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Abstract
Background: Intraoperative neurophysiological monitoring (IONM) has been widely applied in brain vascular surgeries to reduce postoperative neurologic deficit (PND). This study aimed to investigate the effect of IONM during clipping of unruptured intracranial aneurysms (UIAs).Methods: Between January 2013 and August 2020, we enrolled 193 patients with 202 UIAs in the N group (clipping without IONM) and 319 patients with 343 UIAs in the M group (clipping with IONM). Patients in the M group were intraoperatively monitored for motor evoked potentials (MEPs) and somatosensory evoked potentials (SSEPs). Irreversible evoked potential (EP) change was defined as EP deterioration that did not recover until surgery completion. Sustained PND was defined as neurological symptoms lasting for more than one postoperative month.Results: Ten (3.1%) and 13 (6.7%) in the M and N groups, respectively, presented with PND. Compared with the N group, the M group had significantly lower occurrence rates of sustained PND [odds ratio (OR) = 0.36, 95% confidence interval (CI) = 0.13–0.98, p = 0.04], ischemic complications (OR = 0.39, 95% CI = 0.15–0.98, p = 0.04), and radiologic complications (OR = 0.40, 95% CI = 0.19–0.82, p = 0.01). Temporary clipping was an independent risk factor for ischemic complications (ICs) in the total patient group (OR = 6.18, 95% CI = 1.75–21.83, p = 0.005), but not in the M group (OR = 5.53, 95% CI = 0.76–41.92, p = 0.09). Regarding PND prediction, considering any EP changes (MEP and/or SSEP) showed the best diagnostic efficiency with a sensitivity of 0.900, specificity of 0.940, positive predictive value of 0.321, negative predictive value (NPV) of 0.997, and a negative likelihood ratio (LR) of 0.11.Conclusion: IONM application during UIA clipping can reduce PND and radiological complications. The diagnostic effectiveness of IONM, specifically the NPV and LR negative values, was optimal upon consideration of changes in any EP modality.
Highlights
Intracranial aneurysms occur in 3–5% of adults; upon rupture, it causes subarachnoid hemorrhage (SAH), which results in critical neurological damage or, in the worst case, death [1, 2]
Microsurgical clipping is essential to preventing unruptured intracranial aneurysm (UIA) rupture; caution should be exercised as surgery bears risks of systemic complications, including pneumonia, seizure, infection, cerebral ischemia, and intracranial hemorrhage [6, 7]
We found that Intraoperative neurophysiological monitoring (IONM) usage allowed flexibility in setting the time for temporary clipping (TC) application rather than having to adhere to set times
Summary
Intracranial aneurysms occur in 3–5% of adults; upon rupture, it causes subarachnoid hemorrhage (SAH), which results in critical neurological damage or, in the worst case, death [1, 2]. Microsurgical UIA clipping and endovascular coil embolization are two procedures widely used for UIA repair and rupture prevention [5]. Microsurgical clipping is essential to preventing UIA rupture; caution should be exercised as surgery bears risks of systemic complications, including pneumonia, seizure, infection, cerebral ischemia, and intracranial hemorrhage [6, 7]. Intraoperative neurophysiological monitoring (IONM) has been widely applied in brain vascular surgeries to reduce postoperative neurologic deficit (PND). This study aimed to investigate the effect of IONM during clipping of unruptured intracranial aneurysms (UIAs)
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