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Monday, February 16, 2009

Neuromonitoring:- a Review on PubMed Publications

We do not get much time to go read all the published papers on Neuromonitoring, unlike during the Laboratory research days, my visit to PubMed is less frequent, but yet I do not give up on my practice to go here and spend some time in catching up with the latest papers.  In my recent visit to the PubMed, I found the following ongoing research activities in the field of neuromonitoring. 
This is a very brief review, will help re-route the interested readers or visitors to the PubMed original article. Right now, I have access to only the abstracts, so just by going through the abstracts of recently published article I thought to list the recent papers here. 
PubMed Search "Neuromonitoring" check the links direct to the articles.
Current Treatment Options in NeurologyCurrent Treatment Options in Neurology
Curr Treat Options Neurol. 2009 Mar;11(2):137-49.
Seder DBJarrah S argues that though Therapeutic Hypothermia (TH) is the most immediate and well known technique to review patients suffering from cardiac arrest (known as Encephalopathic survivors), a combined approach that involves various emerging tools such as critical care or Neuromonitoring can yield better outcome of patients, usage of neuromonitoring is critical during decooling phase...!
In the same journal of Curr Treat Options Neurol, another article emphasize the knowledge and usage of multimodality neuromonitoring for better outcome of patients aneurysmal subarachnoid hemorrhage (SAH)
a non traumatic hemmorrhage caused by either a tumor,infection or vascular malformation. 
2.Critical care management of subarachnoid hemorrhage."This article reviews the natural history of aneurysmal SAH and
strategies for disease management in the acute setting, including available tools for monitoring brain function.
Intensive care management of patients with SAH focuses on prevention of further neurologic injury. Aneurysmal rebleeding, hydrocephalus, seizures, and delayed ischemic injury represent major threats"
In vascular surgeries like carotid endarterectomy and when the internal carotid artery (ICA) is clamped the neuromonitoring playes an important role in giving early warning of Ischemia or embolism, especially the Sensory evoked potential and EEG monitoring.  Some of the techniques used are Transcranial Doppler (TCD) to measure the mean blood flow velocity, and Near-infrared Spectroscopy (NIRS) to assess the dynamics of "haemoglobine", but these techniques according to Bein BFudickar AScholz J. the practicability of using TCD and NIRS posses problems in about 20% patients?. Bein et all suggests the "Gold Standard" for better outcome and patient safety is to use intraoperative monitoring of SSEP?.
 3. [Anesthesia in vascular surgery--monitoring of cerebral function].
"Use of somatosensory evoked potentials (SEP) is the most widespread cerebral neuromonitoring during vascular surgery due to its high reliability and simple application. Sensitivity and specifity for ischemic lesions are 100% and 94%-99%, respectively. SEP are regarded as the gold standard for cerebral neuromonitoring in anaesthetized patients".
British Journal of Surgery Br J of Surg , In this British Journal of Surgery Publication,
4. Randomized clinical trial of visualization versus neuromonitoring of recurrent laryngeal nerves during thyroidectomy.  Barczyński MKonturek ACichoń S discuss about testing the hypothesis "Neuromonitoring of Recurrent Layrngeal nerves during Thyroidectomy?.  Unlike Barczyriski et al., who concluded the that the neuromonitoring in their surgical procedures
"Nerve monitoring decreased the incidence of transient but not permanent RLN paresis compared with visualization alone, particularly in high-risk patients".

These Italian surgery team in  video-assisted thyroidectomy (VAT) a same day surgical procedure, they found Intraoperative monitoring of reccurrent laryngeal monitoring helped prevent permanent damages to laryngeal nerves. 

"Intraoperative neuromonitoring (IONM) was used for RLN identification. Intact parathyroid hormone (iPTH) levels were determined early postoperatively at +6-h. Postoperative complications, conversion rate were analyzed. RESULTS: No cases required conversion to open surgery or ordinary recovery (i.e. >24h). Incidence of temporary hypoparathyroidism was 11.6% (5/43) with no case of symptomatic hypocalcemia. Incidence of temporary RLN injury was 2.3% (1 patient) with no case of permanent or bilateral RLN injury. All patients were satisfied with the type of recovery. CONCLUSIONS: This preliminary report is an example of the safe incorporation between new technologies (IONM, early iPTH measurement) with improvement of the quality and safety of VAT performed in a one-day surgery setting. (this is a Dec 2008 article, not 2009?)
The Laryngoscope 6. In this latest issue of Laryngoscope, risks of VOICE alterations? (vocal cord damage due to laryngeal nerve injury) has been discussed. The Columbia University surgical team presents their data in this interesting finding and the authors conclude that there was 100% preservation of vocal cords during this minimally invasive, local anesthesia induced thyroidectomy.  The authors 
"Inabnet WBMurry TDhiman SAviv JLifante JC discuss that the dentification and preservation of the external branch of the superior laryngeal nerve (EBSLN) is paramount for normal vocal function preservation after thyroidectomy. 
Thyroidectomy was successfully completed under local anesthesia in all cases. The recurrent laryngeal nerve(s) was identified and preserved in each patient as demonstrated by normal perioperative transnasal flexible laryngoscopy.
A total of 15 EBSLNs were at risk, but only 8 EBSLNs (53%) were definitively identified.
 Neuromonitoringdemonstrated preservation of the EBSLN in 100% of cases.
The analysis of the results of the VHI-10 questionnaire before and 3 weeks after surgery indicated no significant change in patients' perception of voice severity. CONCLUSION:: Monitoring of the EBSLN during thyroidectomy under local anesthesia is a feasible alternative to conventional nerve monitoring under general anesthesia. This technique may be useful for the preservation of voice quality during a minimally invasive thyroidectomy under local anesthesia"