Neuromonitoring in

anesthesia

Classification of monitoring techniques:

The brain can be monitored in terms of:
Function
Cerebral blood flow (CBF) & intracranial

pressure (ICP)
Brain oxygenation and metabolism

Monitoring of FUNCTION:
Electroencephalograms (EEG)
Raw EEG
Computerized Processed EEG: Compressed spectral array, Density

spectral array, Aperiodic analysis, Bispectral analysis (BIS)

Evoked Potential
Sensory EP:
Somatosensory EP
Visual EP
Brain stem auditory EP

Motor EP:

- Transcranial magnetic MEP

- Transcranial electric MEP
- Direct spinal cord stimulation
EMG

- Cranial nerve function (V, VII, IX, X, XI, XII)

EEG

EEG
Electroencephalogram surface

recordings of the summation of excitatory

and inhibitory postsynaptic potentials
generated by pyramidal cells in cerebral
cortex
EEG:
Measures electrical function of brain
Indirectly measures blood flow
Measures anesthetic effects

EEG
Three uses perioperatively:
Identify inadequate blood flow to cerebral

cortex caused by surgical/anestheticinduced reduction in flow

Guide reduction of cerebral metabolism
prior to induced reduction of blood flow
Predict neurologic outcome after brain insult
Other uses: identify consciousness,

unconsciousness, seizure activity, stages of

sleep, coma

EEG
Electrodes placed so that

mapping system relates

surface head anatomy to
underlying brain cortical
regions

3 parameters of the

signal:

Amplitude size or

voltage of signal
Frequency number of
times signal oscillates
Time duration of the
sampling of the signal

EEG
EEG Waves :

Beta: high freq, low

amp (awake state)
Alpha: med freq, high
amp (eyes closed
while awake)
Theta: Low freq (not
predominant)
Delta: very low freq
high amp (depressed
functions/deep coma

Abnormal EEG
Regional problems - asymmetry in frequency,

amplitude or unpredicted patterns of such

Epilepsy high voltage spike with slow waves
Ischemia slowing frequency with preservation of

amplitude or loss of amplitude (severe)

Global problems affects entire brain,

symmetric abnormalities
Anesthetic agents induce global changes similar to

global ischemia or hypoxemia (control of anesthetic

technique is important

Anesthetic agents and EEG

Subanesthetic doses of inhaled anesthetics (0.3 MAC):
Increases frontal beta activity (low voltage, high frequency)

Light anesthesia (0.5 MAC):

Larger voltage, slower frequency

General anesthesia (1 MAC):

Irregular slow activity

Deeper anesthesia (1.25 MAC):

Alternating activity

Very deep anesthesia (1.6 MAC):

Burst suppression eventually isoelectric

Non-anesthetic Factors Affecting EEG

Surgical
1.

Cardiopulmonary bypass

2.

Occlusion of major cerebral

vessel (carotid crossclamping, aneurysm
clipping)

3.

4.

Retraction on cerebral
cortex
Surgically induced emboli
to brain

Pathophysiologi

c Factors
1. Hypoxemia
2. Hypotension
3. Hypothermia
4. Hypercarbia and

hypocarbia

Uses of EEG
1. Carotid endarterectomy
2. Cerebral aneurysm surgery when temporary

clipping is used.
3. Cardiopulmonary bypass procedure
4. Extracranial-intracranial bypass procedure
5. Deliberate metabolic supression for cerebral

protection.
Surgery that place the brain at risk (difficulties:

restricted access)
Seizure monitoring in ICU

Processed EEG
The gold standard for intra-op EEG monitoring:

continuous visual inspection of a 16- to 32channel analog EEG by experienced

electroencephalographer

Processed EEG: methods of converting raw EEG

to a plot showing voltage, frequency, and time

Monitors fewer channels, less experience required

Reasonable results obtained.

The common processing techniques used are

time domain analysis and frequency domain
analysis.

