Skip to main content
SpringerLink
Log in

Evoked potential monitoring and temporary clipping in cerebral aneurysm surgery

  • Clinical Articles
  • Published:
Acta Neurochirurgica Aims and scope Submit manuscript

Summary

Temporary occlusion of the parent artery greatly facilitates the dissection of large cerebral aneurysms, while much reducing the risk of intraoperative rupture and avoiding the use of profound arterial hypotension. Intraoperative somatosensory evoked potential (SEP) monitoring was carried out in 25 aneurysm cases where temporary clipping was employed electively under moderate hypothermia. Occlusion times ranged from 6.3 to 52 minutes at 28.7 ‡C to 32.5 ‡C.

Among 15 middle cerebral artery (MCA) occlusion cases the SEP was lost within 5 or 6 minutes in two cases undergoing early surgery and in one case with marked vasospasm and was lost within 9 minutes in one case with pre-existing infarction in the territory of the MCA. The SEP persisted throughout MCA occlusion periods of 6.3 to 52 minutes in 8 cases. Occlusion of parent arteries of unruptured aneurysms was well tolerated. At least 2 minutes of MCA occlusion after loss of the SEP were tolerated without neurological sequelae, while transient new deficits were seen when MCA occlusion was continued for 4 and for 4 + 11 minutes and an increased deficit was seen when occlusion was continued for 7 minutes after loss of the SEP.

In each of the internal carotid artery (ICA) occlusion and bilateral anterior cerebral artery occlusion groups the SEP was lost in one case and was absent for about one minute before reperfusion was instituted. The ICA case had a transient deficit lasting about 4 hours; no other complications were seen in these two groups. Complications were not seen in any case where the SEP was not lost during the occlusion period.

Factors affecting collateral perfusion and possible means of increasing tolerance to ischaemia in this situation are discussed. It is concluded that: 1. appropriate SEP monitoring is of value in avoiding sequelae to temporary cerebral arterial occlusion; 2. patients at high risk from ischaemic damage during temporary occlusion include those subjected to early surgery, those in Hunt and Hess's grade III and those who had a neurological deficit at the time of subarachnoid haemorrhage; and 3. hypothermia allows longer occlusion times than at normothermia with a low morbidity and deserves reappraisal for use in this situation.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Astrup J, Symon L, Branston NM, Lassen NA (1977) Cortical evoked potential and extracellular K+ and H+ at critical levels of brain ischemia. Stroke 8: 51–57

    PubMed  Google Scholar 

  2. Astrup J, Siesjö BK, Symon L (1981) Thresholds in cerebral ischemia — the ischemic penumbra. Stroke 12: 723–725

    PubMed  Google Scholar 

  3. Batjer H, Samson D (1986) Intraoperative aneurysmal rupture: incidence, outcome and suggestions for surgical management. Neurosurgery 18: 701–706

    PubMed  Google Scholar 

  4. Belopavlovic M, Buchthal A (1985) Barbiturates for cerebral aneurysm surgery. Acta Neurochir (Wien) 76: 73–81

    Google Scholar 

  5. Botterell EH, Lougheed WM, Scott JW, Vandewater SL (1956) Hypothermia and interruption of carotid, or carotid and vertebral circulation, in the surgical management of intracranial aneurysms. J Neurosurg 13: 1–41

    PubMed  Google Scholar 

  6. Branston NM, Ladds A, Symon L, Wang A-D (1984) Comparison of the effects of ischemia on the early components of the somatosensory evoked potential in brainstem, thalamus and cerebral cortex. J Cereb Blood Flow Metab 4: 68–81

    PubMed  Google Scholar 

  7. Branston NM, Strong AJ, Symon L (1977) Extracellular potassium activity, evoked potential and tissue blood flow. J Neurol Sci 32: 305–321

    PubMed  Google Scholar 

  8. Branston NM, Symon L, Crockard HA (1976) Recovery of the cortical evoked response following temporary middle cerebral artery occlusion in baboons: relation to local blood flow and pO2. Stroke 7: 151–157

    PubMed  Google Scholar 

  9. Branston NM, Symon L, Crockard HA, Pasztor E (1974) Relationship between the cortical evoked potential and local cortical blood flow following acute middle cerebral artery occlusion in the baboon. Exp Neurol 45: 195–208

    PubMed  Google Scholar 

  10. Brown SC, Lam AM, Manninen PH (1986) Monitoring somatosensory evoked potentials in man during isoflurane and isoflurane-nitrous oxide anaesthesia. Can Anaesth Soc J 33: 580

    Google Scholar 

  11. Farrar JK, Gamache FW, Ferguson GG, Barber J, Varkey GP, Drake CG (1981) Effects of profound hypotension on cerebral blood flow during surgery for intracranial aneurysms. J Neurosurg 55: 857–864

