IONM in Cranial Surgery

Introduction

The cranial nerves are monitored with for a variety of surgical procedures. The modalities that are monitored typically include spontaneous and triggered EMG recordings and motor evoked potentials.

1. The recurrent laryngeal nerve, a branch of the vagus nerve (CN X), is monitored for thyroidectomies. The recurrent laryngeal nerve, one of approximately 11 branches of CN X, innervates the intrinsic muscles of the larynx. This nerve is monitored using an endotracheal tube that is lined with recording electrodes.. 2. The facial nerve (CN VII) is monitored for parotidectomies, tympanoplasties, mastoidectomies, microvascular decompressions, etc. Major branches of CN VII include the temporal, zygomatic, buccal, marginal mandibular, and cervical. The temporal branch innervates the frontalis, orbicularis oculi and corrugator supercilii muscles. The zygomatic branch innervates the orbicularis oculi muscle. The buccal branch innervates the orbicularis oris, buccinator and zygomaticus muscles. The marginal mandibular branch innervates the mentalis muscle. The cervical branch innervates the platysma, a sheet of muscle fibers extending from the collarbone to the jaw. Pairs of recording electrodes are typically placed at the muscles of each branch. 3. The glossopharyngeal (CN IX) can be monitored for microvascular decompressions and acoustic neuroma resections. For acoustic neuroma resections, multiple cranial nerves could be at risk of injury depending on the size of the tumor, including the vestibulocochlear (CN VIII), facial (CN VII) nerve, vagus nerve (CN X), hypoglossal nerve (CN XII), and accessory nerve (CN XI).

Neurovascular information

The brain is very sensitive to changes in blood flow. Cerebral blood flow is maintained and regulated by a homeostatic process called autoregulation. Cerebral blood flow is maintained at approximately 40-70 ml per minute for every 100 g of brain tissue, which occurs over a wide range of arterial blood pressures (~60 - 160 mm Hg) in a healthy brain. To maintain constant cerebral blood flow, several homeostatic mechanisms converge to maintain a balance between vasoconstriction and vasodilation, which includes myogenic, neurogenic, metabolic, and endothelial components (Armstead, Anesthesiol Clin. 2016; 34(3): 465–477).