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Objective: To determine the utility of electroencephalography (EEG) in predicting postoperative delirium (POD) in patients who underwent cardiovascular surgeries with EEG monitoring., Methods: A total of 1161 patients who underwent cardiovascular surgeries with EEG monitoring were included in the study, and their data were retrospectively reviewed. POD assessment was done utilizing Intensive Care Delirium Screening Checklist (ICDSC). Patients with a score of > 4 on ICDSC were diagnosed with POD., Results: Of 1161 patients, 131 patients had EEG changes and 56 (42.74%) of 131 patients experienced POD. Of 1030 patients without EEG changes, 219 (21.26%) experienced POD. EEG showed specificity of 91.5% and negative predictive value of 78.7% in detecting POD. On multivariable analysis, EEG changes showed a strong association with POD (OR adj 1.97 CI (1.30-2.99), p = 0.001) with persistent EEG changes showing even a higher risk of developing POD (OR adj 2.65 (1.43-4.92), p = 0.002)., Conclusion: EEG change has specificity of 91.5% emphasizing the need for its implementation as a diagnostic tool for predicting POD. Patients with POD are two times more likely to experience significant EEG changes, especially persistent EEG changes when undergoing cardiovascular surgeries., Significance: Intraoperative EEG can detect POD, and EEG changes based therapeutic interventions can mitigate POD., (Copyright © 2024 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. All rights reserved.)

Objective: To evaluate the diagnostic accuracy of intraoperative neurophysiological monitoring (IONM) during endovascular treatment (EVT) of ruptured intracranial aneurysms (rIA)., Methods: IONM and clinical data from 323 patients who underwent EVT for rIA from 2014-2019 were retrospectively reviewed. Significant IONM changes and outcomes were evaluated based on visual review of data and clinical documentation., Results: Of the 323 patients undergoing EVT, significant IONM changes were noted in 30 patients (9.29%) and 46 (14.24%) experienced postprocedural neurological deficits (PPND). 22 out of 30 (73.33%) patients who had significant IONM changes experienced PPND. Univariable analysis showed changes in somatosensory evoked potential (SSEP) and electroencephalogram (EEG) were associated with PPND (p-values: <0.001 and <0.001, retrospectively). Multivariable analysis showed that IONM changes were significantly associated with PPND (Odd ratio (OR) 20.18 (95%CI:7.40-55.03, p-value: <0.001)). Simultaneous changes in both IONM modalities had specificity of 98.9% (95% CI: 97.1%-99.7%). While sensitivity when either modality had a change was 47.8% (95% CI: 33.9%-62.0%) to predict PPND., Conclusions: Significant IONM changes during EVT for rIA are associated with an increased risk of PPND., Significance: IONM can be used confidently as a real time neurophysiological diagnostic guide for impending neurological deficits during EVT treatment of rIA., (Copyright © 2024 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. All rights reserved.)

Background: Perioperative stroke after cardiac surgical procedures carries significant morbidity. Dual intraoperative neurophysiological monitoring with electroencephalography (EEG) and somatosensory-evoked potentials detects cerebral hypoperfusion and predicts postoperative stroke in noncardiac procedures. We further evaluated preoperative risk factors and intraoperative neuromonitoring ability to predict postoperative stroke after cardiac operations., Methods: All patients who underwent cardiac operations with intraoperative neurophysiological monitoring from 2009 to 2020 at a single academic medical center were retrospectively analyzed. Patients with circulatory arrest were excluded. Risks factors analyzed were sex, age, tobacco use, hypertension, diabetes mellitus, dyslipidemia, atrial fibrillation, prior cerebrovascular accident, cerebrovascular disease, antiplatelet/anticoagulant use, abnormal somatosensory-evoked potentials and EEG baselines, and significant somatosensory-evoked potentials and EEG