Time domain analysis

EEG is split into small

epochs of a given duration,
usually about 1-4 sec.

The frequency and/or

amplitude information
contained in each epoch is
depicted graphically.

A change in the value of

the variables derived form
this display is expected to
represent a change in the
raw EEG.

Frequency domain analysis

The EEG is split into small

epochs.
Each epoch is further

resolved into its component

sine waves and
reconstructed as frequency
Vs power plot by using
Fourier Analysis.

Compressed Spectral Array

(CSA) and Density
Modulated Spectral Array
(DSA)

BIS

Entropy

EVOKED POTENTIALS

Sensory Evoked Potential

Definition: electrical activity

generated in response to
sensory or motor stimulus
Stimulus given, then neural

response is recorded at
different points along
pathway
Sensory evoked potential

Latency time from stimulus

to onset of SER

Amplitude voltage of
recorded response

SEP
Sensory evoked potentials
Somatosensory (SSEP)
Auditory (BAEP)
Visual (VEP)
SSEP produced by electrically stimulating a

cranial or peripheral nerve

If peripheral n. stimulated can record proximally

along entire tract (peripheral n., spinal cord,

brainstem, thalamus, cerebral cortex)

As opposed to EEG, records subcortically

SSEP

Time-locked, event
related, pathway
specific EEG in
respones of peripheral
stimulus

Monitor integrity of the

pathway from
periphery to the cortex

Electrical stimulator placed

at median, ulnar, or
posterior tibial nerves

Indications for SSEP

Indications:
Scoliosis correction
Spinal cord decompression and
stabilization after acute injury
Brachial plexus exploration
Resection of spinal cord tumor
Resection of intracranial lesions
involving sensory cortex
Clipping of intracranial aneurysms
Carotid endarterectomy
Thoracic aortic aneurysm repair

 Carotid endarterectomy
Similar sensitivity has been found between SSEP and

EEG
SSEP has advantage of monitoring subcortical ischemia
SSEP disadvantage do not monitor anterior portions frontal or temporal lobes
Cerebral Aneurysm
SSEP can gauge adequacy of blood flow to anterior

cerebral circulation
Evaluate effects of temporary clipping and identify
unintended occlusion of perforating vessels supplying
internal capsule in the aneurysm clip

Limitations
Motor tracts not directly monitored
Posterior spinal arteries supply dorsal
columns
Anterior spinal arteries supply anterior
(motor) tracts
Possible to have significant motor
deficit postoperatively despite normal
SSEPs
SSEPs generally correlate well with
spinal column surgery

Visual Evoked Potential (VEP)

Using LED goggles to create stimulus
Difficult to perform

Brainstem Auditory Evoked Potential (BAEP)

Repetitive clicks delivered to the ear
Reflects the VIII nerve & brainstem well-being

AEP

 Auditory (BAEP) rapid clicks elicit

responses
CN VIII, cochlear nucleus, rostral

brainstem, inferior colliculus, auditory

cortex
Procedures near auditory pathway and
posterior fossa
Decompression of CN VII, resection of

acoustic neuroma, sectioning CNVIII for

intractable tinnitus
Resistant to anesthetic drugs

Limitations
Responds to injury by increased latency,

decreased amplitude, ultimately disappearance

Problem is response non-specific
Surgical injury
Hypoperfusion/ischemia
Changes in anesthetic drugs
Temperature changes

Signals easily disrupted by background electrical

activity (ECG, EMG activity of muscle movement,

etc)
Baseline is essential to subsequent interpretation

Anesthetic agents and SEP

Most anesthetic drugs increase

latency and decrease amplitude

Exceptions:
Nitrous oxide: latency stable, decrease
amplitude
Etomidate: increases latency, increase in
amplitude
Ketamine: increases amplitude
Opiods: no clinically significant changes
Muscle relaxants: no changes

