Neuroprotective role of neurophysiological monitoring during endovascular procedures in the brain and spinal cord.

ABSTRACT

The goal of endovascular neurosurgery is to occlude aneurysms and arteriovenous malformations (AVMs) or to reduce the vascular supply to hypervascularized tumors, while preserving function in the normal neural tissue. However, the intra-arterial injection of embolizing materials into the cerebral or spinal circulation exposes to the risk of ischemic complications. Under general anesthesia, unless a wake-up test is performed, the only way to assess the functional integrity of sensory and motor pathways is to use neurophysiological monitoring. Somatosensory (SEPs) and muscle motor evoked potentials (mMEPs) can be used in combination with pharmacological provocative tests (PTs) to predict the effects of embolization. Amytal blocks neuronal activity, while lidocaine blocks axonal conduction. Therefore, a positive Amytal or lidocaine test (i.e. more than 50% decrease in SEP amplitude and/or mMEP disappearance) indicates that the vessel distal to the tip of the microcatheter supplies the functional gray or white matter of the spinal-cord respectively and cannot be embolized. Brain and spinal-cord vascularization and hemodynamics are extremely complex and even more unpredictable in the presence of a vascular malformation, but using a combined SEPs, MEPs and PTs protocol, morbidity related to endovascular procedures is very low. Given the high sensitivity of peripheral recordings to spinal-cord ischemia, experimental and clinical studies support the concept that whenever the mechanism of spinal-cord injury is purely ischemic, recording mMEPs may suffice. Reports on the use of PTs and neurophysiological monitoring during embolization of brain AVMs in critical areas are more anecdotal and mainly limited to the use of short-acting barbiturates. Our preliminary experience using lidocaine and combining SEP and mMEP monitoring is encouraging, since no false negative results were observed. Finally, if the sensitivity of this method is very high, its specificity has not been tested because embolization is abandoned whenever PTs are consistently positive. Accordingly, the possibility of false positive results cannot be excluded.