Case report
Density spectral array of BIS VISTA™ monitoring system in a functional hemispherectomy
Monitorización con espectrograma del sistema de monitorización BIS VISTA™ en una hemisferectomía funcional
C. Luis
, E. Vilà, L. Moltó, A. Pardo, J.L. Fernández Candila, S. Pacreu
Corresponding author
Departamento de Anestesiología y Reanimación, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
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A) Imagen antes de la desconexión frontal en la que se ve un aumento de potencia en las bandas de baja frecuencia (0,1-4<span class="elsevierStyleHsp" style=""></span>Hz) y en las bandas alfa (8-12<span class="elsevierStyleHsp" style=""></span>Hz) del hemisferio cerebral derecho (ambas de color rojo), donde se encontraba el foco de epilepsia. B) Se observa una marcada disminución de potencia en las bandas de baja frecuencia y alfa en el lado derecho después de la desconexión frontal.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "C. Luis, E. Vilà, L. Moltó, A. Pardo, J.L. Fernández Candila, S. Pacreu" "autores" => array:6 [ 0 => array:2 [ "nombre" => "C." "apellidos" => "Luis" ] 1 => array:2 [ "nombre" => "E." "apellidos" => "Vilà" ] 2 => array:2 [ "nombre" => "L." "apellidos" => "Moltó" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Pardo" ] 4 => array:2 [ "nombre" => "J.L." "apellidos" => "Fernández Candila" ] 5 => array:2 [ "nombre" => "S." 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Luis, E. Vilà, L. Moltó, A. Pardo, J.L. Fernández Candila, S. Pacreu" "autores" => array:6 [ 0 => array:4 [ "nombre" => "C." "apellidos" => "Luis" "email" => array:1 [ 0 => "61307@parcdesalutmar.cat" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "E." "apellidos" => "Vilà" ] 2 => array:2 [ "nombre" => "L." "apellidos" => "Moltó" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Pardo" ] 4 => array:2 [ "nombre" => "J.L." "apellidos" => "Fernández Candila" ] 5 => array:2 [ "nombre" => "S." "apellidos" => "Pacreu" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Departamento de Anestesiología y Reanimación, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Monitorización con espectrograma del sistema de monitorización BIS VISTA™ en una hemisferectomía funcional" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1755 "Ancho" => 3176 "Tamanyo" => 568826 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Color spectrogram during functional hemispherectomy. Part A: an image before frontal disconnection showing an increase in low frequency band (0.1–4<span class="elsevierStyleHsp" style=""></span>Hz) and alpha band (8–12<span class="elsevierStyleHsp" style=""></span>Hz) power in the right hemisphere, where the focus of epilepsy was. Part B: there is a marked decrease in power in the low frequency and alpha bands on the right side after frontal connection.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Electroencephalogram (EEG) monitoring used in clinical practice offers information about level of consciousness. The bispectral index (BIS) VISTA™ Monitoring System (BVMS) (Aspect Medical Systems Inc, Norwood, MA) consists of the BIS VISTA Monitor, the BIS<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>4, the PIC-4 and a BIS Bilateral Sensor. The BVMS was designed to allow the user to both record and display 4 EEG channels, two from each side of the brain. This monitor also shows changes in the power spectrum distribution through the Density Spectral Array (DSA).<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> Asymmetry (ASYM) is a processed variable indicating the percentage of EEG power present in left or right hemispheres with respect to total (left and right) EEG power. ASYM graphical data may be plotted as part of the DSA display. The ASYM scale begins at 20% at the center line and runs left or right to 100%. In a situation of clear hemispheric difference, the ASYM Indicator points to the hemisphere that measures greater power. DSA also shows the frequency at which 95% of the total power lies below<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> (SEF 95).</p><p id="par0010" class="elsevierStylePara elsevierViewall">Functional hemispherectomy (FH) is a surgical technique used in the pediatric population to treat drug-resistant epilepsy with frequent seizures caused by extensive hemispheric lesions such as Rasmussen's encephalitis, Sturge–Weber syndrome, or cortical focal dystrophy. It consists of the disconnection of a cerebral hemisphere by resection of the main white matter tracts involved in the propagation of epileptogenic activity. As the central nervous system is still developing in the pediatric population, motor deficits and/or linguistic alterations that may appear in the postoperative period are generally slight.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> In contrast, adults undergoing brain resections seem to have lower tolerance and may incur greater negative consequences.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">4–6</span></a> One study investigating bilateral BIS monitoring in adult patients during hemispherectomy found no differences between left and right hemispheres.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a> To our knowledge, there have been no studies to date on the use of DSA in this type of surgery.</p><p id="par0015" class="elsevierStylePara elsevierViewall">We report the use of bilateral BIS monitoring with asymmetry analysis during the maintenance of general anesthesia in a patient undergoing FH. Our observations suggest that routine use of this monitoring system may help ensure and verify the effectiveness of the surgery.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 40-year-old woman, weight: 74<span class="elsevierStyleHsp" style=""></span>kg, height: 165<span class="elsevierStyleHsp" style=""></span>cm, with extensive inflammation of the right cerebral hemisphere caused by cortical focal dystrophy, had undergone mesial frontal lobe surgery 25 years earlier. However, she continued to experience epileptic seizures and daily absences. She presented mild mental retardation, memory problems, and left hemiparesis, with a slow and spastic gait. The baseline EEG showed irritative activity in the right frontal lobe. Monitoring with EEG-video was performed before surgery and showed asymmetry of basal rhythm, slowing of right hemisphere and left frontal lobe activity, considerable interictal activity and 13 clinical epileptic seizures. She was scheduled for right FH to treat epilepsy.