Takeshi Itakura

Intraoperative monitoring of visual evoked potential: introduction of a clinically useful method

OBJECT To obtain a clinically useful method of intraoperative monitoring of visual evoked potentials (VEPs), the authors developed a new light-stimulating device and introduced electroretinography (ERG) to ascertain retinal light stimulation after induction of venous anesthesia. METHODS The new stimulating device consists of 16 red light-emitting diodes embedded in a soft silicone disc to avoid deviation of the light axis after frontal scalp-flap reflection. After induction of venous anesthesia with propofol, the authors performed ERG and VEP recording in 100 patients (200 eyes) who were at intraoperative risk for visual impairment. RESULTS Stable ERG and VEP recordings were obtained in 187 eyes. In 12 eyes, stable ERG data were recorded but VEPs could not be obtained, probably because all 12 eyes manifested severe preoperative visual dysfunction. The disappearance of ERG data and VEPs in the 13th eye after frontal scalp-flap reflection suggested technical failure attributable to deviation of the light axis. The criterion for amplitude changes was defined as a 50% increase or decrease in amplitude compared with the control level. In 1 of 187 eyes the authors observed an increase in intraoperative amplitude and postoperative visual function improvement. Of 169 eyes without amplitude changes, 17 manifested improved visual function postoperatively, 150 showed no change, and 2 worsened (1 patient with a temporal tumor developed a slight visual field defect in both eyes). Of 3 eyes with intraoperative VEP deterioration and subsequent recovery upon changing the operative maneuver, 1 improved and 2 exhibited no change. The VEP amplitude decreased without subsequent recovery to 50% of the control level in 14 eyes, and all of these developed various degrees of postoperative deterioration of visual function. CONCLUSIONS With the strategy introduced here it is possible to record intraoperative VEPs in almost all patients except in those with severe visual dysfunction. In some patients, postoperative visual deterioration can be avoided or minimized by intraoperative VEP recording. All patients without an intraoperative decrease in the VEP amplitude were without severe postoperative deterioration in visual function, suggesting that intraoperative VEP monitoring may contribute to prevent postoperative visual dysfunction.

Motor evoked potential monitoring of the vagus nerve with transcranial electrical stimulation during skull base surgeries

OBJECT Dysphasia is one of the most serious complications of skull base surgeries and results from damage to the brainstem and/or cranial nerves involved in swallowing. Here, the authors propose a method to monitor the function of the vagus nerve using endotracheal tube surface electrodes and transcranial electrical stimulation during skull base surgeries. METHODS Fifteen patients with skull base or brainstem tumors were enrolled. The authors used surface electrodes of an endotracheal tube to record compound electromyographic responses from the vocalis muscle. Motor neurons were stimulated using corkscrew electrodes placed subdermally on the scalp at C3 and C4. During surgery, the operator received a warning when the amplitude of the vagal motor evoked potential (MEP) decreased to less than 50% of the control level. After surgery, swallowing function was assessed clinically using grading criteria. RESULTS In 5 patients, vagal MEP amplitude permanently deteriorated to less than 50% of the control level on the right side when meningiomas were dissected from the pons or basilar artery, or when a schwannoma was dissected from the vagal rootlets. These 5 patients had postoperative dysphagia. At 4 weeks after surgery, 2 patients still had dysphagia. In 2 patients, vagal MEPs of one side transiently disappeared when the tumors were dissected from the brainstem or the vagal rootlets. After surgery, both patients had dysphagia, which recovered in 4 weeks. In 7 patients, MEP amplitude was consistent, maintaining more than 50% of the control level throughout the operative procedures. After surgery all 7 patients were neurologically intact with normal swallowing function. CONCLUSIONS Vagal MEP monitoring with transcranial electrical stimulation and endotracheal tube electrode recording was a safe and effective method to provide continuous real-time information on the integrity of both the supranuclear and infranuclear vagal pathway. This method is useful to prevent intraoperative injury of the brainstem corticobulbar tract or the vagal rootlets and to avoid the postoperative dysphagia that is often associated with brainstem or skull base surgeries.