change as well as their permanence. Patients were divided into 2 groups by 30-day postoperative stroke occurrence. Univariate and multivariate logistical regressions were used for postoperative stroke significant predictors, and Kaplan-Meier curves estimated survival., Results: The study included 620 patients (67.6% men), mean age 65.1 ± 14.1 years, with stroke in 5.32%. In univariate analysis, diabetes (odds ratio [OR], 2.62) and permanence of EEG change (OR, 5.35) were each associated with increased postoperative stroke odds. In multivariate analysis, diabetes (OR, 2.64) and permanent EEG change (OR, 4.22) were independently significantly associated with postoperative stroke. Overall survival was significantly better for patients with no intraoperative neurophysiological monitoring changes (P < .005)., Conclusions: Permanent EEG change and diabetes were significant postoperative stroke predictors in cardiac operations. Furthermore, overall survival out to 10 years postoperatively was significantly higher in the group without intraoperative neurophysiological monitoring changes, emphasizing its important predictive role., (Copyright © 2023 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Transient ischemic attacks (TIA) after carotid endarterectomy (CEA) are not well-studied. We aimed to investigate the characteristics and the predictive role of intraoperative neurophysiological monitoring (IONM) in TIA post-CEA., Methods: Patients who underwent CEA utilizing IONM from 2009-2020 were included. Analyses included TIA incidence, sensitivity, specificity, and predictive values of IONM, risk factor regression analyses, and mortality Kaplan Meier plots., Results: Out of 2232 patients, 46 experienced TIA, 14 of which were within 24 hours of CEA (p < 0.01). Nine of these patients displayed significant IONM changes during CEA. The odds of TIA increased with somatosensory evoked potential (SSEP) changes (Odds Ratio (OR): 2.48 95% Confidence Interval (CI): 1.14-5.4), electroencephalogram (EEG) changes (OR: 2.65 95% CI: 1.22-5.77), and combined SSEP/EEG changes (OR: 2.98 95% CI: 1.17-7.55). Patients with TIA were less likely to be alive after an average of 4.3 years (OR: 0.5 95% CI: 0.26-0.96)., Conclusions: The odds a patient will have TIA post-CEA are greater in patients with IONM changes. This risk is inversely related to the time post-CEA., Significance: Changes in IONM during CEA predict postoperative TIA. Post-CEA TIA may increase long-term mortality, thus further research is needed to better elucidate clinical implications of postoperative TIA., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. All rights reserved.)

Objective: We examined significant intraoperative neurophysiologic monitoring (IONM) changes and perioperative stroke as independent risk factors of long-term cardiovascular-related mortality in patients who have undergone carotid endarterectomy (CEA)., Methods: Records of patients who underwent CEA with IONM at the University of Pittsburgh Medical Center between January 1, 2009 and December 31, 2019 were analyzed retrospectively. Cardiovascular-related mortality was compared between the significant IONM change group and no IONM change group and between the perioperative stroke group and no perioperative stroke group., Results: Our final cohort consisted of 2,090 patients. Patients with significant IONM changes showed nearly twice the rate of cardiovascular-related mortality up to 10 years post-CEA (hazard ratio (HR) = 1.98; 95% confidence interval (CI) [1.20 - 3.26]). Patients with perioperative stroke were four times more likely than patients without perioperative stroke to experience cardiovascular-related mortality (HR = 4.09; 95% CI [2.13 - 7.86])., Conclusions: Among CEA patients who underwent CEA and who experienced significant IONM changes or perioperative stroke, we observed long-term increased and sustained risk of cardiovascular-related mortality., Significance: Significant IONM changes are valuable in predicting the risk of long-term outcomes following CEA., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. All rights reserved.)

