Usefulness of epidurally evoked cortical potential monitoring during cervicomedullary glioma surgery

This report describes a patient with an intramedullary ependymoma at the region of the cervicomedullary junction in whom there was an abolition of somatosensory evoked potentials following median nerve stimulation. During intraoperative monitoring of cortical potentials elicited by epidural cervical cord stimulation, the tumor was removed. Posterior epidural stimulation appeared to depolarize more ascending fibers than did stimulation of a single peripheral nerve. We recommend that, in cases of operations in this vital area, epidurally evoked cortical potentials be monitored intraoperatively.     

颈内动脉闭塞复合再通手术的护理配合

总结传统颈内动脉内膜剥脱手术与复合再通手术护理配合要点：①根据术前脑血管造影结果,提前准备用物,并熟悉其性能和使用方法;②手术室仪器布局合理,避免术中反复移动;③患者体位及无菌区域的护理;④管路的固定及护理;⑤导管和血管鞘在血栓预防中的使用及术中抗凝配合;⑥术中观察使用肝素钠的剂量并配合追加给药;⑦术中并发症的观察及护理。本组69例再通成功,1例行数字减影血管造影后即显示再通,1例出现颈内动脉海绵窦瘘,立即停止手术,未造成不良后果,所有切口均为一级愈合。     

Detection of acute femoral artery ischemia during neuroembolization by somatosensory and motor evoked potential monitoring

Neuromonitoring can be used to map out particular neuroanatomical tracts, define physiologic deficits secondary to specific pathology or intervention, or predict postoperative outcome and proves essential in the detection of central and peripheral ischemic events during neurosurgical intervention. Herein, we describe an instance of elective balloon-assisted coiling of a recurrent basilar tip aneurysm in a 61-year-old woman, where intraoperative somatosensory evoked potentials (SSEPs) and transcranial motor evoked potentials (TcMEPs) were lost in the right lower extremity intraoperatively. We aim to highlight that targeted use of monitoring proves advantageous in both the open surgical and endovascular setting, even in the avoidance of potential iatrogenic peripheral nerve damage and limb ischemia as documented herein. Consideration of the increased risk for peripheral ischemia in the neurointerventional setting is especially imperative in particular populations where blood vessels might be of diminished size, such as in infants, young children, and severely deconditioned adults.     

Artifact detection and removal during auditory evoked potential monitoring

Various artifacts can distort or obscure evoked potential waveforms. The algorithms presented in this paper scan the output electroencephalographic signal for artifacts during evoked potential recordings. If possible, the artifact is removed; if not possible, that sweep is excluded from the averaging process required to raise the evoked response above the background electroencephalographic activity. An artifact is detected if 1 or more amplitude or frequency parameters exceed a threshold. These thresholds have been determined after constructing histograms of the parameters concerned using a number of control evoked potential recordings containing no visually recognizable artifacts. The distributions of the parameters shown by these histograms give information about their normal range. The method improves the quality of the waveform in many cases, but its effectiveness strongly depends on the characteristics of the artifacts concerned.This research is supported by the Dutch Technology Foundation (STW).     

General anesthesia vs combined anesthesia during internal carotid artery surgery

Methods 50 patients underwent surgery on internal carotid artery. The first group of patients were performed combined anesthesia with Propofol , Phentanil and superficial cervical plexus block (SCPB). Second group were administrated Phentanil and Propofol. Monitoring: blood pressure, BIS, dose of anesthetic agents. Results of study indicated that combined method of anesthesia with SCPB provided better brain perfusion because of high level of MBP (mean blood pressure) at the time of occlusion of ICA and more stable hemodynamic indices. In addition second group of patient had longer period of recovery due to higher dose of Phentanil than the first group. CONCLUSION: Combined anesthesia with propofol, phentanil and CPB provides better analgesia and require less dose of opiodes anesthetics.     

