Suzuki Kengo, Mikami Takeshi, Sugino Toshiya, Wanibuchi Masahiko, Miyamoto Susumu, Hashimoto Nobuo, Mikuni Nobuhiro
Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan.
Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan.
World Neurosurg. 2014 Dec;82(6):e739-45. doi: 10.1016/j.wneu.2013.08.034. Epub 2013 Sep 11.
Various modalities have been used to confirm the blood flow through parent arteries or surrounding perforating arteries during surgical aneurysm clipping, including motor-evoked potentials (MEPs), Doppler ultrasound, and indocyanine green videoangiography. Nonetheless, contralateral hemiparesis due to arterial blood flow insufficiency may arise because of false-positive or false-negative errors. By performing controlled intraoperative awakening during aneurysm clipping, we compared patients' voluntary movements with simultaneous MEP.
Four patients with anterior choroidal artery aneurysms and one patient with a dorsal internal carotid artery aneurysm were included in this study. MEP and intraoperative voluntary movements under awake craniotomy were assessed simultaneously during and after the clipping procedure.
Aneurysms were safely and successfully clipped in all patients, with no evidence of postoperative neurological deficits. Voluntary movements and MEP findings did not differ from the control state in three patients. In the other two patients, we observed a discrepancy between MEP amplitudes and voluntary movements. In one patient, deterioration and subsequent improvement in voluntary movements were preceded by MEP amplitude reduction during clipping. In the other patient, MEP amplitude did not change although voluntary movement deteriorated during temporary occlusion of the internal carotid artery.
Intraoperative neurological assessment during aneurysmal clipping under awake craniotomy is feasible and safe, and should be valuable for the assessment of ischemia, especially in the anterior choroidal artery. From a neurophysiologic viewpoint, MEP may be insufficiently sensitive for evaluating voluntary movement under ischemia.
在手术夹闭动脉瘤期间，已采用多种方式来确认通过供血动脉或周围穿支动脉的血流，包括运动诱发电位（MEP）、多普勒超声和吲哚菁绿血管造影。尽管如此，由于假阳性或假阴性错误，可能会出现因动脉血流不足导致的对侧偏瘫。通过在动脉瘤夹闭过程中进行控制性术中唤醒，我们将患者的自主运动与同步MEP进行了比较。
本研究纳入了4例脉络膜前动脉动脉瘤患者和1例颈内动脉背侧动脉瘤患者。在夹闭过程中和夹闭后，同时评估清醒开颅手术期间的MEP和术中自主运动。
所有患者的动脉瘤均被安全、成功夹闭，无术后神经功能缺损的证据。3例患者的自主运动和MEP结果与对照状态无差异。在另外2例患者中，我们观察到MEP波幅与自主运动之间存在差异。在1例患者中，夹闭期间MEP波幅降低，随后自主运动恶化并随后改善。在另1例患者中，尽管在颈内动脉临时闭塞期间自主运动恶化，但MEP波幅未改变。
清醒开颅夹闭动脉瘤期间的术中神经功能评估是可行且安全的，对于评估缺血，尤其是脉络膜前动脉缺血应具有重要价值。从神经生理学角度来看，MEP在评估缺血状态下的自主运动时可能不够敏感。