Objective: Previous studies have shown that pedicle screw stimulation thresholds ≤6-8 mA yield a high diagnostic accuracy of detecting misplaced screws. Our objective was to determine the optimal "low" stimulation threshold to predict new postoperative neurologic deficits and identify additional risk factors associated with deficits., Methods: We included patients with complete pedicle screw stimulation testing who underwent posterior lumbar spinal fusion surgeries from 2010-2012. We calculated the diagnostic accuracy of pedicle screw responses of ≤4 mA, ≤6 mA, ≤8 mA, ≤10 mA, ≤12 mA, and ≤20 mA to predict new postoperative lower-extremity (LE) neurologic deficits. We used multivariate modeling to determine the best logistic regression model to predict LE deficits and identify additional risk factors. Statistics software packages used were Python3.8.5, NumPy 1.19.1, Pandas 1.1.1, and SPSS26., Results: We studied 1179 patients who underwent 8584 pedicle screw stimulations with somatosensory evoked potential and free-run electromyographic monitoring for posterior lumbar spinal fusion. Twenty-five (2.1%) patients had new LE neurologic deficits. A stimulation threshold of ≤8 mA had a sensitivity/specificity of 32%/90% and a diagnostic odds ratio/area under the curve of 4.34 [95% confidence interval: 1.83, 10.27]/0.61 [0.49, 0.74] in predicting postoperative deficit. Multivariate analysis showed that patients who had pedicle screws with stimulation thresholds ≤8 mA are 3.15 [1.26, 7.83]× more likely to have postoperative LE deficits while patients who have undergone a revision lumbar spinal fusion surgery are 3.64 [1.38, 9.61]× more likely., Conclusions: Our results show that low thresholds are indicative of not only screw proximity to the nerve but also an increased likelihood of postoperative neurologic deficit. Thresholds ≤8 mA prove to be the optimal "low" threshold to help guide a correctly positioned pedicle screw placement and detect postoperative deficits., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: In the present study, we investigated the role of intraoperative neuromonitoring (IONM) in internal carotid artery (ICA) injury during endoscopic endonasal skull base surgery (EESBS)., Methods: The study group included all 13 patients who had experienced an ICA injury during EESBS with IONM from 2004 to 2017. The medical records were reviewed for the perioperative data. The IONM reports were reviewed to evaluate the baseline somatosensory evoked potentials (SSEP), electroencephalography (EEG), and brainstem auditory evoked potentials (BAEP) and their significant changes related to ICA injury and/or the subsequent surgical/endovascular interventions., Results: All 13 patients had undergone SSEP and 7 patients had BAEP monitoring during surgery. EEG was added during emergent angiography following the surgery for 5 patients. Two patients showed significant SSEP changes, and one showed significant SSEP and EEG changes, indicating cerebral hypoperfusion. Of these 3 patients, patient 1 had experienced irreversible SSEP loss with postoperative stroke. Patients 2 and 3 had SSEP and/or EEG changes that had recovered to baseline after interventions without postoperative deficits. Despite ICA injury, 10 patients showed no significant SSEP and/or EEG changes, and all 7 patients with BAEP monitoring showed no significant BAEP changes, indicating adequate cerebral and brainstem perfusion, respectively. The injured ICA was sacrificed in 4 patients, of whom 3 showed stable SSEP and 1 had experienced irreversible SSEP loss. IONM correlated with the postoperative neurologic examination findings in all cases, adequately predicting the neurologic outcomes after ICA injury., Conclusion: SSEP and EEG monitoring can accurately detect cerebral hypoperfusion and provide real-time feedback during surgery. SSEP and EEG changes predicted for neurologic outcomes and guide surgical decisions regarding the preservation or sacrifice of the ICA. Comprehensive multimodality monitoring according to the surgical risks can serve to detect and guide the management of ICA injury in EESBS., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objectives: We assessed whether significant intraoperative electroencephalography (EEG) changes have predictive value for perioperative stroke within 30 days after carotid endarterectomy (CEA) procedures for carotid stenosis (CS) patients. We also assessed the diagnostic accuracy of various EEG changes in predicting perioperative stroke., Methods: We searched databases for reports with outcomes of CS patients who underwent CEA with intraoperative EEG monitoring. We calculated the sensitivity, specificity, and diagnostic odds ratio (DOR) of EEG changes for predicting perioperative stroke. Sensitivity and specificity were presented with forest plots and a summary receiver operating characteristic (ROC) curve., Results: The meta-analysis included 10,672 patients. Intraoperative EEG changes predicted 30-day stroke with a sensitivity of 46% (95% CI, 38-54%) and specificity of 86% (95% CI, 83-88%). The estimated DOR was 5.79 (95% CI, 3.86-8.69). The estimated DOR for reversible and irreversible EEG changes were 8.25 (95% CI, 3.34-20.34) and 70.84 (95% CI, 36.01-139.37), respectively., Conclusion: Intraoperative EEG changes have high specificity but modest sensitivity for predicting perioperative stroke following CEA. Patients with irreversible EEG changes are at high risk for perioperative stroke., Significance: Intraoperative EEG changes can help surgeons predict the risk of perioperative stroke for CS patients following CEA., Competing Interests: Declaration of Competing Interest None of the authors have potential conflicts of interest to be disclosed., (Copyright © 2020 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. All rights reserved.)