脑干诱发电位对椎基底动脉系短暂性缺血发作的诊断价值

BACKGROUND：Brainstemauditoryevokedpotential（BAEP）canobjectivelyreflexnerveconductionfunctionofauricularconductionpathwayandindirectivelyreflexfunctionalstatusofthebrainstem．OBJECTIVE：ToinvestigatediagnosisvalueofBAEPinbasilararterytransientischemicattack（TIA）patients．UNIT：DepartmentofNeurology，SecondHospitalofLiaoyangSUBJECTS：１００casesdiagnosedasbasilararteryTIApa－tientswereselectedwith６８malesand３２females，age５１－８６years．INTERVENTION：BAEPtestwe…     

Neurological monitoring during carotid artery stenting: the Duck Squeezing Test.

PURPOSE: To examine the usefulness of a novel method for neurological monitoring during carotid artery stenting (CAS). METHODS: The records of patients who underwent elective CAS between June 1996 and October 1998 were reviewed to identify those who had neurological changes during the procedure. We examined whether the neurological change had been detected by a change in the ability of the patient to respond to predetermined commands involving a small rubber duck placed in the contralateral hand. RESULTS: hundred seventy patients (320 vessels) underwent monitoring using the Duck Squeezing Test; 10 suffered neurological events during the procedure. Four of these were transient and temporally related to balloon inflation. Another 6 were tentatively ascribed to distal embolism. All instances were accompanied by a change in the patient's ability to perform the Duck Squeezing Test, which allowed the identification of the abnormal clinical situation. In addition, there were 4 false-positive tests secondary to the patient accidentally dropping the rubber duck. CONCLUSIONS: The Duck Squeezing Test is a sensitive and specific method for monitoring patients during elective CAS. Its practical applicability is based on sound neurophysiological concepts, which underscore the clinical importance of the test.     

Hybrid surgery for symptomatic chronic complete occlusion of the internal carotid artery: A case report

Currently, there are antiplatelet drugs, extracranial-intracranial (EC-IC) vascular bypass, carotid endarterectomy (CEA), endovascular intervention (EI), and other revascularization procedures for symptomatic chronic internal carotid artery occlusion (CICAO). In consulting the literature, we found that existing techniques for single treatments cannot achieve satisfactory results when there is a long segment occlusion with plaque attached to the intracranial segment and a short stump at the initial segment. We reported the case of a 50-year-old male patient with blurred vision, headache, and weakness in the right upper limb. After the exclusion of other neurological diseases, he was diagnosed with symptomatic CICAO; the occlusion segment was long and the stump was too short. We performed a novel hybrid surgery for the patient—a carotid endarterectomy combined with internal carotid artery stenting. After 6 months of follow-up, computed tomography angiography (CTA) confirmed that the left internal carotid artery was unobstructed, and the symptoms were relieved. A brief review of the literature is presented in addition to this report.     

听觉诱发电位指数在脊柱侧弯矫形手术唤醒过程中的变化

目的:观察听觉诱发电位指数在脊柱侧弯矫形手术唤醒过程的变化,探讨听觉诱发电位指数对体动反应和术中记忆的意义。方法:15例择期脊柱侧弯矫形手术病例,采用异丙酚-氧化亚氮复合麻醉。用A-line监护仪监测麻醉和唤醒过程的听觉诱发电位指数。结果:麻醉诱导前基础听觉诱发电位指数为78.7±14.3。麻醉过程中听觉诱发电位指数最高值为35.2±14.2,最低值10.3±3.6,平均值21.9±3.9。平均值、最高值、最低值之间的差异有显著性意义,说明听觉诱发电位指数存在较大的自身波动。唤醒试验中停药即刻听觉诱发电位指数为18.7±6.3,自主体动时27.7±8.4,指令活动时71.3±16.3。自主活动时听觉诱发电位指数与最高值和平均值的差异无显著性意义,说明听觉诱发电位指数并不能预示体动反应。指令活动时的听觉诱发电位指数显著高于麻醉过程中的听觉诱发电位指数提示听觉诱发电位指数可以很好地预示指令活动。所有患者对术中唤醒过程都没有记忆,表明听觉诱发电位指数不能特异地预示术中知晓。结论:尽管听觉诱发电位指数本身有较大的波动,但是可以很好的预示指令活动的出现,因此可以反映麻醉恢复期患者意识的恢复,但是实验中未发现听觉诱发电位指数对体动反应和术中记忆具有预示意义。     