Evoked potentials elicited on the cerebellar cortex by electrical stimulation of the rat spinocerebellar tract.

BACKGROUND In the current study, as a first step to develop a monitoring method of cerebellar functions, we tried to record evoked potentials on the cerebellar cortex by electrical stimulation of the rat SCT, which is located in the Inf-CPed. METHODS The experimental study was performed on rats. Unilateral muscular contractions of quadriceps femoris muscle were elicited by electrical stimulation. The evoked potentials were recorded from the surface of the ipsilateral cerebellum and the contralateral primary sensory cortex. RESULTS The highly reproducible potentials obtained from the ipsilateral cerebellar hemisphere were named SCEP. The SCEP exhibited one negative peak with a latency of 11.7 +/- 0.3 milliseconds (N(11)). Short-latency somatosensory evoked potential was recorded from the contralateral primary sensory cortex with a latency of 19.1 +/- 0.6 milliseconds. Coagulation of the ipsilateral Inf-CPed caused disappearance or marked reduction of the SCEP N(11), but it did not change the SSEP. On the other hand, sectioning of the ipsilateral dorsal column resulted in the disappearance of the SSEP, but it did not affect the SCEP N(11). CONCLUSIONS Reproducible SCEP was recorded from the rat cerebellar hemisphere by electrical stimulation of the quadriceps femoris muscle. We posit that the SCEP differs from the SSEP, which ascends via the dorsal column, and that it is conducted by the dorsal SCT located in the Inf-CPed. Our results suggest that it may be possible to detect the dysfunction of the Inf-CPed electrophysiologically by using SCEP.

26. A comparative study of motor evoked potential monitoring elicited by direct electrical cortical stimulation and transcranial electrical stimulation during aneurysm surgery

The aim of this study was to study interhemispheric inhibition (IHI) after bilateral (bil-task) and right finger extension tasks (rttask). Participants were 16 healthy adults. The IHI was studied before and after the finger extension tasks (bil-task and rt-task) by paired-pulse technique with transcranial magnetic stimulation (TMS). MEPs were recorded with surface electrodes placed over the right extensor digitorum communis (EDC). The intensities of both condition and test stimuli were set at 120% of the resting motor threshold. The condition stimulus was applied to the right M1, and the test stimulus was applied to the left M1.The condition-test interval was set at 10 and 15 ms. The IHI ratio was obtained by mean conditioned MEP amplitude/mean test MEP amplitude. The IHI ratio increased significantly after bil-task and the increment lasted for 30 min. The IHI ratio also increased after rt-task, however, the increment did not last for 30 min. Our results suggest that the IHI is more disinhibited after the bilateral finger movements than the unilateral finger movements.

71. Intraoperative monitoring of visual-evoked potential for temporal lesions – Correlation between VEP findings and postoperative visual field

To test the effect of motor imagery as compared to voluntary muscle contraction on the excitability of the anterior horn cells, we studied F-wave persistence and amplitude, monitoring the force by a transducer. F-waves were recorded from the first dorsal interosseus muscle at rest and under a battery of motor tasks which comprised mental imagery and mild to moderate abduction of the index finger in 10 increments up to 30% of the maximal force. During each step lasting for 20 s, 20 stimuli were applied to the ulnar nerve at the wrist at the rate of one per second. In 12 healthy subjects, F-wave persistence (mean ± SD) significantly (p < 0.05) increased from 32.5 ± 11.9% at rest to 58.3 ± 15.2% during motor imagery and to 87–91% during voluntary contraction. Similarly, F-wave amplitude significantly (p < 0.05) increased from 41.3 ± 77.1 lV at rest to 91.2 ± 142.7 lV during motor imagery and to 183–274 lV during voluntary contraction. In contrast, F-wave latency changed little regardless of motor tasks. Motor imagery, though to a lesser degree than muscle contraction, effectively enhances the excitability of the anterior horn cells, thereby increasing F-wave persistence and amplitude above the baseline.