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Warning criteria for MEP monitoring during carotid endarterectomy: a retrospective study of 571 patients

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Abstract

Monitoring of transcranial electrical motor evoked potentials (tcMEP) during carotid endarterectomy (CEA) has been shown to effectively detect intraoperative cerebral ischemia. The unique purpose of this study was to evaluate changes of MEP amplitude (AMP), area under the curve (AUC) and signal morphology (MOR) as additional MEP warning criteria for clamping-associated ischemia during CEA. Therefore, the primary outcome was the number of MEP alerts (AMP, AUC and MOR) in the patients without postoperative motor deficit (false positives). We retrospectively reviewed data from 571 patients who received CEA under general anesthesia. Monitoring of somatosensory evoked potentials (SSEP) and tcMEP was performed in all cases (all-or-none MEP warning criteria). The percentages of false positives (primary parameter) of AMP, AUC and MOR were evaluated according to the postoperative motor outcome. In the cohort of 562 patients, we found significant SSEP/MEP changes in 56 patients (9.96%). In 44 cases (7.83%) a shunt was inserted. Nine patients (1.57%) were excluded due to MEP recording failure. False positives were registered for AMP, AUC and MOR changes in 121 (24.01%), 148 (29.36%) and 165 (32.74%) patients, respectively. In combination of AMP/AUC and AMP/AUC/MOR false positives were found in 9.52% and 9.33% of the patients. This study is the first to evaluate the correctness of the MEP warning criteria AMP, AUC and MOR with regard to false positive monitoring results in the context of CEA. All additional MEP warning criteria investigated produced an unacceptably high number of false positives and therefore may not be useful in carotid surgery for adequate detection of clamping-associated ischemia.

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References

  1. Malcharek MJ, Ulkatan S, Marino V, Geyer M, Llado-Carbo E, Perez-Fajardo G, Arranz-Arranz B, Climent J, Aloj F, Franco E, Chiacchiari L, Kulpok A, Sablotzki A, Hennig G, Deletis V. Intraoperative monitoring of carotid endarterectomy by transcranial motor evoked potential: a multicenter study of 600 patients. Clin Neurophysiol. 2013;124(5):1025–30. https://doi.org/10.1016/j.clinph.2012.10.014.

    Article  CAS  PubMed  Google Scholar 

  2. Alcantara SD, Wuamett JC, Lantis JC, Ulkatan S, Bamberger P, Mendes D, Benvenisty A, Todd G. Outcomes of combined somatosensory evoked potential, motor evoked potential, and electroencephalography monitoring during carotid endarterectomy. Ann Vasc Surg. 2014;28(3):665–72. https://doi.org/10.1016/j.avsg.2013.09.005.

    Article  PubMed  Google Scholar 

  3. Malcharek MJ, Kulpok A, Deletis V, Ulkatan S, Sablotzki A, Hennig G, Gille J, Pilge S, Schneider G. Intraoperative multimodal evoked potential monitoring during carotid endarterectomy: a retrospective study of 264 patients. Anesth Analg. 2015;120(6):1352–60. https://doi.org/10.1213/ane.0000000000000337.

    Article  PubMed  Google Scholar 

  4. Malcharek MJ, Herbst V, Bartz GJ, Manceur AM, Gille J, Hennig G, Sablotzki A, Schneider G. Multimodal evoked potential monitoring in asleep patients versus neurological evaluation in awake patients during carotid endarterectomy: a single-centre retrospective trial of 651 patients. Minerva Anestesiol. 2015;81(10):1070–8.

    CAS  PubMed  Google Scholar 

  5. Marino V, Aloj F, Vargas M, Spinelli G, Pompeo F, Chiacchiari L, Servillo G, Franco E. Intraoperative neurological monitoring with evoked potentials during carotid endarterectomy versus cooperative patients under general anesthesia technique: a retrospective study. J Neurosurg Anesthesiol. 2018;30(3):258–64. https://doi.org/10.1097/ANA.0000000000000430.

