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J Neurosurg. 2018 Mar 1:1-13. doi: 10.3171/2017.8.JNS17791. [Epub ahead of print]

Intraoperative use of transcranial motor/sensory evoked potential monitoring in the clipping of intracranial aneurysms: evaluation of false-positive and false-negative cases.

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Departments of1Neurosurgery.
2Neurology, and.
3Anesthesiology and Pain Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.


OBJECTIVESomatosensory and motor evoked potentials (SEPs and MEPs) are often used to prevent ischemic complications during aneurysm surgeries. However, surgeons often encounter cases with suspicious false-positive and false-negative results from intraoperative evoked potential (EP) monitoring, but the incidence and possible causes for these results are not well established. The aim of this study was to investigate the efficacy and reliability of EP monitoring in the microsurgical treatment of intracranial aneurysms by evaluating false-positive and false-negative cases.METHODSFrom January 2012 to April 2016, 1514 patients underwent surgery for unruptured intracranial aneurysms (UIAs) with EP monitoring at the authors' institution. An EP amplitude decrease of 50% or greater compared with the baseline amplitude was defined as a significant EP change. Correlations between immediate postoperative motor weakness and EP monitoring results were retrospectively reviewed. The authors calculated the sensitivity, specificity, and positive and negative predictive values of intraoperative MEP monitoring, as well as the incidence of false-positive and false-negative results.RESULTSEighteen (1.19%) of the 1514 patients had a symptomatic infarction, and 4 (0.26%) had a symptomatic hemorrhage. A total of 15 patients showed motor weakness, with the weakness detected on the immediate postoperative motor function test in 10 of these cases. Fifteen false-positive cases (0.99%) and 8 false-negative cases (0.53%) were reported. Therefore, MEP during UIA surgery resulted in a sensitivity of 0.10, specificity of 0.94, positive predictive value of 0.01, and negative predictive value of 0.99.CONCLUSIONSIntraoperative EP monitoring has high specificity and negative predictive value. Both false-positive and false-negative findings were present. However, it is likely that a more meticulously designed protocol will make EP monitoring a better surrogate indicator of possible ischemic neurological deficits.


AChA = anterior choroidal artery; DSA = digital subtraction angiography; EP = evoked potential; GOS = Glasgow Outcome Scale; ICG = indocyanine green; ICH = intracerebral hemorrhage; MEP = motor evoked potential; MVD = microvascular Doppler; NMB = neuromuscular blockade; NPV = negative predictive value; PPV = positive predictive value; SAH = subarachnoid hemorrhage; SDH = subdural hemorrhage; SEP = somatosensory evoked potential; UIA = unruptured intracranial aneurysm; diagnostic technique; evoked potential; false negative; false positive; mRS = modified Rankin Scale; unruptured intracranial aneurysms; vascular disorders


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