Department of Neurology, University of Kentucky, Lexington, Kentucky, USA.
Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
World Neurosurg. 2021 Apr;148:e43-e57. doi: 10.1016/j.wneu.2020.11.154. Epub 2020 Dec 7.
In the present study, we investigated the role of intraoperative neuromonitoring (IONM) in internal carotid artery (ICA) injury during endoscopic endonasal skull base surgery (EESBS).
The study group included all 13 patients who had experienced an ICA injury during EESBS with IONM from 2004 to 2017. The medical records were reviewed for the perioperative data. The IONM reports were reviewed to evaluate the baseline somatosensory evoked potentials (SSEP), electroencephalography (EEG), and brainstem auditory evoked potentials (BAEP) and their significant changes related to ICA injury and/or the subsequent surgical/endovascular interventions.
All 13 patients had undergone SSEP and 7 patients had BAEP monitoring during surgery. EEG was added during emergent angiography following the surgery for 5 patients. Two patients showed significant SSEP changes, and one showed significant SSEP and EEG changes, indicating cerebral hypoperfusion. Of these 3 patients, patient 1 had experienced irreversible SSEP loss with postoperative stroke. Patients 2 and 3 had SSEP and/or EEG changes that had recovered to baseline after interventions without postoperative deficits. Despite ICA injury, 10 patients showed no significant SSEP and/or EEG changes, and all 7 patients with BAEP monitoring showed no significant BAEP changes, indicating adequate cerebral and brainstem perfusion, respectively. The injured ICA was sacrificed in 4 patients, of whom 3 showed stable SSEP and 1 had experienced irreversible SSEP loss. IONM correlated with the postoperative neurologic examination findings in all cases, adequately predicting the neurologic outcomes after ICA injury.
SSEP and EEG monitoring can accurately detect cerebral hypoperfusion and provide real-time feedback during surgery. SSEP and EEG changes predicted for neurologic outcomes and guide surgical decisions regarding the preservation or sacrifice of the ICA. Comprehensive multimodality monitoring according to the surgical risks can serve to detect and guide the management of ICA injury in EESBS.
本研究旨在探讨术中神经监测（IONM）在经鼻内镜颅底手术（EESBS）中颈内动脉（ICA）损伤中的作用。
研究组纳入了 2004 年至 2017 年间接受 EESBS 并伴有 IONM 的 13 例 ICA 损伤患者。回顾了围手术期数据。回顾了 IONM 报告，以评估基线体感诱发电位（SSEP）、脑电图（EEG）和脑干听觉诱发电位（BAEP）及其与 ICA 损伤和/或随后的手术/血管内干预相关的显著变化。
所有 13 例患者均接受了 SSEP 监测，7 例患者接受了 BAEP 监测。5 例患者在术后紧急血管造影时加用了 EEG。其中 2 例患者 SSEP 发生明显变化，1 例患者 SSEP 和 EEG 均发生明显变化，提示脑灌注不足。这 3 例患者中，患者 1 术后发生不可逆性 SSEP 丧失伴脑卒中。患者 2 和 3 的 SSEP 和/或 EEG 变化在干预后恢复至基线，无术后缺损。尽管发生了 ICA 损伤，但 10 例患者的 SSEP 和/或 EEG 无明显变化，7 例接受 BAEP 监测的患者的 BAEP 无明显变化，分别提示脑和脑干灌注充足。4 例患者牺牲了损伤的 ICA，其中 3 例 SSEP 稳定，1 例发生不可逆性 SSEP 丧失。IONM 与术后神经检查结果在所有病例中均相关，充分预测了 ICA 损伤后的神经结局。
SSEP 和 EEG 监测可准确检测脑灌注不足，并在手术过程中提供实时反馈。SSEP 和 EEG 变化预测神经结局，并指导关于保留或牺牲 ICA 的手术决策。根据手术风险进行全面的多模态监测，可以发现并指导 EESBS 中 ICA 损伤的管理。
