title: Transcranial electric stimulation for intraoperative motor evoked potential monitoring: Stimulation parameters and electrode montages.
abstract: OBJECTIVE
  To evaluate the efficacy of constant current transcranial electric stimulation (TES) parameters for eliciting muscle motor evoked potentials (MEPs) in the abductor pollicis brevis muscles (APB) and the tibialis anterior muscles (TA). The following parameters were tested intraoperatively: interstimulus interval (ISI), individual stimulation pulse duration within a train of five stimuli. Different montages of stimulating electrodes were assessed for effectiveness and focality. Further, reference values for APB and TA motor thresholds in neurosurgical patients with normal motor status under total intravenous anesthesia were determined.
  
  
  METHODS
  Motor thresholds of contralateral muscle MEPs were determined at 0.1, 0.2, 0.4, and 0.5 ms pulse duration and ISIs of 2, 3, 4, and 5 ms using a train of five monophasic constant current pulses with C3/C4 (27 patients). The stimulating electrodes were positioned at C1, C2, C3, C4, Cz, and Cz+6 cm. Different montages were used to determine the most effective and the most focal stimulation montages for the APB and TA muscles (30 patients). Eighty-six patients with clinically normal motor function were studied for motor threshold reference values.
  
  
  RESULTS
  The prolongation of the pulse duration has the strongest effect to decrease the motor threshold, which proportionally increases the delivered charge. The lowest stimulation threshold to elicit muscle MEPs in the APB and TA muscles is achieved with a train of stimuli consisting of an individual stimulus pulse duration of 0.5 ms. An ISI of 4 ms gave the lowest motor thresholds, but did not reach statistical significance compared to 3 ms. The stimulating electrode montage C3/C4 (C4/C3) allows for the lowest stimulation thresholds, but the vigorous muscle contractions it has is a disadvantage. The most focal stimulating electrode montages for the contralateral APB muscles are C3/Cz and C4/Cz, respectively, and for the TA muscles Cz/Cz+6 cm.
  
  
  CONCLUSIONS
  In adult neurosurgical patients with a normal motor status under total intravenous anesthesia, an individual pulse duration of 0.5 ms and an ISI of 4 ms provide the lowest motor thresholds. Pragmatically, C1/C2, resp., C2/C1 montage provides monitorable responses in both APB and TA muscles at reasonable stimulation thresholds without inducing movements disturbing surgery and especially microdissection. If the most focal hemispheric stimulation for the distal upper extremity muscles is required, the use of C3 or C4 referenced to Cz is recommended.
  
  
  CONCLUSIONS
  The stimulation parameters within a train of five pulses with an individual pulse duration of 0.5 ms and an ISI of 4 ms provide the lowest motor threshold. These data confirm not only studies for D wave recovery but also provide optimal stimulation parameters for intraoperative near threshold stimulation.
authors.affiliation: Department of Neurosurgery, Klinikum der Johann Wolfgang Goethe Universität, Frankfurt/Main, Germany. a.szelenyi@em.uni-frankfurt.de
authors.forename: Andrea
authors.initials: A
authors.lastname: Szelényi
authors.forename: Karl F
authors.initials: KF
authors.lastname: Kothbauer
authors.forename: Vedran
authors.initials: V
authors.lastname: Deletis
mesh_terms: D000771:Anesthesia, Intravenous; D001369:Axons / Q000502:physiology; D004558:Electric Stimulation; D004566:Electrodes; D004569:Electroencephalography; D019054:Evoked Potentials, Motor / Q000502:physiology*; D006801:Humans; D007432:Intraoperative Period; D016343:Monitoring, Intraoperative / Q000379:methods*; D018482:Muscle, Skeletal / Q000502:physiology*; D019635:Neurosurgical Procedures; D012016:Reference Values; D034941:Upper Extremity / Q000294:innervation / Q000502:physiology