Physiologic factors affecting

SEPs
Hypotension
Hyperthermia and hypothermia
Mild hypothermia (35-36 degrees) minimal effect
Hypoxemia
Hypercapnia
Significant anemia (HCT <15%)
Technical factor: poor electode-to skin-

contact and high electrical impedence (eg

electrocautery)

Motor Evoked Potentials

Motor EP:

- Transcranial magnetic MEP

- Transcranial electric MEP
- Direct spinal cord stimulation

Motor Evoked Potentials

Transcranial electrical

MEP monitoring
Stimulating electrodes

placed on scalp
overlying motor cortex
Application of electrical
current produces MEP
Stimulus propagated
through descending
motor pathways

Motor Evoked Potentials

MEPs very sensitive to

anesthetic agents
Possibly due to

anesthetic depression of
anterior horn cells in
spinal cord

Intravenous agents

produce significantly
less depression

TIVA often used

No muscle relaxant

EMG
Early detection of surgically

induced nerve damage and

assessment of level of nerve
function intra-operatively.
Active or passive.
Uses:
1. Facial nerve monitoring
2. Trigeminal nerve monitoring
3. Spinal Accessory nerve

Cerebral blood flow and ICP

monitoring

Intra-cranial Pressure
The pressure inside the lateral

ventricles/lumbar subarachnoid space in

supine position.

The normal value of ICP is 10-15 mm Hg

in adults.

Indications for ICP monitoring

1. Head Injury
2. Brain Tumors
3. Subarachnoid Heamorrhage
4. Hydrocephalus
5. Neuromedical conditions

Techniques of ICP monitoring

ICP waveforms

ICP shows a pulsatile recording with slow

respiratory component superimposed on
a biphasic recording synchronous with
cardiac cycle.

Normally, respiratory oscillations are

greater than the cardiac oscillations, but
when ICP increases, arterial pulsations
also assume greater amplitude

Abnormalities of ICP
waveforms
A WAVES: plateau waves

indicate ICP above

40mmHg and are
sustained for 5-20min.
B WAVES: Amplitude of

20mmHg and occur at

the rate of 1-2/min. Occur
synchronus with cheynestokes breathing
C WAVES: no pathological

significance

Transcranial Doppler
Measures the blood flow velocity in major

cerebral blood vessles.

Examination carried out through the temporal

window, orbital foramen or foramen magnum.

Using 2MHz probe.
MCA commonly used.
Change in velocity is proportional to change in

flow considering the vessel diameter is

constant.

Interpretation of waveforms

Pulsatality Index = (Peak Systolic

Velocity - End
Diastolic Velocity) / Mean Velocity

Clinical applications of TCD

1.

It is useful as a noninvasive monitor of CBF.

2.

It is helpful to diagnose cerebral vasospasm and

monitor response to therapy in patients with
subarachnoid haemorrhage and head injury.

3.

It is used to study autoregulation of CBF and cerebral

vascular response to carbon dioxide.

4.

It can be used to assess intracranial circulatory status

in raised ICP.

5.

It can be a useful tool to identify intraoperative cerebral

embolisation during surgery on carotid artery and
cardiopulmonary bypass procedures.

6.

It can be used to optimise CPP and hyperventilationin

Intravascular tracer
compounds
Method originally described by Kety and Schmidt.
Administration of radioactive isotope of xenon-133
Measurement of radioactivity washout with gamma

detectors.
Disadvantages: 1.Exposure to radioactivity

2.Cumbersome detector equipment

3.Focal areas of hypoperfusion
missed
4.Snapshot of CBF not continuous
monitor.

Thermal diffusion cerebral blood flow

monitoring
The rate at which heat
dissipates in a tissue depends
on the tissues thermal
conductive properties and the
blood flow in that area.
Measurement is automatically
suspended if the passive
thermistor measures a brain
temperature of 39.1 C.
The inability to monitor during a
febrile episode may constitute a
true limitation of the technique

Click icon to add picture

Monitoring of cerebral oxygenation

and metabloism

Monitoring of cerebral oxygenation and

metabloism

Brain tissue oxygenation

Jugular bulb venous oximetry monitoring
Microdialysis catheter
Near Infrared Spectroscopy (NIRS)

Jugular venous oximetry

:principle
(A-V)DO2 x CBF = CMRO2

When CMRO2 is constant, any change in

CBF is associated with a reciprocal
change in the cerebral arteriovenous
oxygen difference.

