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    34 views17 pages

    Intraoperative Monitoring

    Uploaded by

    Juliana
    ART

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    © All Rights Reserved
    Download as PDF or read online from Scribd
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    ooked Potentials (735-8610188 50.00 + 20 Intraoperative Monitoring of Auditory and Brain-Stem Function Rodney A. Radtke, MD* and C. William Erwin, MD} During the past several yeas, intraoperative monitoring of brainstem auditory evoked potentials (BAES) has become routine practice in many medical centers." "#8 £93! During posterior fossa surgical proce- es, the continuous recording of BAEPs has allowed neurophysolozic assessment of auditory and brain-stem function in the anesthetized patient, ‘The initial description of intraoperative use of BAEPs appeated in 1978, when Levine and co-authors deseribed their experience in stall umber ‘of patients. Subsequently” several lager series extended the experience ‘with introperative BAEPs and were quickly followed by widespread use ‘of the technique throughost the United States 53" BAEPs are ideally suted for use inthe operating room because they are not significantly altered by the anesthetic agents or physiologi changes ‘encountered during surgery **® Their use does not increase operative time or subject the patient to additional risk, The intraoperative BAEP is a robust response that caa be reliably recorded in essentially all patients with adequate preoperative hearing function. The use of BABS allows rapid sampling of eighth nerve and brain-tem function, Intraoperative changes in the BAEP are frequently noted and adjustinent ofthe surgical approach usually results inimprovement inthe response anda maintenance of funetion postoperatively. Recently, the use of intraoperative BAES was demonstrated to be associated with significantly reduced postoperative morbidity." As a result of all these factors, BAEPs are playing an Inreasngly important rl in posterior os sre prec Table 1 lists the surgeal procedures during which BAEP monitors 5 commonly employed #5825 The man appli has ben i surgical approach to the cerebellopontine angle (CPA). This approve primarily threatens auditory function due to injury of the eighth nerve or “stant Pro Men so ‘fiat Prieur a Men sab) and Pfr cy From Divison of Neurlny, Duke Unerty Medial Centr, Duss, Noth Carina Newt Cnet Val 6, No.4, Nore 1988 99 900 Roney A. Rapre axp G, WILLIAM Rw “Table 1 Intraoperatice BAER: Suricl Procedures Monitored T, Procedures i he erbelpoatie and PA) 1 Mistorselardecomprestion of anal nerves § Mtn ver ner 2, Oiler poser proedanes Basar artery aneunen i Paster no nv i m peripheral auditory stractures. More recently, BAEPs have been applied {6 other posterior fossa procedures including resection of vasular abnor ‘malities or brainstem tumors, These procedures are less likely to threaten the auditory nerve, and BAEPs are employed primarily to assess brain stem function. [BRAIN-STEM AUDITORY EVOKED POTENTIALS ‘Technique of Intraoperative Recording ‘The use of acoustically shelled headphones in the operating room is precluded by their mass, which intrudes into the operative field. A wide Yarlety of ear insert transducers sultable for operating room use is avallable. We hive suewessfully used inexpensive microstereo earphones in over 150, posterior fossa surgical eases They ean easily be placed atthe opening (ofthe ear canal and covered with water-resistant tape to avoid contamination fiom surgical Acs, Evoked potential equipment manufacturers offer rolded ear inserts connected by several inches of a polyvinyl tube to a transducer, The displacement ofthe transducer away fom the ear physically Femnoves it from the ds that may accumulate intraoperatively, The length Df the tube delays sound aerival atthe cochlea and temporally separates the BAEP from the stimulus artifact generated by the transducer. Absolute latencies of all BAEP waveforms are delayed but interpeak latencies are tunalected by this toc Intraoperative BAEP stimulation parameters are very similar to those ted in the laboratory. Aerating clicks of 100 psec dusation are used to reduce stimulus artifact that can be a prablem at high-intensity stimulation ‘with monophasic pulses, However, rarefaction or condensation clicks can be utilized f they offer better resolution of the BAEP response. The usual stimulus intensity Is 7D ABHL, but frequently 4s increased to 85 or 95 ABHL to. maximize the response, The higher stimulus intensity is often required for waveform resolution due to the large amount of ambient noise present intraoperatively. The ear on the side of the surgical