Background: Complete aneurysm obliteration is the goal of aneurysm treatment. In selected cases, a neck remnant may be left to preserve a critical branch. Literature on ophthalmic artery sacrifice in the treatment of cerebral aneurysms and subsequent risk of vision loss is limited., Case Description: Herein, we describe 2 cases where the ophthalmic artery originated from the aneurysm dome, resulting in a situation where we either incompletely obliterate the aneurysm or sacrifice the ophthalmic artery in order to completely clip the lesion, risking visual function., Conclusions: We report for the first time the use of visual evoked potential monitoring and intraoperative awakening to test visual function following intentional ophthalmic artery sacrifice to demonstrate gross vision preservation., (Copyright © 2020. Published by Elsevier Inc.)

Background: Iatrogenic spinal cord injury (iSCI) during spinal corrective surgery can result in devastating complications, such as paraplegia or paraparesis. Perioperatively, iSCI often occurs as a direct injury during spinal cord instrumentation placement. Currently, treatment of iSCI remains limited to posttraumatic hypothermia, which has demonstrated some value in recent clinical trials. Here we report the outcomes of preinjury hypothermia initiated preprocedurally and maintained for a considerable time after iSCI., Methods: Twenty-six female Sprague-Dawley rats were assigned at random to either a normothermic group (36 °C) or a hypothermic group (32 °C) and then underwent a laminectomy procedure at the T8 level. Each group was further divided at random to receive a 200-kdyn force contusive spinal cord injury or a sham impact. Hypothermic rats were then rewarmed after 2 hours of hypothermic treatment. Behavioral scores, temperature profiles, weights, and somatosensory evoked potentials were obtained at baseline and at specified time points after the procedure., Results: The median survival was 42 days for the iSCI hypothermic group and 11 days for the iSCI normothermic group (hazard ratio, 3.82; 95% confidence interval, 1.52-9.57). The probability of survival was significantly higher in the iSCI hypothermic group compared with the iSCI normothermic group (χ 2  = 4.18; P = 0.040). The hypothermic group exhibited a higher Basso, Beattie and Bresnahan (BBB) locomotor rating scale score (17 vs. 14; P < 0.01), lower normalized latencies (1.06 ± 0.16 seconds vs. 1.34 ± 0.17 seconds; P = 0.04), and higher peak-to-peak amplitudes (0.32 ± 0.10 μV vs. 0.12 ± 0.09 μV; P = 0.005)., Conclusions: The use of prophylactic hypothermia before iSCI was significantly associated with an increased survival rate, higher BBB scores, and improved neurophysiological measures., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: Somatosensory evoked potentials (SSEPs) have proven useful as an intraoperative modality to predict perioperative stroke during carotid endarterectomy (CEA). However, the predictive value of SSEPs for predicting stroke 30 days postoperatively remains unclear. The primary objective is to evaluate the efficacy of intraoperative SSEP change in predicting the risk of stroke in the postoperative period beyond 24 h but within 30 days. Our secondary aim is to evaluate the predictive value of each subcategory of SSEP change., Methods: We performed a meta-analysis of 25 prospective/retrospective studies from PubMed, Web of Science, and Embase regarding SSEP monitoring for postoperative outcomes in symptomatic and asymptomatic CEA patients., Results: A 8307-patient cohort composed the total sample population, of which 54.17% had symptomatic CS. For SSEP change and stroke greater than 24 h but within 30 days, the diagnostic odds ratio was 8.68. The diagnostic odds ratio was 3.88 for transient SSEP change and stroke; 49.29 for persistent SSEP change and stroke; 36.45 for transient SSEP loss and stroke; and 281.35 for persistent SSEP loss and stroke., Conclusions: Patients with SSEP changes are at increased risk of perioperative stroke within the entire 30-day period. There is a noticeable step-wise increase in the predicted risk of stroke with the severity of SSEP changes., Significance: SSEP changes can serve as a predictor for 30-day perioperative stroke during CEA., (Copyright © 2018. Published by Elsevier B.V.)