慢性颈内动脉闭塞复合术后患者高灌注综合征的风险评估及护理

总结65例慢性颈内动脉闭塞复合术后患者高灌注综合征的风险评估及护理要点。通过成立高灌注综合征风险评估管理小组、总结高风险因素、制订风险评估表,对患者进行风险评估及分级。护理上,对高风险患者加强风险管理,提高预警意识;实施血压三级管理,严格控制血压;密切观察病情,进行专科病情监测。该组患者经过上述风险评估与护理,高灌注综合征发生率为3.08%,低于5.40%的报告数据,且预后较好,均痊愈出院。     

EEG sources of noise in intraoperative somatosensory evoked potential monitoring during propofol anesthesia

Objective. It was hypothesized that somato- sensory evoked potentials can be achieved faster by selective averaging during periods of low spontaneous electroen- cephalographic (EEG) activity. We analyzed the components of EEG that decrease the signal-to-noise ratio of somatosensory evoked potential (SEP) recordings during propofol anesthesia. Methods. Patient EEGs were recorded with a high sampling frequency during deep anesthesia, when EEGs were in burst suppression. EEGs were segmented visually into bursts, spindles, suppressions, and artifacts. Tibial somatosensory evoked potentials (tSEPs) were averaged offline separately for burst, suppression, and spindle segments using a signal bandwidth of 30–200 Hz. Averages achieved with 2, 4, 8, 16, 64, 128, and 256 responses were compared both visually, and by calculating the signal-to-noise ratios. Results. During bursts and spindles, the noise levels were similar and significantly higher than during suppressions. Four to eight times more responses had to be averaged during bursts and spindles than during suppressions in order to achieve a similar response quality. Averaging selectively during suppressions can therefore yield reliable tSEPs in approximately one-fifth of the time required during bursts. Conclusion. The major source of EEG noise in tSEP recordings is the mixed frequency activity of the slow waves of bursts that occur during propofol anesthesia. Spindles also have frequency components that increase noise levels, but these are less important, as the number of spindles is fewer. The fastest way to obtain reliable tSEPs is by averaging selectively during suppressions.     

Cautionary findings for motor evoked potential monitoring in intracranial aneurysm surgery after a single administration of rocuronium to facilitate tracheal intubation

Journal of Clinical Monitoring and Computing - Administration of rocuronium to facilitate intubation has traditionally been regarded as acceptable for intraoperative motor evoked potential (MEP)...     

Adjunctive ultrasonography during carotid artery stenting to minimize iodine contrast use

Carotid artery stenting (CAS) in patients with chronic kidney disease carries a significant risk of contrast‐induced nephropathy. We report a case of CAS with adjunctive sonography to reduce the amount of contrast medium during angiography. A 71‐year‐old man presented with a symptomatic right carotid stenosis. He was selected for CAS due to significant medical comorbidity, which included severe renal impairment. A preoperative noncontrast CT was performed to assess anatomical suitability and to plan arch vessel cannulation. We undertook CAS with the use of intraoperative ultrasound. Sonography was used to monitor the manipulation of wires, catheters, and stents. Four milliliters of contrast was required to complete the procedure successfully with no deterioration in postoperative renal function. Adjunctive ultrasound is feasible to reduce contrast use in patients with severe renal impairment undergoing CAS. © 2012 Wiley Periodicals, Inc. J Clin Ultrasound, 41:323–326, 2013     