    PubMed  Google Scholar 

  12. Greenberg IM (1984) Cerebral aneurysm rupture during neurosurgery. Neurosurgery 15: 243–245

    PubMed  Google Scholar 

  13. Hoff JT, Pitts LH, Spetzler R, Wilson CB (1977) Barbiturates for protection from cerebral ischemia in aneurysm surgery. Acta Neurol Scand [Suppl] 64: 158–159

    Google Scholar 

  14. Hume AL, Cant BR (1978) Conduction time in central somatosensory pathways in man. Electroenceph Clin Neurophysiol 45: 361–375

    PubMed  Google Scholar 

  15. Hume AL, Cant BR, Shaw NA (1979) Central somatosensoryvconduction time in comatose patients. Ann Neurol 5: 379–384

    PubMed  Google Scholar 

  16. Hume AL, Durkin MA (1986) Central and spinal somatosensory conduction times during hypothermie cardiopulmonary bypass and some observations on the effects of fentanyl and isoflurane anesthesia. Electroenceph Clin Neurophysiol 65: 46–58

    PubMed  Google Scholar 

  17. Hunt WE, Hess RM (1968) Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg 28: 14–20

    PubMed  Google Scholar 

  18. Jabre A, Symon L (1987) Temporary vascular occlusion during aneurysm surgery. Surg Neurol 27: 47–63

    PubMed  Google Scholar 

  19. Jones TH, Morawetz RB, Crowell RM, Marcoux FW, Fitz-Gibbon SJ, DeGirolami U, Ojemann RG (1981) Thresholds of focal cerebral ischemia in awake monkeys. J Neurosurg 54: 773–782

    PubMed  Google Scholar 

  20. Kidooka M, Nakasu Y, Watanabe K, Matsuda M, Hauda J (1987) Monitoring of somatosensory evoked potentials during aneurysm surgery. Surg Neurol 27: 69–76

    PubMed  Google Scholar 

  21. Lam AM, Manninen PH, Contreras J, Diamond C, Kutt JL, Penny F (1986) Monitoring of somatosensory evoked responses during cardiopulmonary bypass — the influence of temperature. Anesth Analg 65: S 85

    Google Scholar 

  22. Lesnick JE, Michele JJ, Simeone FA, DeFeo S, Welsh FA (1984) Alterations of somatosensory evoked potentials in response to global ischemia. J Neurosurg 60: 490–494

    PubMed  Google Scholar 

  23. Ljunggren B, SÄveland H, Brandt L, Kagström E, Rehncrona S, Nilsson PE (1983) Temporary clipping during early operation for ruptured aneurysm: preliminary report. Neurosurgery 12: 525–530

    PubMed  Google Scholar 

  24. McPherson RS, Mahla M, Johnson R, Traystman RJ (1985) Effects of enflurane, isoflurane and nitrous oxide on somatosensory evoked potentials during fentanyl anesthesia. Anesthesiology 62: 626–633

    PubMed  Google Scholar 

  25. Markand ON, Warren CH, Moorthy SS, Stoelting RK, King RD (1984) Monitoring of multimodal evoked potentials during open heart surgery under hypothermia. Electroenceph Clin Neurophysiol 59: 432–440

    PubMed  Google Scholar 

  26. Marsh WR, Anderson RE, Sundt TM (1986) Effect of hyperglycemia on brain pH levels in areas of focal incomplete ischemia in monkeys. J Neurosurg 65: 693–696

    PubMed  Google Scholar 

  27. Meyer JS (1958) Circulatory changes following occlusion of the middle cerebral artery and their relation to function. J Neurosurg 15: 653–673

    PubMed  Google Scholar 

  28. Momma F, Wang A-D, Symon L (1987) Effects of temporary arterial occlusion on somatosensory evoked responses in aneurysm surgery. Surg Neurol 27: 343–352

    PubMed  Google Scholar 

  29. Mooij JJA, Buchthal A, Belopavlovic M (1987) Somatosensory evoked potential monitoring in temporary middle cerebral artery occlusion during aneurysm surgery. Neurosurgery 21: 492–496

    PubMed  Google Scholar 

  30. Nakagawa Y, Ohtsuka K, Tsuru M, Nakamura N (1984) Effects of mild hypercapnia on somatosensory evoked potentials in experimental cerebral ischemia. Stroke 15: 275–278

    PubMed  Google Scholar 

  31. Pasch T, Huk W (1986) Cerebral complications following induced hypotension. Eur J Anaesthesiol 3: 299–312

    PubMed  Google Scholar 

  32. Pathak KS, Brown RH, Cascorbi HF, Nash CL (1984) Effects of fentanyl and morphine on intraoperative cortical-evoked potentials. Anesth Analg 63: 833–837

    PubMed  Google Scholar 

  33. Peterson DO, Drummond JC, Todd MM (1986) Effects of halothane, enflurane, isoflurane and nitrous oxide on somatosensory evoked potentials in humans. Anesthesiology 65: 35–40

