İntraoperatif Serebral Nöromonitörizasyon
Özet
İntraoperatif Serebral Nöromonitörizasyon (İONM), cerrahi müdahale sırasında merkezi sinir sisteminin fonksiyonel bütünlüğünü korumayı ve olası nörolojik hasarları erkenden saptamayı amaçlayan hayati bir yöntemdir. Bu süreç, anestezi derinliğinin kontrolü, farkındalık riskinin azaltılması ve beynin yeterli oksijenlenmesi ile kan akışının izlenmesi gibi kritik hedeflere odaklanır. Metin, monitörizasyon yöntemlerini dört ana kategoride incelemektedir. Serebral kan akımı, Transkranial Doppler ve Termal Difüzyon Flowmetri kullanılarak dinamik olarak izlenir. Serebral oksijenasyon takibi için non-invaziv bir yöntem olan Yakın Kızılötesi Spektroskopi (NIRS) kullanılır; burada bölgesel oksijen satürasyonunun (rSO2) bazal değerin %20 altına düşmesi kritik eşik kabul edilir. Elektrofizyolojik yöntemler kapsamında SEP, MEP, VEP ve BAEP gibi uyandırılmış potansiyeller aracılığıyla sinir yolaklarının işlevselliği, EMG ile de sinir köklerindeki anlık değişimler takip edilir. Son olarak, beyindeki elektriksel aktivite EEG ile izlenirken, Bispektral İndeks (BİS) bu verileri 0-100 arası sayısal bir değere dönüştürerek anestezi derinliğini ve bilinci ölçer. Özellikle vasküler, kardiyak ve nöroşirürji operasyonlarında bu yöntemlerin kombine kullanımı, postoperatif nörolojik komplikasyonları ve hastanede kalış süresini önemli ölçüde azaltmaktadır.
Intraoperative Cerebral Neuromonitoring (IONM) is a vital method aimed at preserving the functional integrity of the central nervous system and detecting potential neurological damage early during surgery. This process focuses on critical goals such as controlling anesthesia depth, reducing the risk of awareness, and monitoring adequate cerebral oxygenation and blood flow. The text examines monitoring methods in four main categories. Cerebral blood flow is dynamically monitored using Transcranial Doppler and Thermal Diffusion Flowmetry. For cerebral oxygenation, Near-Infrared Spectroscopy (NIRS), a non-invasive method, is used, where a drop in regional oxygen saturation (rSO2) of 20% below the baseline is considered the critical threshold. Within electrophysiological methods, the functionality of neural pathways is tracked through evoked potentials such as SEP, MEP, VEP, and BAEP, while EMG monitors instantaneous changes in nerve roots. Finally, electrical activity in the brain is monitored with EEG, and the Bispectral Index (BIS) measures anesthesia depth and consciousness by converting this data into a numerical value between 0-100. The combined use of these methods, especially in vascular, cardiac, and neurosurgical operations, significantly reduces postoperative neurological complications and hospital stay durations.
Referanslar
Penfield W, Steelman H: The treatment of focal epilepsy by cortical excision. Ann Surg 126: 740-761, 1947.
Vauzella C, Stagnara P, Jouvinroux P: Functional monitoring of spinal cord activity during spinal surgery. Clin Orthop Relat Res 93:173-178, 1973.
McLain RF, Saavedra FM: Intraoperative nonparalytic monitoring. In: Benzel EC (ed), Spine Surgery: Techniques, Complication Avoidance, and Management. 3rd ed. Chapter 179. Philadelphia, PA: Elsevier/Saunders, 2012:1701-1703.
Lu Y, Qureshi SA: Cost effectiveness studies in spine surgeries: A narrative review. Spine J 14:2748-2762, 2014.
Hogue CW Jr, Palin CA, Arrowsmith JE. Cardiopulmonary bypass management and neurologic outcomes: an evidence-based appraisal of current practices. Anesth Analg. 2006 Jul;103(1):21-37.
Grocott HP, Davie S, Fedorow C. Monitoring of brain function in anesthesia and intensive care. Curr Opin Anaesthesiol. 2010 Dec;23(6):759-64.