Objective: The efficacy of selective shunting during carotid endarterectomy (CEA) using intraoperative monitoring (IOM) for detection of cerebral ischemia is well established. There is mounting evidence that monitoring of both electroencephalography (EEG) and somatosensory evoked potentials (SSEPs) increases the sensitivity of cerebral ischemia detection. Predictors of cerebral ischemia requiring selective shunt placement using IOM of both EEG and SSEPs have not been previously identified., Methods: Consecutive patients who underwent CEA between January 1, 2000, and December 31, 2010, were retrospectively analyzed. Primary end points were IOM changes at any time during the operation or IOM changes with carotid cross-clamping. Risk factors assessed included demographics; baseline comorbidities; severity of ipsilateral and contralateral disease; symptomatic status; and use of statin, antiplatelet, and beta-blocker medications. Univariate and multivariate logistic regression was used for analysis., Results: During the 11-year study period, a total of 758 patients underwent 804 CEAs (mean age, 70.6 ± 9.5 years; 59.8% male; 39.2% symptomatic) using IOM of both SSEPs and EEG for selective shunting guidance. Postoperative stroke rate was 1.37%; 27.1% of patients had significant SSEP or EEG changes, and 49.1% of these were clamp induced (within 5 minutes of cross-clamping). Of these patients, 83.2% received a shunt (11.4% overall). The most common reason that a shunt was not placed after cross-clamp-induced changes was that the changes resolved with further blood pressure elevation (8 of 17 patients). Clamp-induced IOM changes were predictive of postoperative stroke (odds ratio [OR], 5.5; P = .005). Risk factors for clamp-induced IOM changes were contralateral carotid occlusion (OR, 2.5; P = .01), symptomatic stenosis (OR, 1.8; P = .006), and diabetes (OR, 1.6; P = .03), whereas there was a trend toward increased risk with female sex (OR, 1.5; P = .08). Risk factors for any IOM change (clamp and nonclamp induced) were symptomatic carotid stenosis (OR, 1.8; P < .001), use of beta blockers (OR, 1.5; P = .03), and female sex (OR, 1.5; P = .02)., Conclusions: Whereas some patients can be expected to experience IOM changes by monitoring of SSEPs and EEG, a much smaller percentage will receive a shunt. Contralateral carotid occlusion, symptomatic stenosis, diabetes, and female sex increase the risk of clamp-induced IOM changes and should be anticipated to need a shunt. Patients receiving beta blockers are likely to experience IOM changes during the operation that are not associated with clamping., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Temporary arterial occlusion (TAO) is valuable for minimizing intraoperative rupture risk during intracranial aneurysm microsurgery; however, it may be associated with ischemic injury. This study aims to identify surgical and intraoperative neurophysiologic monitoring factors that predict perioperative stroke risk after TAO., Methods: We performed a retrospective chart review of 177 intracranial aneurysm surgeries at our institution in which TAO was performed before placement of a permanent clip under monitoring with somatosensory evoked potentials (SSEPs) and electroencephalography. Perioperative stroke was defined as a new-onset neurologic deficit that developed within 24 hours postoperatively that was correlated with hypodensity on postoperative computed tomography., Results: Ten (6%) patients developed perioperative stroke in the vascular territory of TAO. SSEP changes were observed in 50% (5/10) of patients with perioperative stroke and in 14% (24/167) of patients without stroke (P = 0.003). Mean maximum single-episode TAO duration for patients who developed perioperative stroke was 12.6 minutes (95% confidence interval 8.1-17.1) and TAO duration for patients without stroke was 8.0 minutes (95% confidence interval 7.3-8.7; P = 0.026). In patients with SSEP changes, risk of stroke was particularly elevated with unruptured aneurysms (P = 0.013) compared with patients with ruptured aneurysms. Temporary clip location, number of occlusive episodes, onset and duration of intraoperative neurophysiologic monitoring changes, and rupture status were not predictive of perioperative stroke., Conclusions: SSEP changes and increased single-episode TAO duration are independently associated with increased perioperative stroke risk. SSEP changes are most predictive for perioperative stroke in