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Detection of ischemia in endovascular therapy of cerebral aneurysms: a perspective in the era of neurophysiological monitoring

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Abstract

A prospective study was performed to evaluate the efficacy of neurophysiological monitoring (NPM) techniques in the detection of ischemic changes that may be seen during endovascular treatment of cerebral aneurysms. Sixty three patients underwent NPM during first-stage endovascular treatment of cerebral aneurysms. The endovascular procedures included coil embolization (26 patients), balloon-remodeling coiling (16 patients), stent-assisted coiling (ten patients), balloon-stent-assisted coiling (nine patients), and balloon test occlusion (two patients). NPM included electroencephalography, somatosensory evoked potentials, and brain stem auditory evoked potentials, depending on the location of the aneurysm and its associated vascular territory. NPM changes were seen in three patients (4.8%), and the procedures were altered immediately. No neurological changes were found postendovascularly. Ten patients demonstrated abnormal angiographic findings without concurrent NPM changes, of which five patients developed visual disturbance or hemiparesis. It is concluded that NPM is a valuable monitoring tool for endovascular treatment of cerebral aneurysms.

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Acknowledgment

This study was kindly cooperated with Drs. C.G. McDougall, F.C. Albuquerque, and R.F. Spetzler, Barrow Neurological Institute, Phoenix, AZ, USA. Part of the funding was supported by the State Administration of Foreign Experts Affairs of China. There is no conflict of interests.

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Authors and Affiliations

  1. Department of Neurosurgery, Zhongshan Hospital, Xiamen University, 361004, Xiamen, China

    Lukui Chen

  2. Barrow Neurological Institute, Phoenix, AZ, USA

    Robert F. Spetzler, Cameron G. McDougall & Felipe C. Albuquerque

  3. Department of Neurosurgery, Chinese PLA General Hospital, Chinese PLA Postgraduate Medical School, 28, Fuxing Road, Haidian District, 100853 Beijing, 361004, Xiamen, China

    Lukui Chen & Bainan Xu

Authors
  1. Lukui Chen
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  2. Robert F. Spetzler
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  3. Cameron G. McDougall
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  4. Felipe C. Albuquerque
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  5. Bainan Xu
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Correspondence to Bainan Xu.

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Comments

Johannes Sarnthein, Zurich, Switzerland

The present paper is one of few in the literature that report neurophysiological monitoring during endovascular procedures for cerebral aneurysms. In three patients, changes in evoked potentials were observed, which indicated risk of procedure-related morbidity. Consequently, treatment strategy was adapted, and no new postoperative deficits occurred. However, it will of course never be known whether neurological deficits would have actually occurred without adapting treatment strategy. In other patients, infarctions occurred in areas not covered by neuromonitoring and resulted in neurological deficits. Thus, as always, one has to (1) carefully select the potentials to be monitored and (2) define the conclusions that can be drawn from changes in potentials.

Gerasimos Baltsavias, Anton Valavanis, Zurich, Switzerland

Chen et al in their prospective study of 63 cases of neurophysiologic monitoring (NPM) during endovascular treatment of cerebral aneurysms aimed to assess the effectiveness and efficacy of NPM in detecting significant ischemia during such operations. In their report, it is not clear whether this population comprises of a consecutive series of patients or some inclusion–exclusion criteria were applied. Also, it is not mentioned the reason why MEPs were not employed.

NMP changes were seen in three patients during balloon remodeling, which led to immediate balloon deflation without postoperative clinical neurological deficit. On the other hand, in ten cases of abnormal angiographic findings, no NPM changes were detected. In eight of these cases, it is not clear whether no NPM changes were to be expected as the authors mentioned, whereas in the two other cases with severe angiographic complications, no NPM changes were detected as well. In total, five out of ten patients with angiographic complications developed clinical neurological deficit. None of them was detected in NPM.

Based on the above-described results, one should conclude that the NPM setup that the authors applied failed in 100% of cases to detect angiographically and clinically (confirmed by CT, MR) proved ischemia during endovascular therapy of aneurysms, whereas it is not clear if the three cases with NPM changes did not represent a false positive finding.

In conclusion and regardless of potential real benefit of NPM during neuroendovascular operations, we would say that evaluation of its efficacy should not be the goal of such a study. Otherwise, the effectiveness of the above-described setup was demonstrated very poor. Therefore it should be emphasized that according to the present study the decision-making during endovascular procedures cannot be based on NPM changes, but rather on the real-time and proper evaluation of the angiographic findings. Moreover, none intraoperative monitoring technique can substitute or reduce the value of the individualized approach and indication for treatment, combined with a non-aggressive technique and appropriate interpretation of the angiographic findings.

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Chen, L., Spetzler, R.F., McDougall, C.G. et al. Detection of ischemia in endovascular therapy of cerebral aneurysms: a perspective in the era of neurophysiological monitoring. Neurosurg Rev 34, 69–75 (2011). https://doi.org/10.1007/s10143-010-0276-3

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