</p><p id="par0025" class="elsevierStylePara elsevierViewall">On entering the operating room, electrocardiogram, noninvasive blood pressure and percent oxygen saturation were monitored. A bilateral BIS electrode strip was placed in the front temporal position according to the International 10–20 system of electrode placement. The patient had baseline levels BIS of around 90 on each side. However, we observed no differences in BIS and DSA between the two hemispheres due to epileptic seizures. Anesthesia was induced with midazolam (1.5<span class="elsevierStyleHsp" style=""></span>mg), a bolus of propofol (150<span class="elsevierStyleHsp" style=""></span>mg), fentanyl (300 mcg) and rocuronium (40<span class="elsevierStyleHsp" style=""></span>mg) and maintained via total intravenous anesthesia (TIVA) with propofol (4.7<span class="elsevierStyleHsp" style=""></span>mg/kg/h) and an infusion of remifentanil (0.1<span class="elsevierStyleHsp" style=""></span>mcg/kg/min) to keep BIS values within the 45–60 range. Rocuronium (0.3<span class="elsevierStyleHsp" style=""></span>mg/kg/h) was also administered.</p><p id="par0030" class="elsevierStylePara elsevierViewall">At the beginning of surgery, we observed a power increase in low frequency (0.1–4<span class="elsevierStyleHsp" style=""></span>Hz) and alpha bands (8–12<span class="elsevierStyleHsp" style=""></span>Hz) in the right hemisphere, the site of the epileptogenic focus. After frontal disconnection there was a marked decrease of power in low frequency and alpha bands on the right side (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Subsequently, with temporal, parietal, occipital, insula and corpus callosum disconnection, there were no changes in the spectrogram. Unlike DSA, the BIS trend did not reflect differences between the two hemispheres.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">At the conclusion of the procedure, while still in the operating room, neuromuscular blockade was reversed and the trachea was extubated. The patient was transferred to the recovery room awake, somnalent and comfortable. There were no noticeable differences between the patient's preoperative and postoperative neurological examinations in terms of neuromuscular function, linguistic abilities or cognitive level. She presented no epileptic seizures in the following months.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">FH has been recommended in patients <3 years old with drug-resistant epilepsy and extensive hemispheric lesions, because they can compensate neurological deficits that can be caused by the disconnection of the commissures and the large interlobar fasciculi.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> Given that in adults the acquired neurological deficits could be less tolerable, especially when they involve motor and linguistic functions, FH is infrequently performed in this population. There are few studies evaluating the changes in neurological functions in adults undergoing FH.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> One of them was carried out by Cukiert et al.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">4</span></a> They evaluated the intelligence quotient of 16 adults before and after surgery, and observed improvement in cognitive functions and verbal language expression in most. Furthermore, none presented postoperative worsening. However, the population size was relatively small.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">FH has been proven to be an effective alternative treatment, with a rate of seizure-free patients following surgery ranging from 65% to 100%. The outcome seems to depend on the etiology of the underlying lesion.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a> The longest series in the literature consist mainly of pediatric patients and show better results in patients with vascular lesions (67%–100% seizure-free following surgery) or Rasmussen's encephalitis (65%–100%), than in those with malformations of cortical development (45%–60%). In published series, patients with hemimegalencephaly show poorer results (<40%). Data on the efficacy and safety of this intervention in adults are scarce.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">FH is a complex surgery, and the most common cause of surgical failure is incomplete disconnection. Although there is a high possibility of insular involvement in intractable epilepsy suggesting hemispheric pathology, the insular cortex is not routinely removed, due to the risk of injury to the main arteries on the surface of the insula and deep structures such as the basal ganglia. Some studies have suggested that intraoperative electrocorticography may be safely utilized to provide valuable information while providing a tailored approach to insular removal.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">9</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">DSA applies fast-Fourier transform to convert raw EEG into a time-compressed and color-coded display, also termed a color spectrogram.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">1,2</span></a> There are no publications on the use of DSA in FH. Its clinical applications include monitoring depth of sedation,<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">10</span></a> detecting cerebral ischemia, and identifying seizures. During propofol and remifentanil anesthesia, bilateral monitoring of DSA allowed us to detect differences in the power spectrum between the two hemispheres.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">DSA showed higher alpha power in the affected side (right), suggesting the location of the epileptogenic focus.