title: Impact of brain shift on intraoperative neurophysiological monitoring with cortical strip electrodes.
abstract: BACKGROUND
  Intraoperative neurophysiological monitoring has become the standard procedure for locating eloquent regions of the brain. Such continuous electrical stimulation of motor pathways is usually applied by means of flat silicon-embedded electrodes placed directly on the motor cortex. However, shifting of the silicon strip on the cortical surface as well as electrode displacement due to brain shift underneath the electrode can lead to inaccurate recordings not directly caused by intraoperative impairment of the motor cortex or the motor pathways.
  
  
  METHODS
  This prospective study was conducted to quantify cortical brain shift during open cranial surgery and to assess its impact on electrode positioning in 31 procedures near the precentral gyrus. Three groups of different lesion volumes were distinguished. Movement of the cortex between opening of the dura and completion of tumor removal as well as cortical electrode shifting were digitally measured and analyzed.
  
  
  RESULTS
  Cortical surface structures evidenced a significantly larger shift (up to 23.4 mm) in comparison to the electrode strips (up to 4.2 mm) in lesions with a volume of over 20 ml. Cortex shifting highly correlated with lesion volume, whereas strip electrode movement was almost unidirectional and did not differ significantly among the three groups. However, the way they were placed (completely on the cortex vs. partly underlying or overlapping the craniotomy borders) affected the magnitude of their intraoperative displacement. As a consequence, 3 of the 31 cases (9.3%) showed a significant change in the recorded motor responses due to intraoperative dislocation of the stimulating electrode.
  
  
  CONCLUSIONS
  Changes in the location of cerebral structures due to intraoperative brain shift may exert a marked influence on intraoperative neurophysiological monitoring if cortical strip electrodes are used. Therefore, long-term monitoring of the central region requires continuous checking of the position of stimulating electrodes and, if necessary, correction of their location.
authors.affiliation: Department of Neurosurgery, Benjamin Franklin University Hospital, Free University of Berlin, Hindenburgdamm 30, 12200 Berlin, Germany.
authors.forename: O
authors.initials: O
authors.lastname: Suess
authors.forename: Th
authors.initials: T
authors.lastname: Kombos
authors.forename: O
authors.initials: O
authors.lastname: Ciklatekerlio
authors.forename: R
authors.initials: R
authors.lastname: Stendel
authors.forename: S
authors.initials: S
authors.lastname: Suess
authors.forename: M
authors.initials: M
authors.lastname: Brock
mesh_terms: D000328:Adult; D000368:Aged; D001254:Astrocytoma / Q000473:pathology / Q000503:physiopathology* / Q000601:surgery*; D001932:Brain Neoplasms / Q000473:pathology / Q000503:physiopathology* / Q000601:surgery*; D004525:Efferent Pathways / Q000503:physiopathology; D004566:Electrodes; D005260:Female; D005909:Glioblastoma / Q000473:pathology / Q000503:physiopathology* / Q000601:surgery*; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative; D009044:Motor Cortex / Q000473:pathology / Q000503:physiopathology* / Q000601:surgery*; D009046:Motor Neurons / Q000502:physiology; D009068:Movement / Q000502:physiology*; D011446:Prospective Studies