevent hearing loss.
Xuhui Wang, Parthasarathy D. Thirumala, Aalap Shah, Paul Gardner, Miguel Habeych, Donald J. Crammond, Jeffrey Balzer and Michael Horowitz
The objective of this study was to investigate the clinical characteristics, intraoperative findings, complications, and outcomes after the first microvascular decompression (MVD) in patients with and without previous botulinum neurotoxin treatment for hemifacial spasm (HFS).
The authors analyzed 246 MVDs performed at the University of Pittsburgh Medical Center between January 1, 2000, and December 31, 2007. One hundred and seventy-six patients with HFS underwent botulinum neurotoxin injection treatment prior to first MVD (Group I), and 70 patients underwent their first MVD without previous botulinum neurotoxin treatment (Group II). Clinical outcome data were obtained immediately after the operation, at discharge, and at follow-up. Follow-up data were collected from 177 patients with a minimum follow-up period of 9 months (mean 54.48 ± 27.84 months).
In 246 patients, 89.4% experienced immediate postoperative relief of spasm, 91.1% experienced relief at discharge, and 92.7% experienced relief at follow-up. There was no significant difference in outcomes and complications between Group I and Group II (p > 0.05). Preoperatively, patients in Group I had higher rates of facial weakness, tinnitus, tonus, and platysmal involvement as compared with Group II (p < 0.05). The posterior inferior cerebellar artery and vertebral artery were intraoperatively identified as the offending vessels in cases of vasculature compression in a significantly greater number of patients in Group II compared with Group I (p = 0.008 and p = 0.005, respectively, for each vessel). The lateral spread response (LSR) disappeared in 60.48% of the patients in Group I as compared with 74.19% in Group II (p > 0.05). No significant differences in complications were noted between the 2 groups.
Microvascular decompression is an effective and safe procedure for patients with HFS previously treated using botulinum neurotoxin. Intraoperative monitoring with LSR is an effective tool for evaluating adequate decompression.
Satoshi Maesawa, Douglas Kondziolka, C. Edward Dixon, Jeffrey Balzer, Wendy Fellows and L. Dade Lunsford
Object. Any analysis of the potential role of stereotactic radiosurgery for epilepsy requires the experimental study of its potential antiepileptogenic, behavioral, and histological effects. The authors hypothesized that radiosurgery performed using subnecrotic tissue doses would reduce or abolish epilepsy without causing demonstrable behavioral side effects. The kainic acid model in rats was chosen to test this hypothesis.
Methods. Chronic epilepsy was successfully created by stereotactic injection of kainic acid (8 µg) into the rat hippocampus. Epileptic rats were divided into three groups: high-dose radiosurgery (60 Gy, 16 animals), low-dose (30 Gy, 15 animals), and controls. After chronic epilepsy was confirmed by observation of the seizure pattern and by using electroencephalography (EEG), radiosurgery was performed on Day 10 postinjection. Serial seizure and behavior observation was supplemented by weekly EEG sessions performed for the next 11 weeks. To detect behavioral deficits, the Morris water maze test was performed during Week 12 to study spatial learning and memory. Tasks involved a hidden platform, a visible platform, and a probe trial.
After radiosurgery, the incidence of observed and EEG-defined seizures was markedly reduced in rats from either radiosurgically treated group. A significant reduction was noted after high-dose (60 Gy) radiosurgery in Weeks 5 to 9 (p < 0.003). After low-dose (30 Gy) radiosurgery, a significant reduction was found after 7 to 9 weeks (p < 0.04). During the task involving the hidden platform, kainic acid—injected rats displayed significantly prolonged latencies compared with those of control animals (p < 0.05). Hippocampal radiosurgery did not worsen this performance. The probe trial showed that kainic acid—injected rats that did not undergo radiosurgery spent significantly less time than control rats in the target quadrant (p = 0.03). Rats that had undergone radiosurgery displayed no difference compared with control rats and demonstrated better performance than rats that received kainic acid alone (p = 0.04). Radiosurgery caused no adverse histological effects.
Conclusions. In a rat model, radiosurgery performed with subnecrotic tissue doses controlled epilepsy without causing subsequent behavioral impairment.
Hun Cho, Edwin M. Nemoto, Howard Yonas, Jeffrey Balzer and Robert J. Sclabassi
Object. Cerebral ischemia that occurs during carotid endarterectomy is commonly monitored by means of somatosensory evoked potentials (SSEPs) and electroencephalography (EEG). The authors conducted this study to determine whether cerebral ischemia could also be reliably detected by cerebral oximetry.
Methods. Twenty-nine patients who underwent carotid endarterectomy were monitored by means of SSEPs, EEG, and cerebral oximetry with a model NIRO500 (20 patients) or INVOS3100A (nine patients) oximeter. Changes in amplitude of SSEPs were graded as follows: 0, no change; 1, decrease of less than 50%; 2, decrease of greater than 50%; and 3, 100% decrease. As measured with the NIRO500 oximeter, closing the common caro-tid artery decreased mean oxyhemoglobin levels twice as much (p < 0.005) in the group with SSEPs of 1 to 3 (−13.11 ± 5.59 µM [mean ± standard deviation], 12 patients) as in the group with SSEPs of 0 (−6.22 ± 5.59 µM, eight patients). The rise in deoxyhemoglobin was also greater (p < 0.05). Two of nine patients monitored with the INVOS3100A oximeter had SSEPs of 1 and 3, and their regional saturation of oxygen (rSO2) values fell by −11.50 and −11.51, respectively. In the remaining seven patients with SSEPs of 0, the rSO2 ranged between −2.00 and −6.10 with no overlap with the group with SSEPs of 1 to 3. The increase in oxyhemoglobin monitored using the NIRO500 oximeter and rSO2 monitored using the INVOS3100A machine after opening the external carotid artery was less than that seen after opening the internal carotid artery. Both types of oximeters could detect cerebral ischemia but whereas false negatives occurred with the NIRO500, none was observed with the INVOS3100A. Extracranial contamination was also four times less frequent with the INVOS3100A than with the NIRO500 monitor.
Conclusions. The results indicate that at least as measured with the INVOS3100A instrument, a decrease in rSO2 of −10 or more or a decrease below an rSO2 of 50 is indicative of cerebral ischemia of sufficient severity to decrease the amplitude of SSEPs.