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> These differences were present until the frontal disconnection. The usefulness of DSA has been criticized due to the high variability among patients and because a single descriptor is not enough to measure depth of anesthesia. Our case shows that a complex algorithm such as the BIS trend failed to detect differences between the two hemispheres, while DSA was able to do so. With more experience, DSA may in fact prove to be a very useful intraoperative neuromonitoring adjunctive tool.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Nevertheless, one limitation of DSA is the absence of information from areas further from the electrodes. Its usefulness is dependent on the location of the epileptogenic focus – it is thus not useful in patients with focal parieto-occipital disorders. If the focus is in the parieto-occipital region, it may be displayed on the monitor as ASYM.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> In our patient, we were able to observe differences because the epileptogenic focus was in the frontal area.</p><p id="par0070" class="elsevierStylePara elsevierViewall">This parameter allows the anesthesiologist to know that in future surgeries the patient will show no differences in DSA between the two hemispheres. It is advisable to titrate anesthetic depth using bilateral BIS monitoring to ensure the safe conduct of anesthesia in patients who have had a FH.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Although, admittedly, the results of a case report must be viewed with caution, and extrapolation is limited, DSA could be useful for guiding the location of the epilepsy focus (especially if it is frontal). Further studies are needed to determine whether it is useful for monitoring the effectiveness of FH, according to the changes produced in the different surgical phases.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflict of interest</span><p id="par0080" class="elsevierStylePara elsevierViewall">All signing authors declare that they do not have conflict of interests.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1092857" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1035713" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1092858" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1035714" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflict of interest" ] 8 => array:2 [ "identificador" => "xack371309" "titulo" => "Acknowledgments" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-07-25" "fechaAceptado" => "2018-03-06" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1035713" "palabras" => array:3 [ 0 => "Density spectral array" 1 => "Bilateral bispectral index" 2 => "Functional hemispherectomy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1035714" "palabras" => array:3 [ 0 => "Espectrograma" 1 => "Índice biespectral bilateral" 2 => "Hemisferectomía funcional" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">We present the case of an adult patient with drug-resistant epilepsy caused by extensive inflammation in the right cerebral hemisphere. She was scheduled to undergo right functional hemispherectomy, which is common in pediatric surgery, but about which few studies have been published with respect to adult patients. During the intraoperative period, the density spectral array of the bilateral bispectral index (BIS) VISTA™ monitoring system was used. We observed a power increase in low frequency (0.1–4<span class="elsevierStyleHsp" style=""></span>Hz) and alpha bands (8–12<span class="elsevierStyleHsp" style=""></span>Hz) in the right hemisphere, where the epileptogenic focus was. During disconnection from the frontal lobe, there was a marked decrease of power in low frequency and alpha bands on the right side, with no changes during disconnection from other areas of the brain. We think that further studies are needed to determine whether the density spectral array can be a useful tool for monitoring the effectiveness of functional hemispherectomy.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Presentamos el caso de una paciente adulta con epilepsia farmacorresistente secundaria a una inflamación extensa del hemisferio cerebral derecho, que fue programada para realizársele una hemisferectomía funcional. Se trata de una cirugía habitual en pediatría, pero con pocas publicaciones en pacientes adultos. Durante el intraoperatorio se utilizó el espectrograma perteneciente al sistema de monitorización VISTA™ del índice biespectral bilateral (BIS). Se objetivó un aumento de potencia en las bandas de baja frecuencia (0,1-4<span class="elsevierStyleHsp" style=""></span>Hz) y en las bandas alfa (8-12<span class="elsevierStyleHsp" style=""></span>Hz) del hemisferio cerebral derecho, donde se encontraba el foco epileptógeno. Durante la desconexión del lóbulo frontal se observó una marcada disminución de potencia en dichas bandas, sin objetivarse cambios durante la desconexión de las otras áreas cerebrales. Pensamos que se necesitan más estudios para saber si el espectrograma puede ser una herramienta útil para monitorizar la efectividad de la hemisferectomía funcional.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Luis C, Vilà E, Moltó L, Pardo A, Fernández Candila JL, Pacreu S. Monitorización con espectrograma del sistema de monitorización BIS VISTA™ en una hemisferectomía funcional. Rev Esp Anestesiol Reanim. 2018;65:473–476.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1755 "Ancho" => 3176 "Tamanyo" => 568826 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Color spectrogram during functional hemispherectomy. Part A: an image before frontal disconnection showing an increase in low frequency band (0.1–4<span class="elsevierStyleHsp" style=""></span>Hz) and alpha band (8–12<span class="elsevierStyleHsp" style=""></span>Hz) power in the right hemisphere, where the focus of epilepsy was. Part B: there is a marked decrease in power in the low frequency and alpha bands on the right side after frontal connection.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0060" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical electroencephalography for anesthesiologists" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "P.L. Purdon" 1 => "A. Sampson" 2 => "K.J. Pavone" 3 => "E.N. 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