approach is fhe primary site of stimulation, To reduce transcranial stimulation, white noise 40 dB below the click intensity is delivered to the contralateral ear. (Our routine stimulation rate is BVSce. The range we have used intraoper- atively is 11 to Sl/sec. An exact fraction of 60 should not be used in order to avoid the incorporation of 60 Hz artifact. Many authors avoid the we of Istmaorenarive Moxmmonne or Avprrony axp Baan-Stes Fusco 901 the faster rates because of deterioration ofthe quality ofthe BAEP response. However, in our experience, the benefit of « quick turnaround time and earlier demonstration ofa sguifeant change outweighs the minor deter ration in response quality. With the SL Hz stimulation rate, tral of 2000 replications ean be completed in slightly over I minote (depending on the number of artfict-contaninated sweeps). After averaging. approximately 100 to 200 stimuli (5 to 10 sec), the latency of wave V can frequently be Aetermined and communicated to the surgeon if warranted ‘The montage and recording parameters for intraoperative BAEPs are essentially identical to those used in the diagnostic laboratory recordings. ‘Two channel derivations tsing ipsilateral ear Ai to Cz and contralateral ear Ac to Cr are recorded. A ground is placed at Fe. Two surfice electrodes are placed at each site inthe event of leetrode displacement or dysfunction daring the operation. Rontine filter settings ae a low-frequency Alter of 150 Hz and @ high-frequency filter of 300 He, A typical tal incorporates the average of 1000 to 4060 stimull depending on the signal-to-noise ratio We routinely expand our analysis time to 15 msee beeanso wave V may be displaced beyond 10 msce with operative manipulation. Analysis of BAEP Response Wave V is the most easly defined and the most robust waveform fn the BAEP. It may be the only component recorded in patients with significant conduction or reurosensory hearing imparments, In the hostile ‘operating room environment, the earlier waveforms may not be as easly resolved. Therefore, all uthors have resorted to analyzing the latency and amplitude of wave V as the primary criterion of change in the BAEP.* = ‘atm 2:50 Attention is focused on the BAEP response obtained on stimulation of the ear ipslateral to the surgeal approach. Change in the wave V latency is best seen with a serial display of responses including the intraoperative basolino as well as the last several trials. This allows deter- ‘mination of the overall ateney and amplitude changes, as well as assessment of rapid changes. oceurring over the most recent averages, Oceasional averages are obtained from stimulation ofthe contralateral ear to evaluate any alteration in brain-stem function Wave V latency changes of less than 0.5 mace are commonly seen carly in the operative course. > This mild shift occurs during opening tnd isnot associated with direct surgical threat to auditory or brainstem fimction. These initial changes are not recorded from stimulation of the contralateral ear and as such are not die to the effects of anesthesia or change in core body temperature. More likey, this mild, unilateral delay cof wave V is due to the effects of local temperature change or irrigation solutions. In any case, this mild delay has no. associated vditory or neurologic morbidity and ‘snot considered clinically significant, Although such mild shifts (ess than 0.5 msec) can be ignored, there is still no consensus as to the degree of wave V delay or amplitude loss that is clinically important. Delntons of a signifeant latoney shit from baseline have included 0.5 msee,* 1.0 msee,*"" 1.5 msee,” and 0.07 msec per minute." Toss of greater than 50 per cent of wave V amplitude ts also Aeseribed as indicative ofa potentially important change." In our own 2 Rove A. Raps ano C. Wautia En ‘experience, we have used 4 1.0 mse shift as reprosentative of a change that warrants communication with the surgeon.” * An abrupt shift occurring ata rate greater than 0.1 msee pee minute is also cause for concer, even A the total shift of 1.0 msec has not been reached. A wave V amplitude Joss of greater than 50 per cent is abo probably significant but is rarely seen in the absence of an accompanying latency shift. One author has Argued that the total loss of an identifiable wave V is the only change ‘worthy of altering the surgical approach." However, analysis of our data Teveals that patients with shifts greater than oF equal to 1.0 msec have a Fisk of auditory morbidity that is significantly different from those having « Tesser shift Therefore, we continue to use the relatively conservative value of 1.0 msec BABE: are extremely sensitive to intraoperative manipulation and as a result will demonstrate changes that are frequently not accompanied by postoperative deficits (alse-postive result), Ideally, any monitoring te! nique should consistently identify those patients at rsk for neurophysilogic ‘compromise but not cause unnecessary prolongation or alteration of the Surgleal procedure. In 70 consecutive cases of microvascular decompres (MVD), 43 per cent of the procedures were altered owing to the develop rent of a sift of grester than 1.0 msce.