Sensitivity and Specificity of Intraoperative Neuromonitoring for Identifying Safety and Duration of Temporary Aneurysm Clipping Based on Vascular Territory, a Multimodal Strategy

• Published in: World neurosurgery Vol. 100; pp. 522 - 530
• Main Authors: Staarmann, Brittany, MD, O’Neal, Kelly, CNIM, R EP T, BS, Magner, Mark, MD, Zuccarello, Mario, MD
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.04.2017
• Subjects: Brain Mapping - methods; Cerebral aneurysms; Female; Humans; Intracranial Aneurysm - diagnosis; Intracranial Aneurysm - epidemiology; Intracranial Aneurysm - surgery; Intraoperative monitoring; Intraoperative Neurophysiological Monitoring - utilization; Male; Middle Aged; Multimodal Imaging - statistics & numerical data; Neurosurgery; Neurosurgical Procedures - statistics & numerical data; Ohio - epidemiology; Operative Time; Postoperative Complications - diagnosis; Postoperative Complications - epidemiology; Postoperative Complications - prevention & control; Postoperative deficits; Prevalence; Reproducibility of Results; Risk Factors; Sensitivity and Specificity; Somatosensory evoked potentials; Transcranial motor evoked potentials; Treatment Outcome; milliseconds; postoperative deficits; motor-evoked potential; ischemic tolerance ratio; ITR; IONM; American Clinical Neurophysiology Society; second; millimeter; intraoperative monitoring; intraoperative neuromonitoring; V; internal carotid artery; microseconds; ACA; volts; mm; electroencephalography; EEG; ms; ICA; somatosensory-evoked potentials; MCA; SSEP; middle cerebral artery; transcranial motor-evoked potentials; s; μs; MEP; ACNS; somatosensory-evoked potential; cerebral aneurysms; anterior cerebral artery; Somatosensory evoked potentials; Postoperative deficits; Transcranial motor evoked potentials; Cerebral aneurysms; Intraoperative monitoring; BA
• ISSN: 1878-8750; 1878-8769
• DOI: 10.1016/j.wneu.2017.01.009

Abstract Background Patients who undergo clipping of cerebral aneurysms face inherent risk for new postoperative neurological deficits. Intraoperative neuromonitoring (IONM) is used often for early detection of ischemic changes, while still potentially reversible. However, the value, safety, and efficacy of temporary clipping and multimodal intraoperative neuromonitoring (IONM) to minimize risks are debated. Our retrospective series examined the sensitivity and specificity of IONM using transcranial motor evoked potentials (MEPs) and somatosensory evoked potentials (SSEPs), and quantified the safety of temporary clipping by duration and vascular territory. Methods Our prospectively collected database (2010-2013) included 123 consecutive patients who underwent clipping of 133 cerebral aneurysms with use of IONM. We determined postoperative deficit rate, and sensitivity and specificity of monitoring to predict these changes intraoperatively. Rate of permanent deficit after temporary clipping was correlated with duration, vascular territory, and IONM findings. Results Of 133 clipped aneurysms, 15 instances of IONM changes occurred, including 12 temporary without new postoperative deficit and 3 permanent with new postoperative deficit. SSEP monitoring predicted 1 of the permanent deficits and transcranial MEP predicted the other 2 deficits. Conclusions Multimodal IONM was highly specific and sensitive for detecting new deficits. Three patients with new deficits had temporary clipping, including 2 patients with IONM changes not temporally associated with clip placement. Our 1.1% rate of permanent neurological deficit attributed to temporary clipping support its safety. Differences in patterns of IONM changes among vascular territories warrant further investigation.