Robba C, Cardim D, Sekhon M, Budohoski K, Czosnyka M. Transcranial Doppler: a stethoscope for the brain-neurocritical care use. J Neuro Res 2018; 96: 720-30.
Aaslid R, Markwalder TM, Nornes H. Noninvasive transcranial Doppler ultrasound recording of flow velocity in basal cerebral arteries. J Neurosurg 1982; 57: 769-74.
Cipolla MJ. The Cerebral Circulation. San Rafael (CA): Morgan & Claypool Life Sciences; 2009. PMID: 21452434.
10.Mahal I, Davie SN, Grocott HP. Cerebral oximetry and thoracic surgery. Curr Opin Anaesthesiol. 2014 Feb;27(1):21-27.
Samra SK, Dy EA, Welch K, Dorje P, Zelenock GB, Stanley JC. Evaluation of a cerebral oximeter as a monitor of cerebral ischemia during carotid endarterectomy. Anesthesiology. 2000 Oct;93(4):964-70.
Rohlwink UK, Figaji AA. Methods of monitoring brain oxygenation. Childs Nerv Syst. 2010 Apr;26(4):453-64.
Bratton SL, Roberts JS. Variation in the use of mechanical ventilation for asthma: how big a gap? Pediatr Crit Care Med. 2007 Mar;8(2):186-7.
Jobsis FF. Noninvasive, infrared monitoring of cerebral and myocardial oxygen sufficiency and circulatory parameters. Science. 1977;198(4323):1264-7.
Toet MC, Lemmers PM. Brain monitoring in neonates. Early Hum Dev. 2009;85(2):77-84.
Edmonds HL Jr, Ganzel BL, Austin EH 3rd. Cerebral oximetry for cardiac and vascular surgery. Semin Cardiothorac Vasc Anesth. 2004 Jun;8(2):147-66.
Denault A, Deschamps A, Murkin JM. A proposed algorithm for the intraoperative use of cerebral near-infrared spectroscopy. Semin Cardiothorac Vasc Anesth. 2007 Dec;11(4):274-81.
Paisansathan C, Hoffman WE, Gatto RG, Baughman VL, Mueller M, Charbel FT. Increased brain oxygenation during intubation-related stress. Eur J Anaesthesiol. 2007 Dec;24(12):1016-20.
Goldman S, Sutter F, Ferdinand F, Trace C. Optimizing intraoperative cerebral oxygen delivery using noninvasive cerebral oximetry decreases the incidence of stroke for cardiac surgical patients. Heart Surg Forum. 2004;7(5):E376-81.
Germon TJ, Evans PD, Barnett NJ, Wall P, Manara AR, Nelson RJ. Cerebral near infrared spectroscopy: emitter-detector separation must be increased. Br J Anaesth. 1999 Jun;82(6):831-7.
Yoshitani K, Kawaguchi M, Tatsumi K, Kitaguchi K, Furuya H. A comparison of the INVOS 4100 and the NIRO 300 near-infrared spectrophotometers. Anesth Analg. 2002 Mar;94(3):586-90; table of contents.
Murkin JM. Cerebral oximetry: monitoring the brain as the index organ. Anesthesiology. 2011 Jan;114(1):12-3.
Kishi K, Kawaguchi M, Yoshitani K, Nagahata T, Furuya H. Influence of patient variables and sensor location on regional cerebral oxygen saturation measured by INVOS 4100 near-infrared spectrophotometers. J Neurosurg Anesthesiol. 2003 Oct;15(4):302-6.
Yao FS, Tseng CC, Ho CY, Levin SK, Illner P. Cerebral oxygen desaturation is associated with early postoperative neuropsychological dysfunction in patients undergoing cardiac surgery. J Cardiothorac Vasc Anesth. 2004 Oct;18(5):552-8.
Casati A, Fanelli G, Pietropaoli P, Proietti R, Tufano R, Danelli G, Fierro G, De Cosmo G, Servillo G. Continuous monitoring of cerebral oxygen saturation in elderly patients undergoing major abdominal surgery minimizes brain exposure to potential hypoxia. Anesth Analg. 2005 Sep;101(3):740-7.