™* Ifthe complete loss of wave V twas the only eriterion utilized in the same operations, 20 per cent of the procedures would have been altered. This in a clinical setting in which 112 per cent incidence of auditory morbidity had previously been identi the ratio of BAEP changes to expected auditory morbidity was riding on the eriteria used. Although the striter eriterion ‘may result in some needless adjustment or interruption of the surgical procedure, we feel that i offers the best chance to effect a decline in andlitory mosbidity The demonstration of a significant auditory or neurologie deficit in the absence of BAEP change lllse-negative result) has fortunately been ex- tremely rare. We have observed the development of an intraoperative Iidbraia infarct with the maintenance of normal intranperative BAEPs." “Although this may be termed a false negative, such fndings should not be ‘unexpected given the anatomic limitations of the BAEP pathway and its presumed generators. It was this experience that led us to use the upper txtremity somatosensory evoked potentials (SEPs) in addition to BAEPS to Sample larger areas ofthe brain stem. Similarly, Ratdzens has described a patient with normal intraoperative BAEPs that did not avraken from Surgery." The patient presumably suffered diffuse hemispheric injury foulside the BAEP-monitored pathways, and as such this also does not represent a true false nogative. Jannetta and colleagues have reported 2 “rue” false-negative case of a patient who had a major auditory deft postoperatively in spite of no intrasurcal change of the BAEPs." Ojfemann fas deseribed two patients who had the maintenance of an identifiable but altered wave ¥ intraoperatively with a marked loss of functional hearing” Teis posable that these “false negatives” were due to damage of the auditory fibers that occurred alter the monitoring was discontinued: however, the postoperative BARS sind hearing evaluations were not described ‘ade= ‘ouately in those reports to assess that posiility, Our experience includes Istnaorengtive Mowtrontnc oF AUDITOnYAKD BRAN Stes FuNCnON 903) Table 2 Inracperatce BAEPs: Mechanims of Alteration “Tanssedion of dh ware Ochs fier wary aery Retron or ete af eg eve Miplton aa dation ser eg nerve Brainstem cheno comes ‘Techn act 2 Dispicemenoe malfnctin of timator 1 Ostion of tral nt cana ir eal, Hs) « lotvering mie fr ep, ding) AL lc ives fr ample Serotec) 4 single case of a profiand auditory deficit with apparently preserved BAEPs, However, the discrepancy wis due to technical error caused by a shorted wanda: Ct deter itera simulation when the enc fist attempted to unilaterally stimulate the ear on the side of sursery. Mechanical pressure on the eable connecting the transducers to" the stimulator apparently catsed the problem mklway through surgery. This latter ease emphasizes the need for attention to technical detail In order t0 avoid misleading intriperatwe results, “Mechanism of BAEP Chunges ‘Table 2 lists the mos: common mechanisms that produce an alteration of the BAEP response. Certainly transection of the eighth nerve leads to tn abrupt and irreversible loss of wave V and resultant ipsilateral postop. erative deafness." Interestingly, preservation of wave Land occasionally of wave IT is seen in this setting. This reflects the generation of wave 1 in the cochlea and distal portion ofthe eighth nerve and the generation of at least a portion of wave It in the proximal eighth nerve ‘Usually, an abrupt loss of all BAEP waveforms is seen with the eighth ‘nerve anatomically intact. The persistent loss of waves, I-V and. the subsequent deafness fequently assumed to be due to achemia allecting, the cochlea or distal eighth nerve." Support for this theory is found fe experimental work in animal models." Sekiya and Mgller demonstrated hhemorthages inthe area cribosa a the fundus of the internal auditory canal as a result of cerebellar retraction. The hemorrhages appeared to be due to the rupture ofthe branches ofthe Internal Auditory Artery (AA). Ths, ischemia to the periphera auditory structures isthe probable eause of the sudden loss ofall components ofthe auditory response. The loss of wave T which is generated by the cochlea and distal eighth