Based on the principle of reflectance

oximetry.

Jugular venous oximetry

Continuous monitoring of

jugular venous oxygen

saturation (SjVO2 ) is
carried out by a catheter
placed retrograde through
the internal jugular vein
intothe jugular bulb.

For accurate
measurement, the tip of
the catheter must be
within 1 cm of the jugular
bulb.

Indices obtained from SjVO2

1. Jugular venous oxygen

saturation (SjVO2 )
2.

Cerebral arteriovenous
oxygen difference (AVDO2 ) (the difference
between arterial and
jugularvenous oxygen
content) and

3.

Cerebral oxygen
extraction(CEO2 ) (the
difference between SaO2
and SjVO2 ).

Interpretation of SjVO2
Interpretation of jugular venous oxygen saturation (SjvO 2)
Increased values: >90% indicates absolute/relative

hyperemia
Reduced metabolic need comatose/brain death
Excessive flove sever hypercapnia
AVM

Normal Values: 60-70% focal ischemia?

Decreased Values: <50% increased O2 extraction,

indicates a potential risk of ischemia injury

Increased demand: seizure / fever
Decreased supply: decreased flow, decreased hematocrit

As ischemiaprogress to infarction: O2 consumption

decreases

Near Infra-red Spectroscopy

NIRS
The principle of absorption of near-infrared

light by chromophores in the body like

oxyhaemoglobin,deoxyhaemoglobin and
cytochrome aa3.
Light in the near-infrared region (70-1000

nm) is very minimally absorbed by body

tissues. It can penetrate tissues upto 8 cm.
Measure regional cerebral blood flow,

cerebral blood volume, cerebral oxygen

saturation and cerebral metabolism.

NIRS limitations
Inability to assess the contribution of extracranial

tissue to the signal changes.

Presence of intracranial blood in the form of

haematomas and contusions can interfere with the

measurements.
Measures small portion of frontal cortex, contributions from
non-brain sources
Temperature changes affect NIR absorption water spectrum
Degree of contamination of the signal by chromophores in
the skin can be appreciable and are variable
Not validated threshold for regional oxygen saturation not
known (20% reduction from baseline?)

Tissue partial pressure oxygen monitoring:

Based on an oxygen-sensitive electrode originally

described by Clark.
The diffusion of oxygen molecules through an oxygen-

permeable membrane into an electrolyte solution causes

an electric current that is proportional to Po2.

The catheter is placed into the brain tissue through a

twist drill hole into the subcortical white matter.

Normal values for brain tissue oxygen tension are 20-40

mmHg.

In patients with cerebral ischaemia the values are 10

5 mmHg as against 37 12 mmHg in normal individuals

Cerebral Microdialysis
Small catheter inserted with ICP/tissue P O2

monitor
Artificial cerebrospinal fluid,equilibrates with
extracellular fluid,chemical composition
analysis
Markers:
Lactate/pyruvate ratio : onset of ischemia
High level glycerol: inadequate energy to

maintain cellular integrity- membrane breakdown

Glutamate: neuronal injury and a factor in its
exacerbation

 Catheter placement is

usually in high risk

tissue.
Uses:

1.Ischemia/trauma
2.epilepsy
3.Tumor
chemistry

References
Millers anesthesia 8th edition
Neurological monitoring. Dr. G S Rao IJA

2002;46(4)
Advances in neuroanesthesia monitoring

Dr. Pramod Bithal AIIMS new

delhi. 2006 ISACON
GE-Datex Ohmeda Entropy monitor

manual
Coviden BIS monitor users manual

Thankyou
The end