    PubMed  Google Scholar 

  34. Pool JL (1961) Aneurysms of the anterior communicating artery: bifrontal craniotomy and routine use of temporary clips. J Neurosurg 18: 98–111

    PubMed  Google Scholar 

  35. Ralston B, Rasmussen T, Kennedy T (1955) Occlusion of the middle cerebral artery under normotension and anemically induced and chemically induced hypotension. J Neurosurg 12: 26–33

    PubMed  Google Scholar 

  36. Rosomoff HL, Holaday DA (1964) Cerebral blood flow and cerebral oxygen consumption during hypothermia. Am J Physiol 195: 85–88

    Google Scholar 

  37. Sebel PS, Ingram DA, Flynn PJ, Rutherford CF, Rogers H (1986) Evoked potentials during isoflurane anesthesia. Br J Anaesth 58: 580–585

    PubMed  Google Scholar 

  38. Selman WR, Spetzler RF, Roessmann UR, Rosenblatt JI, Crumrine R (1981) Barbiturate-induced coma for focal cerebral ischemia. Effect after temporary and permanent middle cerebral artery occlusion. J Neurosurg 55: 220–226

    PubMed  Google Scholar 

  39. Selman WR, Spetzler RF, Roessmann U, Crumrine R, Macko R (1982) Barbiturate coma in focal cerebral ischemia. Relationship of protection to timing of therapy. J Neurosurg 56: 685–690

    PubMed  Google Scholar 

  40. Spetzler RF, Selman WR, Weinstein P, Townsend J, Mehdorn M, Tellos D, Crumrine RC, Macko R (1980) Chronic reversible cerebral ischemia: evaluation of a new baboon model. Neurosurgery 7: 257–261

    PubMed  Google Scholar 

  41. Sullivan HG, Keenan RL, Isrow L, Feria WA (1980) The critical importance of paCO2 during intracranial aneurysm surgery. J Neurosurg 52: 426–430

    PubMed  Google Scholar 

  42. Suzuki J, Fujimoto S, Mizoik, Oba M (1984) The protective effect of combined administration of antioxidants and perfluorochemicals on cerebral ischemia. Stroke 15: 672–679

    PubMed  Google Scholar 

  43. Suzuki J, Yoshimato T (1979) The effect of mannitol in prolongation of permissible occlusion time of cerebral artery-clinical data of aneurysm surgery. Neurosurgery 1: 13–19

    Google Scholar 

  44. Suzuki J, Yoshimoto T, Kayama T (1984) Surgical treatment of middle cerebral artery aneurysms. J Neurosurg 61: 17–23

    PubMed  Google Scholar 

  45. Symon L (1978) Disordered cerebrovascular physiology in aneurysmal subarachnoid haemorrhage. Acta Neurochir (Wien) 41: 7–22

    Google Scholar 

  46. Symon L (1984) Surgical experiences with intracranial aneurysms. J Neurosurg 61: 1009–1029

    PubMed  Google Scholar 

  47. Symon L, Branston NM, Strong AJ, Hope TD (1977) The concepts of thresholds of ischaemia in relation to brain structure and function. J Clin Path 30 [Suppl] 11: 149–154

    Google Scholar 

  48. Symon L, Hargadine J, Zawirski M, Branston NM (1979) Central conduction time as an index of ischaemia in subarachnoid haemorrhage. J Neurol Sci 44: 95–103

    PubMed  Google Scholar 

  49. Symon L, Wang A-D, Costae Silva IE, Gentili F (1984) Perioperative use of somatosensory evoked responses in aneurysm surgery. J Neurosurg 60: 269–275

    PubMed  Google Scholar 

  50. Umansky F, Gomes B, Dujovny M, Diaz FG, Ausman JI, Mirchandani HG, Berman SK (1985) The perforating branches of the middle cerebral artery. J Neurosurg 62: 261–268

    PubMed  Google Scholar 

  51. Wang AD-J, Costae Silva IE, Symon L, Jewkes D (1985) The effects of halothane on somatosensory and flash visual evoked potentials during operations. Neurol Res 7: 58–62

    PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Kliniek voor Neuro-Chirurgie, Academisch Ziekenhuis, Groningen, The Netherlands

    A. Buchthal FFARCS, MA (Oxon), M. Belopavlovic & J. J. A. Mooij

Authors
  1. A. Buchthal FFARCS, MA (Oxon)
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. M. Belopavlovic
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. J. J. A. Mooij
    View author publications

    You can also search for this author in PubMed Google Scholar

Rights and permissions

Reprints and permissions

About this article

Cite this article

Buchthal, A., Belopavlovic, M. & Mooij, J.J.A. Evoked potential monitoring and temporary clipping in cerebral aneurysm surgery. Acta neurochir 93, 28–36 (1988). https://doi.org/10.1007/BF01409899

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/BF01409899

Keywords

Search

Navigation