nerve, is anatomically consistent with this model of ischemic injury. Vasoapasin has also, been proposed as a cause forthe loss of cochlear function during CPA operations, but no clinical or experimental support for this assertion is availble More commonly, the changes seen intrioperatively are gradual a ‘occur over several minutes Typically, these gradual changes ooeur dur n cerebellar retraction or daring manipulation near the eighth nerve. The BAEP changes are primarily a prolongation of waves I-V with a mainte. nee of wave I." 4! When early waveforms are clearly Klentifed, the change is seen in the I-I or I-III interval. When the changes continue to Progress, waves II-V are ultimately lost but wave [is maintained. Sekiya 904 opvey A. RaDrxe aND C. Wanita Baws land Mgller noted no histologic abnormalities of the eighth nerve or Aisruption ofthe arterial supply when similar BAEP changes were seen in the Rhesus monkey mode." “The exact mechanical canse of this “conduction block” secondary to ‘operative maniplation remins unclear. The intracranial portions of the Chaith nerve are known to be fragile and seasitive to stretch and compres: ‘on. The proximal portions ofthe eighth nerve are covered only by central inyelin that does not include the perineurium (which offers resistance to trotching) or epineurium (which offers resistance to compress ‘The prolongation ofthe I-V interval ean occur during cerebellar retraction (presumably because of stretching) or during dissection near the nerve (Bresumably ovsing to compression) The BAEP changes have been dem: (Gistrated to be reversible (both clinially and experimentally) and offer an ‘opportunity to avert reversible injury to audition "This discussion has emphasized BAEP changes secondary to compro- mise of cochlea or eighth-nerve function. Such lateralized changes are ‘Commonly seen during operations in the CPA. Compromise ofthe brain ‘tear auditory pathways ean also conteibute to BAEP changes. We have dbserved two cases ofa lateralized compressive or ischemic injury to the rain stem that resulted in a unilateral loss ofthe later BAEP waveforms. Postoperatively, these patients hid moderate neurologic deficits and a localized. brainstem injury confirmed on magnetic resonance imaging. Profound bilateral BAEP changes are secondary to diffuse brain-stem {schema or compression and are astocated with severe brain-stem inj ‘Nonpathologic factors also are noted to influence intrioperative BAEP'. ‘the effects of anesthesia or mild hypothermia are usually minimal. * When seen, the assorated wave V shifts occur symmetrically and are less than 0.5 mace.” "There are reports of BAEP responses being lost ‘with change in patient position” This has been interpreted as due to Interruption of the posterior fossa vascular supply with change in head position, but could have also resulted from technical factors for example, Uigplacement of transducer or recording electrodes, occhision of external ‘ality canal. "Techical factors can also contsibute to changes inthe BAEP response. -Malfimetioning of the stimulator, displacement of the transducer, or acen ulation of fluids in the external auditory canal all Tead to an attenuation for lons ofan elfectve auditory stimulus. The hostile intraoperative recording Ghvironment includes many devices that produce interfering electrical Sole. Many electrieal devices, particularly the electrocautery, produce leetrical interference that degrades the signal. Drilling to remove bone, {n addition to producing electrical interference, produces « masking noise thot significantly reduces the BAEP amplitude. At times during the of ion, He use of electrocautery oF the bone drill may need to be interrupted torallow alequate recording of the BAP, Predictive Value of BAEP Changes ‘Even though the exact indication for adjustment of the. surgical approach remains poorly defined, the literature does offer significant Imgorenanive MoNITORING OF AUDITORY AND BRals-SrEM FUNCTION 905 able 3 Intreoperatice BAEPs Pstperatice Hearing LO muse deby No os of bears ‘Transient ous Moderate rs xml mdeate hearing lost Pentten High ak 0 9) for ere bearing bn ets formation regarding the predictive value of different BAEP alterations with regard to postoperaive auditory Function (Table 3) 1, No or mld ltecyslteaions (ead colleagues have described ld hearing less «patent wih only 04 mace ‘Tut's wave V lteny. In Glo, Jenne" be relered to hearing los in & pe tent wih "oo detoroesten’ of BAERa. Gtbesian, xtentre openers bor demonstrated tat no hearing los 6 noted in patents who hve lite rma wave site 2 Sigacant latency alterations (1.0 mace o greats) (Fig. 2), Rando”

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