    Article  PubMed  Google Scholar 

  6. Journee HL, Berends HI, Kruyt MC. The percentage of amplitude decrease warning criteria for transcranial MEP monitoring. J Clin Neurophysiol. 2017;34(1):22–31. https://doi.org/10.1097/WNP.0000000000000338.

    Article  PubMed  Google Scholar 

  7. Quinones-Hinojosa A, Lyon R, Zada G, Lamborn KR, Gupta N, Parsa AT, McDermott MW, Weinstein PR. Changes in transcranial motor evoked potentials during intramedullary spinal cord tumor resection correlate with postoperative motor function. Neurosurgery. 2005;56(5):982–93. https://doi.org/10.1227/01.NEU.0000158203.29369.37.

    Article  PubMed  Google Scholar 

  8. Segura MJ, Talarico ME, Noel MA. A multiparametric alarm criterion for motor evoked potential monitoring during spine deformity surgery. J Clin Neurophysiol. 2017;34(1):38–48. https://doi.org/10.1097/WNP.0000000000000323.

    Article  PubMed  Google Scholar 

  9. MacDonald DB. Overview on criteria for MEP monitoring. J Clin Neurophysiol. 2017;34(1):4–11. https://doi.org/10.1097/WNP.0000000000000302.

    Article  PubMed  Google Scholar 

  10. Biller J, Feinberg WM, Castaldo JE, Whittemore AD, Harbaugh RE, Dempsey RJ, Caplan LR, Kresowik TF, Matchar DB, Toole JF, Easton JD, Adams HP Jr, Brass LM, Hobson RW 2nd, Brott TG, Sternau L. Guidelines for carotid endarterectomy: a statement for healthcare professionals from a Special Writing Group of the Stroke Council, American Heart Association. Circulation. 1998;97(5):501–9. https://doi.org/10.1161/01.CIR.97.5.501.

    Article  CAS  PubMed  Google Scholar 

  11. De Fabritiis A, Conti E, Coccheri S. Management of patients with carotid stenosis. Pathophysiol Haemost Thromb. 2002;32(5–6):381–5. https://doi.org/10.1159/000073605.

    Article  PubMed  Google Scholar 

  12. Deletis V. Intraoperative neurophysiology and methodology for monitoring the motor system. In: Deletis V, Shils J, editors. Neurophysiology in neurosurgery: a modern intraoperative approach. San Diego: Academic Press; 2002. p. 25–51. https://doi.org/10.1016/B978-012209036-3/50004-4.

    Chapter  Google Scholar 

  13. MacDonald DB, Skinner S, Shils J, Yingling C, American Society of Neurophysiological M. Intraoperative motor evoked potential monitoring—a position statement by the American Society of Neurophysiological Monitoring. Clin Neurophysiol. 2013;124(12):2291–316. https://doi.org/10.1016/j.clinph.2013.07.025.

    Article  Google Scholar 

  14. Legatt AD, Emerson RG, Epstein CM, MacDonald DB, Deletis V, Bravo RJ, Lopez JR. ACNS guideline: transcranial electrical stimulation motor evoked potential monitoring. J Clin Neurophysiol. 2016;33(1):42–50. https://doi.org/10.1097/WNP.0000000000000253.

    Article  PubMed  Google Scholar 

  15. Kothbauer K. Motor evoked potential monitoring for intramedullary spinal cord tumor surgery. In: Deletis V, Shils J, editors. Neurophysiology in neurosurgery: a modern intraoperative approach, vol. 1. San Diego: Academic Press; 2002. p. 73–92. https://doi.org/10.1016/B978-012209036-3/50006-8.

    Chapter  Google Scholar 

  16. Szelényi A, Hattingen E, Weidauer S, Seifert V, Ziemann U. Intraoperative motor evoked potential alteration in intracranial tumor surgery and its relation to signal alteration in postoperative magnetic resonance imaging. Neurosurgery. 2010;67(2):302–13. https://doi.org/10.1227/01.NEU.0000371973.46234.46.

