title: Conjunct SEP and MEP monitoring in resection of infratentorial lesions: lessons learned in a cohort of 210 patients.
abstract: OBJECTIVE
  During the surgical removal of infratentorial lesions, intraoperative neuromonitoring is mostly focused on cranial nerve assessment and brainstem auditory potentials. Despite the known risk of perforating vessel injury during microdissection within the vicinity of the brainstem, there are few reports about intraoperative neuromonitoring with somatosensory evoked potentials (SEPs) and motor evoked potentials (MEPs) assessing the medial lemniscus and corticospinal tract. This study analyses the occurrence of intraoperative changes in MEPs and SEPs with regard to lesion location and postoperative neurological outcome.
  
  
  METHODS
  The authors analyzed 210 cases in which patients (mean age 49 ± 13 years, 109 female) underwent surgeries involving the skull base (n = 104), cerebellum (n = 63), fourth ventricle (n = 28), brainstem (n = 12), and foramen magnum (n = 3).
  
  
  RESULTS
  Of 210 surgeries, 171 (81.4%) were uneventful with respect to long-tract monitoring. Nine (23%) of the 39 SEP and/or MEP alterations were transient and were only followed by a slight permanent deficit in 1 case. Permanent deterioration only was seen in 19 (49%) of 39 cases; the deterioration was related to tumor dissection in 4 of these cases, and permanent deficit (moderate-severe) was seen in only 1 of these 4 cases. Eleven patients (28%) had losses of at least 1 modality, and in 9 of these 11 cases, the loss was related to surgical microdissection within the vicinity of the brainstem. Four of these 9 patients suffered a moderate-to-severe long-term deficit. For permanent changes, the positive predictive value for neuromonitoring of the long tracts was 0.467, the negative predictive value was 0.989, the sensitivity was 0.875, and the specificity 0.918. Twenty-eight (72%) of 39 SEP and MEP alterations occurred in 66 cases involving intrinsic brainstem tumors or tumors adjacent to the brainstem. Lesion location and alterations in intraoperative neuromonitoring significantly correlated with patients' outcome (p < 0.001, chi-square test).
  
  
  CONCLUSIONS
  In summary, long-tract monitoring with SEPs and MEPs in infratentorial surgeries has a high sensitivity and negative predictive value with respect to postoperative neurological status. It is recommended especially in those surgeries in which microdissection within and in the vicinity of the brainstem might lead to injury of the brainstem parenchyma or perforating vessels and a subsequent perfusion deficit within the brainstem.
authors.affiliation: Department of Neurosurgery, Hospital of the Johann Wolfgang Goethe University, Frankfurt am Main, Germany.
authors.forename: Kunihiko
authors.initials: K
authors.lastname: Kodama
authors.forename: Mani
authors.initials: M
authors.lastname: Javadi
authors.forename: Volker
authors.initials: V
authors.lastname: Seifert
authors.forename: Andrea
authors.initials: A
authors.lastname: Szelényi
mesh_terms: D000328:Adult; D000368:Aged; D015331:Cohort Studies; D016208:Databases, Factual; D019054:Evoked Potentials, Motor; D005073:Evoked Potentials, Somatosensory; D005260:Female; D006801:Humans; D015192:Infratentorial Neoplasms / Q000601:surgery*; D007431:Intraoperative Complications / Q000175:diagnosis* / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative / Q000379:methods*; D011237:Predictive Value of Tests; D011712:Pyramidal Tracts / Q000503:physiopathology / Q000601:surgery; D012680:Sensitivity and Specificity; D019291:Skull Base / Q000601:surgery; D016896:Treatment Outcome; D055815:Young Adult
keywords: BAEP = brainstem auditory evoked potential; EEG = electroencephalography; MEP = motor evoked potential; MRC = Medical Research Council; SEP = somatosensory evoked potential; TES = transcranial electric stimulation; brainstem cavernoma; coMEP = corticobulbar motor evoked potential; diagnostic and operative techniques; infratentorial neoplasms; intraoperative neuromonitoring; motor evoked potential; somatosensory evoked potential