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Abstract
Introduction Intraoperative neuromonitoring (IONM) is being increasingly utilized during cerebral neuroendovascular procedures to improve patient safety, but empirical evidence regarding the diagnostic accuracy and clinical impact of IONM is still needed.
Methods A multi-institutional database of 2278 cerebral neuroendovascular procedures utilizing multimodality IONM was reviewed. All procedures utilized electroencephalography and somatosensory evoked potentials, and a subset also included motor evoked potentials (MEPs). IONM alerts were categorized as either a significant attenuation or complete loss of response. Retrospective review was used to identify perioperative arterial complications associated with IONM changes which were subcategorized as due to rupture, embolus, instrumentation, or vasospasm. Odds Ratios (OR) for new postoperative deficits were calculated as a function of the type of complication, magnitude of IONM signal change, and signal status at closure. Diagnostic accuracy was measured using sensitivity, specificity, and positive and negative likelihood ratios (PLRs and NLRs).
Results Overall, IONM was highly accurate in diagnosing evolving neurological injury for either the MEP or non-MEP cohorts (table 1). Relative to cases with no alerts, the odds of a new deficit significantly increased as a function of the magnitude of IONM change and type of complication (table 2). For procedures with changes associated with a perioperative complication (n=83), the rate of new neurologic deficit was 60% if the change remained unresolved (n=18/30). However, the rate and risk of new deficit was significantly decreased if a change was partially resolved (28.6%, n=6/21, OR=0.27), and was dramatically decreased if fully resolved (3.1%, n=1/32, OR=0.02) (figure 1).
IONM Alert and Diagnostic Information for All Procedures and 2 Cohort Subgroups
Odds Ratios (OR) for New Deficit Based on Signal Change and Complication. Odds Ratio referent was c
Rate and Odds Ratios (OR)for New Deficit After IONM Change Associated with Perioperatve Arterial Complication as a Function of the Resolution of the Change.
Conclusions IONM has excellent diagnostic accuracy during cerebral neuroendovascular procedures. Both the magnitude and putative cause of IONM change provide diagnostic and prognostic information. Perioperative complications are significantly less likely to result in postoperative dysfunction if there is a timely diagnosis and intervention that results in the resolution of IONM signal change.
Disclosures W. Wilent: None. S. Tjoumakaris: None. P. Jabbour: None. M. Gooch: None. R. Rosenwasser: None. W. Kim: None. J. English: None. O. Belyakina: None. E. Korsgaard: None. J. Cohen: None. A. Sestokas: None.