    Article  PubMed  Google Scholar 

  17. Szelényi A, BuenodeCamargo A, Flamm E, Deletis V. Neurophysiological criteria for intraoperative prediction of pure motor hemiplegia during aneurysm surgery. Case report. J Neurosurg. 2003;99(3):575–8. https://doi.org/10.3171/jns.2003.99.3.0575.

    Article  PubMed  Google Scholar 

  18. Szelényi A, Langer D, Kothbauer K, De Camargo AB, Flamm ES, Deletis V. Monitoring of muscle motor evoked potentials during cerebral aneurysm surgery: intraoperative changes and postoperative outcome. J Neurosurg. 2006;105(5):675–81. https://doi.org/10.3171/jns.2006.105.5.675.

    Article  PubMed  Google Scholar 

  19. Neuloh G, Schramm J. Monitoring of motor evoked potentials compared with somatosensory evoked potentials and microvascular Doppler ultrasonography in cerebral aneurysm surgery. J Neurosurg. 2004;100(3):389–99. https://doi.org/10.3171/jns.2004.100.3.0389.

    Article  PubMed  Google Scholar 

  20. Langeloo DD, Journee HL, de Kleuver M, Grotenhuis JA. Criteria for transcranial electrical motor evoked potential monitoring during spinal deformity surgery A review and discussion of the literature. Neurophysiol Clin. 2007;37(6):431–9. https://doi.org/10.1016/j.neucli.2007.07.007.

    Article  PubMed  Google Scholar 

  21. Jones SJ, Harrison R, Koh KF, Mendoza N, Crockard HA. Motor evoked potential monitoring during spinal surgery: responses of distal limb muscles to transcranial cortical stimulation with pulse trains. Electroencephalogr Clin Neurophysiol. 1996;100:375–83. https://doi.org/10.1016/0168-5597(96)95728-7.

    Article  CAS  PubMed  Google Scholar 

  22. van Dongen EP, ter Beek HT, Schepens MA, Morshuis WJ, Langemeijer HJ, de Boer A, Boezeman EH. Within-patient variability of myogenic motor-evoked potentials to multipulse transcranial electrical stimulation during two levels of partial neuromuscular blockade in aortic surgery. Anesth Analg. 1999;88(1):22–7. https://doi.org/10.1097/00000539-199901000-00005.

    Article  PubMed  Google Scholar 

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There were no funding sources supporting this study or the writing of this manuscript.

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Author notes

  1. Michael J. Malcharek and Judith Hesse have contributed equally as first authors of this work.

Authors and Affiliations

  1. Division of Neuroanesthesia & Intraoperative Neuromonitoring, Department of Anesthesia, Intensive Care and Pain Therapy, Klinikum St. Georg gGmbH, Delitzscher Str. 141, 04129, Leipzig, Germany

    Michael J. Malcharek, Judith Hesse, Kristin Hesselbarth, Armin Sablotzki & Jochen Gille

  2. Research & Development, inomed Medizintechnik GmbH, Im Hausgrün 29, 79312, Emmendingen, Germany

    Kathrin Thoma & Celine Wegner

  3. Department of Vascular Surgery, Klinikum St. Georg gGmbH, Delitzscher Str. 141, 04129, Leipzig, Germany

    Gert Hennig

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  1. Michael J. Malcharek
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Correspondence to Michael J. Malcharek.

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Kathrin Thoma and Celine Wegner are employees of inomed Medizintechnik GmbH, Im Hausgrün 29, 79312 Emmendingen, Germany. There are no other patents, products in development or other marketed products to declare. This does not alter the authors’ adherence to all the PLoS ONE policies on sharing data and materials. No other authors have potential conflicts of interest to be disclosed.

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Malcharek, M.J., Hesse, J., Hesselbarth, K. et al. Warning criteria for MEP monitoring during carotid endarterectomy: a retrospective study of 571 patients. J Clin Monit Comput 34, 589–595 (2020). https://doi.org/10.1007/s10877-019-00345-5

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  • DOI: https://doi.org/10.1007/s10877-019-00345-5

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