Schulz G, Weiss M, Bauersfeld U, Teller J, Haensse D, Bucher HU, Baenziger O. Liver tissue oxygenation as measured by near-infrared spectroscopy in the critically ill child in correlation with central venous oxygen saturation. Intensive Care Med. 2002 Feb;28(2):184-9.
Rasekhi A, Sharifian M, Kazemi K, Hosseini SA. The use of micro pulse oximetery as a new detector of tissue perfusion in solid organ transplantation. Saudi J Kidney Dis Transpl. 2012 Jul;23(4):715-8.
Kaufman J, Almodovar MC, Zuk J, Friesen RH. Correlation of abdominal site near-infrared spectroscopy with gastric tonometry in infants following surgery for congenital heart disease. Pediatr Crit Care Med. 2008 Jan;9(1):62-8.
Monk TG, Reno KA, Olsen BS. Postoperatif cognitive dysfunction is associated with cerebral oxygen desaturation. Anesthesiology 2000; 93: 167.
Yao FS, Tseng CC, Ho CY, Levin SK, Illner P. Cerebral oxygen desaturation is associated with early postoperative neuropsychological dysfunction in patients undergoing cardiac surgery. J Cardiothorac Vasc Anesth. 2004 Oct;18(5):552-8.
ElBardissi AW, Aranki SF, Sheng S, O'Brien SM, Greenberg CC, Gammie JS. Trends in isolated coronary artery bypass grafting: an analysis of the Society of Thoracic Surgeons adult cardiac surgery database. J Thorac Cardiovasc Surg. 2012 Feb;143(2):273-81.
Gottesman RF, Sherman PM, Grega MA, Yousem DM, Borowicz LM Jr, Selnes OA, Baumgartner WA, McKhann GM. Watershed strokes after cardiac surgery: diagnosis, etiology, and outcome. Stroke. 2006 Sep;37(9):2306-11.
Moraca R, Lin E, Holmes JH 4th, Fordyce D, Campbell W, Ditkoff M, Hill M, Guyton S, Paull D, Hall RA. Impaired baseline regional cerebral perfusion in patients referred for coronary artery bypass. J Thorac Cardiovasc Surg. 2006 Mar;131(3):540-6.
John C. Alexander, Jr, MD Chief. Cardiac Surgery Hackensack University Medical Center Hackensack New Jersey. Ann Thorac Surg 2002; 73: 373.
Moller A. Anatomy and Physiology of Motor Systems. In Moller A (ed). Intraoperative Neurophysiological Monitoring. 2nd edition, Humana Press Inc: New Jersey 2006. p.157-9.
Ertekin C. Somatosensoryal spinal ve Serebral Evoked Potansiyeller. In Ertekin C (ed) Santral ve Periferik EMG Anatomi-Fizyoloji-Klinik. İzmir Meta Basım 2006. p.710-1.
Greenberg M. Electrodiagnostics. In Greenberg M. (ed) Handbook of Neurosurgery. Sixth Edition. New York: Thieme Publishers 2006. p.145-8.
Aydınlar E. İntraoperatif Omurilik Monitörlenmesi. In Zileli M, Özer F (ed), Omurga ve Omurilik Cerrahisi. Üçüncü Baskı, Cilt 1, İzmir: İntertıp yayınevi, 2014. p.413-9.
Greenberg M. Electrodiagnostics. In Greenberg M. (ed) Handbook of Neurosurgery. Sixth Edition. New York: Thieme Publishers 2006. p.145-8.
Waxman S. Somatosensory Systems S. In Waxman (ed), Clinical Neuroanatomy. 27th edition. China: Mc Geaw-Hill Education 2013. p.277-83.
Akçay E, Dalgıç A. Spinal tümör cerrahisinde nöronıonitörizasyon. Dalbayralc S, Kaptanoğlu E, Şimşek S, Ateş Ö, Dalgıç A(ed). Omurga ve omurilik tümörleri, TNDer-SPSCG yayınları No: 16, 2014;364-75.
Aydınlar E: İntraopereatif Omurilik monitörlenmesi. Zileli M, Özer F (ed), Omurilik ve Omurga Cerrahisi, Cilt 1.İzmir: intertıp yayınevi, 2014: 413-419.
