NEUROLOGICAL SURGERY & MONITORING

Craniotomies

Marisa Goddard MS CNIM

Neurological Surgeries
Craniotomies are among the most

delicate and intricate surgery type Procedures can be as straight forward as Microvascular Decompressions (MVDs) to as complicated as Posterior Fossa Tumor Resection (Acoustic Neuromas) Knowledge of anatomy and critical structures is imperative in Crani cases Often times surgeons may be trying a new approach or have a challenging time planning the surgery and monitoring is left to the Physiologist to determine

Microvascular Decompression
Procedure that relieves

pressure on a nerve caused by a surrounding blood vessel Most commonly used to treat Trigeminal Neuralgia Monitoring is usually focused on the Motor Cranial Nerve that is being irritated or may be in the path of exposure

Tumors - General
Posterior Fossa Middle Fossa Anterior Fossa Skull Base

Posterior Fossa Tumors (Acoustic Neuroma)

Characterized by a tumor on the

VIIIth Cranial Nerve Monitoring BAERs (ABRs) is critical in such cases as well as CN V and VII due to proximity to the VIIIth nerve Pre Operative hearing tests should be performed and in chart prior to case to determine pre operative loss and to explain baseline deficits

Middle Fossa Tumors

Tumors located in Parietal lobe as

well as Temporal lobes Monitoring EEG as well as SSEPs can help minimize the damage that usually takes place during exploration of the tumor Based on location of the tumor major vessels that surround the area should be noted so that proper focus can be placed on SSEP responses (MCA- Upper SSEPs vs ACA- Lower SSEPs) BAERs may be requested based on location and size of tumor and pt symptoms

Anterior Fossa Tumors

Tumors located in Frontal lobe as

well as pituitary surgeries SSEPs are critical in such cases especially where pituitary tumors are being resected Upper and Lower SSEPs are of interest depending on location and affected blood vessels (sometimes VEPs)

Skull Base Procedures

Usually involves tumors on

brainstem Here is where the nuclei of cranial nerves lie as well as the point of decussation of many evoked potentials BAERs, SSEPs and Motor Cranial Nerve stimulation and EMG is usually monitored with direction of surgery and critical structures

Cerebrovascular Procedures

Aneurysm Clipping and AVMs

In these surgeries even though

straight forward, the condition and structure of the aneurysm can prove fatal if not clamped in time Monitoring EEG as well as SSEPs (Upper and Lower) is most reliable in detecting any ischemic events prior to, during and post clamp Arteriovascular malformations are deformities of blood vessels in the brain (AVMs)

Important Points
Most important information to learn

prior to the surgery is: Location of aneurysm (or malformation) Has the anuerysm bled (this is usually noted by pt having a drain in the skull and being ventilated)

Cerebrovascular Keys
EEG is a primary modality

used not only for monitoring during surgery but to also determine burst suppression for neuroprotection during critical stages of the case Post clamping should not show any deficits in SSEPs or EEG to ensure proper brain perfusion

Cortical Mapping
In many surgeries the

localization of the central sulcus is imperative (Epilepsy surgery vs Tumor Cases) This is achieved with a cortical grid and SSEP stimulation ( at time direct cortical stimulation is performed) Phase reversal denotes location of central sulcus

Motor Mapping

Summary