unruptured cases., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Backgrond: Late stroke and death rates are anticipated to be higher in patients undergoing carotid endarterectomy (CEA) compared with healthy counterparts. However, little is known regarding predictors other than the baseline comorbidities. We have recently shown that dual intraoperative somatosensory evoked potentials (SSEPs) and electroencephalography (EEG) monitoring improves the ability to predict perioperative strokes. We seek to determine if dual intraoperative monitoring (IOM) can further predict long-term strokes and death., Methods: Consecutive patients who underwent CEA under dual SSEP and EEG IOM between January 1, 2000 and December 31, 2010 were analyzed. Patients were divided in 2 groups, those with and those without IOM changes. IOM changes were classified as either occurring during carotid cross-clamp placement or at any time during the operation. End points were time to stroke and death. Log-rank tests and Cox regression analysis were used to identify predictors of postoperative stroke and death., Results: A total of 853 CEAs (mean age 70.6 ± 9.5 years, 58.7% male, 38.9% symptomatic) were performed during the study period with a mean clinical follow-up of 48 ± 38 months. One hundred seven patients (13.6%) had significant SSEP or EEG changes at the time of clamping, while considerably more patients (217, 25.4%) had SSEP and/or EEG changes recorded at any point during the procedure, including clamping. Baseline characteristics including rates of bilateral disease, statin use, and antiplatelet use were similar between groups. Female gender, symptomatic disease, and significant contralateral carotid stenosis were more frequent in the group with IOM changes. The overall stroke-free survival rate at 5 years was significantly higher in patients without IOM changes (94.7% vs. 88.2%, P < 0.05) and at 10 years (86.1% vs. 78.0%, P < 0.05). Despite differences in stroke-free survival, overall survival at 10 years was not different between groups (44.0% in patients with IOM changes vs. 42.8% in patients without, P = 0.7). Renal insufficiency (hazards ratio [HR] 2.13, P = 0.03), diabetes (HR 1.84, P = 005), and age > 80 at the time of operation (HR 3.24, P = 0.001) were significant predictors of late stroke, while statins were significantly protective (HR 0.55, P = 0.05). Controlling for these factors, IOM changes (HR 2.5, P = 0.004) were a strong predictor of long-term risk of stroke after CEA., Conclusion: Intraoperative SSEP and/or EEG changes are predictive of late stroke but not death following CEA indicating a need for further elucidation and management of the underlying risk factors driving the elevated stroke risk in this subset of CEA patients., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Perioperative stroke is a known complication in patients undergoing surgical clipping of cerebral aneurysms., Objective: To evaluate whether intraoperative changes in somatosensory-evoked potential (SSEP) monitoring during cerebral aneurysm clipping is diagnostic of perioperative stroke., Methods: An electronic search of PubMed, Embase, and Web of Science databases was done for studies published through May 2015 on SSEP monitoring in cerebral aneurysm clipping for predicting postoperative outcomes. All titles and abstracts were screened independently on the basis of predetermined criteria. Inclusion criteria included randomized clinical trials and prospective or retrospective cohort reviews; patients with intracranial aneurysms who underwent surgical clipping with intra-operative SSEP monitoring and postoperative neurologic assessment; studies published in English on adult humans ≥18 years with sample size of ≥50; and studies inclusive of an abstract with adequate details on outcomes., Results: A total of 14 articles with a sample population of 2015 patients were analyzed. SSEP monitoring demonstrated a strong mean specificity of 84.5% (95% confidence interval [95% CI] -76.3 to 90.3) but weaker sensitivity of 56.8% (95% CI 44.1-68.6) for predicting stroke. A diagnostic odds ratio of 7.772 (95% CI 5.133-11.767) suggested that the odds of observing an SSEP change among those with a postoperative neurologic deficit were 7 times greater than those without a neurologic deficit., Conclusion: Intraoperative SSEP monitoring is highly specific for predicting neurologic outcome after cerebral aneurysm clipping. Patients with postoperative neurologic