Witham TF, Gökaslan ZL. (çev:Erdoğan E) intradural spinal kord tümörlerinde cerrahi. Vaccaro AR, Albert TJ(ed), (çev.ed;Kahraman S) Spinal cerrahi - Pratik cerrahi noktalar. Habitat yayıncılık 2012:14-17.
Deogaonkar A, Vivar R, Bullock RE, et al. Bispect¬ral index monitoring may not reliably indicate cerebral ischemia during awake carotid endarterectomy. Br J Anaesth 2005;94:800-804. http://dx.doi.org/10.1093/bja/aei115 PMid:15778269.
Morimoto Y, Monden Y, Ohtake K, Sakabe T, Ha¬gihira S. The detection of cerebral hypoperfusion with bispectral index monitoring during general anesthesia. Anesth Analg 2005;100:158-161. http://dx.doi.org/10.1213/01.ANE.0000139347.64944.95 PMid:15616071.
England MR. The changes in bispectral index du¬ring a hypovolemic cardiac arrest. Anesthesiology 1999;91:1947-1949. http://dx.doi.org/10.1097/00000542-199912000-00050 PMid:10598640.
Merat S, Levecque JP, Le Gulluche Y, et al. BIS mo¬nitoring may allow the detection of severe cerebral isc¬hemia. Can J Anaesth 2001;48:1066-1069.
Welsby I, Ryan J, Booth JV, et al. The bispectral in¬dex in the diagnosis of perioperative stroke: A case re¬port and discussion. Anesth Analg 2003;96:435-437.
Hayashida M, Chinzei M, Komatsu K, et al. Detecti¬on of cerebral hypoperfusion with BIS during paediat¬ric cardiac surgery. Br J Anaesth 2003;90:694-698. http://dx.doi.org/10.1093/bja/aeg107 PMid:12697602.
Hayashida M, Kin N, Tomioka T, et al. Cerebral isc¬hemia during cardiac surgery in children detected by combined monitoring BIS and near-infrared spectros¬copy. Br J Anaesth 2004;92:662-669. http://dx.doi.org/10.1093/bja/aeh120 PMid:15033888.
Hemmerling T, Olivier J, Basile F, Le N, Prieto I. Bispectral Index as an Indicator of Cerebral Hypoper¬fusion During Off-Pump Coronary Artery Bypass Graf¬ting. Anesth Analg 2005;100:354-356. http://dx.doi.org/10.1213/01.ANE.0000140245.44494.12 PMid:15673855.
Jameson, L.C. and T.B. Sloan, Using EEG to monitor anesthesia drug effects during surgery. J Clin Monit Comput, 2006. 20(6): p. 445-72.
Sigl JC, Chamoun NG (Kasım 1994). "Elektroensefalogram için bispektral analize giriş". Klinik İzleme Dergisi . 10 (6): 392–404.
Liu, J., H. Singh, and P.F. White, Electroencephalographic bispectral index correlates with intraoperative recall and depth of propofol-induced sedation. Anesth Analg, 1997. 84(1): p. 185-9.
Kearse, L.A., Jr., C. Rosow, A. Zaslavsky, P. Connors, M. Dershwitz, and W. Denman, Bispectral analysis of the electroencephalogram predicts conscious processing of information during propofol sedation and hypnosis. Anesthesiology, 1998. 88(1): p. 25-34.
56. Endo, T., K. Sato, H. Shamoto, and T. Yoshimoto, Effects of sevoflurane on electrocorticography in patients with intractable temporal lobe epilepsy. J Neurosurg Anesthesiol, 2002. 14(1): p. 59-62.
Baker, K.Z., Desflurane and sevoflurane are valuable additions to the practice of neuroanesthesiology: pro. J Neurosurg Anesthesiol, 1997. 9(1): p. 66-8.
Rampil, I.J., S.H. Lockhart, E.I. Eger, 2nd, N. Yasuda, R.B. Weiskopf, and M.K. Cahalan, The electroencephalographic effects of desflurane in humans. Anesthesiology, 1991. 74(3): p. 434-9.