听觉诱发电位指数监测中发生脑电爆发抑制对机体的影响

目的观察用听觉诱发电位指数(AAI)监测全身麻醉深度时,诱导期出现脑电爆发抑制,对其应激反应及术后全麻复苏的影响,即探讨爆发抑制出现后对机体的近期及远期影响。方法在全身麻醉下行腹部手术患者40例,根据患者全麻诱导时是否出现爆发抑制分为2组:爆发抑制组(A组)和未爆发抑制组(B组)。于各时间点采静脉血测定血糖、皮质醇(Cor)水平。术毕复苏期记录睁眼时间,拔管时间,拔管后1 min的镇静(OAA/S)评分情况。结果 9例患者全麻诱导时出现爆发抑制,占全部患者的22.5%,其中AAI最低值为3,均数为8,其余31例患者诱导期未出现爆发抑制。监测应激指标中,插管即刻(T1)的Cor值A组比B组有显著性降低,T1、手术开始即刻(T2)的血糖值A组比B组有显著性降低。在爆发抑制组内比较,T1、T2时点的血糖值比基础值(T0)比较有降低差异有显著性。术毕复苏指标2组比较差异无显著性。结论全身麻醉诱导期出现脑电爆发抑制可以短暂的抑制患者的应激水平,0.5 h后即可恢复,对术后全麻复苏时间和复苏质量无明显影响。     

Total occlusion of the common carotid artery: a modified classification and its relation to clinical status

To investigate the hemodynamics and clinical presentation of common carotid artery occlusion (CCAO), we reviewed 6,415 patients with suspected carotid artery disease in whom a color Duplex imaging (CDI) examination was performed. According to distal vessel patency, the following CDI classification of CCAO was adopted: type I (patent both distal vessels); type II (isolated patency of external carotid artery); type III (isolated patency of internal carotid artery); and type IV (both distal vessels occluded). Thirty-five (0.5%) cases met the CDI criteria for CCAO. Twenty-nine of those (83%) had at least one patent distal vessel. Ten patients (29%) presented with stroke, 20 (57%) with transient ischemic attacks (TIAs) and five (14%) were asymptomatic. The incidence of stroke was higher in type IV (50%) vs. type II (30%) and in type II vs. type I (10%) lesions. Similarly, TIAs presented more often in type II (67%) and IV (50%) vs. in type I (40%) lesions (p = 0.002). Retrograde flow in the ophthalmic artery and concomitant severe contralateral carotid artery stenosis were more often related with type II and IV lesions (p = 0.02 and 0.04, respectively). CCAO is usually accompanied by patent distal vessel(s). The proposed CCAO classification correlates well with the patients' clinical status and may help to better clarify the outcome of this rare entity. Among the main arteries of the developed collateral circulation, only the flow direction in the ophthalmic artery may be of clinical value.     

颈动脉超声评价慢性肾功能衰竭患者动脉硬化的价值

目的 评价慢性肾功能衰竭（CRF）患颈动脉粥样硬化的发病情况。方法 应用高分辨彩色多普勒超声诊断仪,对94例CRF患进行颈动脉检查,测量颈动脉IMT,内径,观察动脉粥样斑块情况,比较血透组、非透析组与腹透组三组颈总动脉的收缩期峰值流速（SPV）,舒张未期峰值流速（DEV）,阻力指数（RI）。结果 颈动脉粥样硬化总发病率为28．72％,三组发生率无差异,颈总动脉血流动力学参数分析,三组平均SPV及DEV无显差异,血透组平均RI明显较非透析组与腹透组大（P＜0．01）。结论 颈动脉超声作为一种无创伤检查方法对CRF患颈动脉粥样硬化诊断和随访均有帮助。     

Safe transcranial electric stimulation motor evoked potential monitoring during posterior spinal fusion in two patients with cochlear implants

Transcranial electric stimulation (TES) motor evoked potentials (MEPs) have become a regular part of intraoperative neurophysiologic monitoring (IONM) for posterior spinal fusion (PSF) surgery. Almost all of the relative contraindications to TES have come and gone. One exception is in the case of patients with a cochlear implant (CI). Herein we illustrate two cases of pediatric patients with CIs who underwent PSF using TES MEPs as part of IONM. In both instances the patients displayed no untoward effects from TES, and post-operatively both CIs were intact and functioning as they were prior to surgery.