Application value of intraoperative neuroelectrophysiological monitoring in brainstem cavernous malformation surgery
Objective To explore the application value of intraoperative neuroelectrophysiological monitoring(IONM)in brainstem cavernous malformation(BSCM)surgery.Methods A retrospective analysis was conducted on the clinical data of 17 patients with BSCM who were admitted to the Department of Neurosurgery,the Fourth Affiliated Hospital of Soochow University(Suzhou Dushu Lake Hospital)from November 2022 to November 2023.All patients presented different degrees of neurological symptoms before surgery,and BSCM resection was performed with the assistance of IONM,including somatosensory evoked potentials(SSEPs),transcranial electric motor evoked potentials(Tce-MEPs),facial motor evoked potentials(FMEPs),brainstem auditory evoked potentials(BAEPs),brainstem mapping,and cranial nerve electromyography.The patient's IONM data,postoperative neurological improvement and complications were documented.Postoperative head MRI was performed within 48 h after the surgery to evaluate surgical resection rate of BSCM.Follow-up cranial MRI was performed 3,6,and 12 months after surgery to further evaluate the resection degree and recurrent rate of BSCM.The Karnofsky Functional Status scale(KPS)was used to assess the neurological status of patients at discharge and final follow-up.Results All 17 patients underwent SSEPs and Tce-MEPs monitoring,with selective BAEPs(8 cases),FMEPs(3 cases),and cranial nerve electromyography(6 cases)monitoring.Mapping monitoring was performed in 4 cases to determine facial nerve motor nuclei.There were no significant changes in intraoperative or postoperative monitoring waveforms in 11 patients.However,some changes were recorded in the amplitude and latency of SSEPs or Tce-MEPs during surgery in 6 patients,including 5 transient changes and 1 persistent abnormal SSEPs.None of the patients had occurrence of IONM-related complications,such as epileptic seizure,arrhythmia,scalp burns at the stimulation electrode site,or direct thermal injury.All 17 surgical operations with BSCM were successfully performed.Total resection was achieved in 16 cases,subtotal resection was performed in 1 case,and the residual BSCM with small postoperative hematoma was completely removed to achieve total resection immediately after the first surgery.Postoperative pathological examination confirmed the diagnosis of BSCM.All patients were conscious after surgery,and no death was documented.Postoperatively,neurological improvement was reported in 12 cases,neurological status remained unchanged in 2 cases,and 3 patients experienced temporary worsening of neurological symptoms.Two patients experienced postoperative complications,including 1 case of cerebrospinal fluid nasal discharge and 1 case of mild acute subdural bleeding.The follow-up period for 17 patients was 3(2,11)months.At the last follow-up,no residual or recurrent cavernous malformations was found in the follow-up MRI.Clinical symptoms did not significantly worsen,and 3 patients with postoperative worsening neurological function showed improvement in symptoms after rehabilitation treatment.The KPS of the 17 patients before surgery,at discharge and the last follow-up were 80.59±7.48,85.88±11.76,and 91.76±9.51 respectively,which demonstrated statistically significance(F=19.53,P＜0.001).The KPS at discharge was higher than that before surgery but lower than that at the last follow-up(both P＜0.05).Conclusion The application of IONM can help the surgeons to remove BSCM safely and maximally in BSCM surgery.Thus,postoperative neurological improvement and reduced surgical related complications could be achieved.
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