deficits are 7 times more likely to have had intraoperative SSEP changes. SSEP monitoring may help design prevention strategies to reduce stroke rates after cerebral aneurysm clipping., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: International registries for acute type A aortic dissection (TAAD) demonstrate stagnant operative mortality rates in excess of 20% and stroke rates of 9% to 25%, with little global emphasis on stroke reduction or carotid involvement. Cerebral malperfusion with TAAD has been linked to poorer outcome. We hypothesize that concomitant carotid dissection or complex dissection flaps in the arch play a major role in stroke development and that aggressive reconstruction of the arch and carotid arteries can improve neurologic outcomes in TAAD., Methods: A standardized protocol focused on expedient care, neurocerebral protection, and common carotid and total arch reconstruction was developed for 264 consecutive TAADs. Arch and complete carotid replacement was based on arch dissection anatomy, carotid involvement, or an intraarch tear. Neurocerebral monitoring with continuous electroencephalogram/somatosensory evoked potentials was used in all cases., Results: The postoperative stroke and hospital mortality rates were 3.4% and 9.1%, and stroke rates by extent of arch replacement were 4%, 3%, and 0% for hemiarch, total arch, and total arch with complete carotid replacement, respectively. An intraoperative change in the electroencephalogram/somatosensory evoked potentials was strongly predictive of stroke and had a negative predictive value of 98.2%., Conclusions: An algorithmic approach to TAAD including (1) rapid transport-to-incision-to-cardiopulmonary bypass established centrally, (2) neurocerebral monitoring, (3) liberal use of total arch replacement for clearly defined indications (and hemiarch for all others), and (4) common carotid arterial replacement for concomitant carotid dissections significantly improves outcomes., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Periprocedural stroke after carotid endarterectomy increases long-term mortality. Intraoperative monitoring with electroencephalography (EEG) and somatosensory-evoked potentials (SSEPs) helps predict perioperative stroke risk. However, the sensitivity of each technique when used independently still remains low. The aim of this study is to determine whether multimodal monitoring leads to an increase in sensitivity and diagnostic accuracy., Methods: Relevant literature was obtained through a search of Embase, PubMed, and Web of Science databases and data were extracted. Data from the University of Pittsburgh Medical Center hospital records for the 2000-2012 period were included. Pooled estimates of sensitivity, specificity, and diagnostic odds ratio were obtained for single and multimodality neurophysiologic monitoring. A McNemar test was used to evaluate for any statistically significant differences in the sensitivities and false-positive rates., Results: The diagnostic odds ratio of dual modality monitoring was found to be 17.4. The specificity of concurrent EEG and SSEP changes in predicting perioperative strokes was calculated to be 96.8% (95% confidence interval 94.1%-98.3%). The sensitivity of combined monitoring with a change in either modality designated as significant was 58.9% (95% confidence interval 41.2%-74.7%). Multimodality monitoring with a change in either EEG or SSEP as the alarm criteria was 1.32 times more sensitive than EEG alone and 1.26 times more sensitive than SSEP alone., Conclusions: The odds of having a change in either EEG or SSEP are 17 times more in patients with perioperative strokes. Dual modality monitoring is more sensitive at predicting perioperative deficits than EEG or SSEP used independently., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Cranial nerve deficits during CEA are a known complication. The purpose of this study is to evaluate if significant changes in somatosensory evoked potentials and electroencephalography increase cranial nerve deficits during CEA., Procedures: This is an observational retrospective case-control study analyzed with data collected from patients who underwent CEA at the University of Pittsburgh Medical Center. Five hundred and eighty-seven patients were included in the final analysis. Due to the small number of cranial nerve deficits and the comparatively large number of potential covariates, we used a regression analysis with Bayesian shrinkage., Findings: Analysis was performed on 587 patients, of which a total of 11 (1.8%) cases of cranial nerve deficits were recorded. The marginal mandibular branch of the facial nerve was injured in nine (81%) patients and hypoglossal nerve was injured in two (19%) patients. Of the 11 patients, 9 cases resolved by the time of discharge, the 2 cases that persisted both were injuries to the facial nerve. Multivariate analysis using Bayesian shrinkage showed that after adjusting for all risk factors only IOM changes increased the risk of cranial nerve deficits (OR 38.47, 95% CI 7.73, 191.42)., Conclusions: Cranial nerve injury is 38 times more likely in patients who experienced a change in IOM during CEA shunt. Future studies examining the effect of stretch and the degree of retraction on the CN might be more helpful in reducing cranial nerve deficits., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Objectives: To examine the relationship between regional cerebral oxygen saturation (rSO2), delayed cerebral ischaemia (DCI), and outcomes after aneurysmal subarachnoid haemorrhage (aSAH)., Research Methodology: Subjects (n = 163) with aSAH, age 21-75 years, and Fisher grade >1 were included in the study. Continuous rSO2 monitoring was performed for 5-10 days after injury using near-infrared spectroscopy with sensors over the frontal/temporal cortex. rSO2<50 indicated desaturation. DCI was defined as neurological deterioration due to impaired cerebral blood flow. Three- and 12-month functional outcomes were assessed by the modified Rankin scale (MRS) as good (0-3) and poor (4-6)., Results: DCI occurred in 57% of patients; of these 66% had rSO2<50. Overall, 56% had rSO2<50 on either side, 21% and 16% had poor MRS at 3 and 12 months. Subjects with rSO2 <50 were 3.25 times more likely to have DCI compared to those with rSO2 >50 (OR 3.25, 95%CI 1.58-6.69), positive predictive value (PPV) = 70%. Subjects with rSO2 <50 were 2.7 times more likely to have poor 3-month MRS compared to those with rSO2 >50 (OR 2.7, 95%CI 1.1-7.2), PPV = 70%., Conclusions: These results suggest that NIRS has the potential for detecting DCI after aSAH. This potential needs to be further explored in a larger prospective study., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Purpose: Facial nerve microvascular decompression (MVD) for hemifacial spasm (HFS) provides relief to most patients. Due to the proximity of the cochlear and facial nerves, hearing loss is a potential MVD complication, however, there is a wide range in the reported incidence of hearing loss (HL) in the literature. In order to better understand the HL incidence in our MVD population, we utilized the combination of speech discrimination scores (SDS) and air and bone pure tone threshold averages (PTA) to identify patients with no hearing change, sensorineural hearing loss, or conductive hearing loss. We also assessed the predictive value of patient-reported hearing deficits on the ultimate audiometric diagnosis of hearing loss., Methods: One hundred and fifty one patients underwent facial nerve MVD at the University of Pittsburgh Medical Center between January 2000 and December 2007. Peri-operative audiometric data, including changes in air and bone pure tone thresholds and speech discrimination scores, were analyzed retrospectively. Criteria from the 1995 American Academy of Otolaryngology Committee on Hearing and Equilibrium consensus were used to analyze post-operative hearing loss. Patient-reported hearing disturbances obtained in the immediate post-operative period were compared to seven-day post-operative conductive and sensorineural HL status., Results: Non-functional, non-serviceable HL (Class D) occurred in 6.6% of patients, while 10.6% developed cumulative non-functional HL (Class C and D). Twenty-nine patients (18.7%) exhibited conductive HL. While patient-reported complaints were predictive of Class C/D HL (<0.0001) with a 56.3% sensitivity and 92.6% specificity, patient-reported complaints were not strongly associated with conductive HL status (p = 0.369) with 17.2% sensitivity and 88.5% specificity., Conclusions: Perioperative hearing evaluations, in conjunction with careful scrutiny of patient complaints and air-bone pure tone testing enables the physician to more precisely quote complication rates and rapidly distinguish potentially reversible conductive hearing pathologies from permanent sensorineural disorders., (Copyright © 2012. Published by Elsevier B.V.)