Intraoperative

N e u ro m o n i t o r i n g
Andrew K. Wong, MD1, Jay L. Shils, PhD
2
, Sepehr B. Sani, MD
1
,
Richard W. Byrne, MD1,*

KEYWORDS

Somatosensory evoked potentials
Motor evoked potentials

Electroencephalogram
Electromyography
Brainstem auditory evoked response

Direct cortical stimulation

KEY POINTS

Intraoperative neuromonitoring provides critical real-time information regarding surgical
anatomic eloquence.

The different intraoperative neuromonitoring modalities monitor specific neuropathways.
Understanding the goal and anatomic relationships involved in the surgical procedure is
critical in determining not only which modalities to use but also how they should be
used and interpreted.

Patient selection is key in the successful implementation of intraoperative neuromonitor-
ing and considerations such as integrity of monitored neuropathway and patient toler-
ance, particularly for modalities that require the patient to be awake, must be taken into
account.

INTRODUCTION

Intraoperative neurophysiological monitoring (IONM) is the evaluation of the nervous

system during surgical procedures where injury to critical neurologic structures is
possible. IONM can be divided into 2 classes: (1) detection of an iatrogenic injury
allowing for reversal or minimization of the injury; and (2) localization (mapping) of crit-
ical neural structures during the procedure to avoid damaging those structures.1
IONM is fast becoming a mainstay in a variety of surgical procedures, including scoli-
osis correction surgery, intramedullary spinal cord tumor resection, and acoustic neu-
roma resection. In other procedures, it is used to improve surgical decision making.1–5
To properly interpret IONM data, the neurophysiologist needs to know the physiologic
state of the patient, the competency of the technologist operating the equipment, the

1
Department of Neurosurgery, Rush University, 1725 West Harrison Street #855, Chicago, IL
60612, USA; 2 Department of Anesthesiology, Rush University, 1653 West Congress Pkwy, Jelke
7, Chicago, IL 60612, USA
* Corresponding author:
E-mail address: [email protected]

Neurol Clin - (2021) -–-

https://doi.org/10.1016/j.ncl.2021.11.010 neurologic.theclinics.com
0733-8619/21/ª 2021 Published by Elsevier Inc.

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2 Wong et al

state of the monitoring equipment, what the surgeon is doing, the preoperative exam-
ination of the patient (including the patient’s history), and the anesthesia administered
to the patient.6
IONM data are either obtained quasi continuously (somatosensory and motor
evoked potentials [SSEP and MEP], electroencephalography [EEG], and free-run elec-
tromyography [fEMG]) or at specific time points such as for functional-anatomic local-
ization (direct nerve and cortical stimulation). Evoked potentials require a stimulus
applied at one point at the nervous system while recording the response at another
point. To achieve optimal responses, all neural elements (axon, synapse, and neuro-
muscular junction) in the signal pathway need to be functioning at some minimal level.
All time-locked electrophysiological signals have 3 distinct properties: (1) the ampli-
tude of the response; (2) the latency, or time of the response from the start of the stim-
ulation; and (3) the morphology.

MODALITIES

Common IONM modalities include: (1) SSEPs which evaluate the sensory pathway
from a point distal to surgical intervention to the sensory nuclei or cortex in the brain
or brainstem; (2) MEPs which evaluate the largest 2% of fibers in the corticospinal tract
from the brain to the muscle via the alpha motor neuron connecting the primary and
secondary motor neurons; (3) fEMG records muscle activity resulting from potential
irritation of a nerve innervating that muscle; (4) triggered EMG (tEMG) records muscle
activity in response to stimulation of a nerve; (5) brainstem auditory evoked responses
(BAERs) evaluate the sensory pathways of the auditory system from the cochlea
through the auditory brainstem nuclei; (6) direct nerve recordings evaluate signal con-
duction through specific nerve segments; (7) EEG records the background activity of
the superficial cortical layers of the brain; (8) single cell microelectrode recordings re-
cord the activity of individual neurons for localization purposes; and (9) direct cortical
stimulation and mapping whereby cortical and subcortical structures are stimulated
directly to localize eloquent regions.
Given that the main areas of anesthetic action are at the synapse, the overall effects
of anesthetic agents on axonal membrane properties (ie, nerve conduction) are negli-
gible, except at extremely high doses. The usual rule is that the more synapses a neu-
ral signal has to travel through, the greater the anesthetic effect. Yet, even a signal
synapse, such as the one between the upper and lower motor neuron (aMN) can
significantly be affected by anesthesia. Each monitoring modality is affected differ-
ently by anesthetic agents depending on the drug effects on specific neurotransmit-
ters and the types of synapses involved in the monitored pathway. Responses are
also affected differently depending on the location and mechanism of neural dysfunc-
tion or injury (eg, neural or vascular).

ELECTROENCEPHALOGRAM

The EEG records the averaged extracellular field potentials of the spontaneous activity
of cortical neurons near the recording electrodes. The number of neurons recorded is
a function of the location of the electrode (scalp, cortical, or intraparenchymal), the
size of the electrode, the distance between the electrode and the neurons, and the tis-
sue between the neurons and the electrode. For recordings, there is an “active” and
“reference” electrode, such that the total activity recorded is the difference in activity
between these electrodes. The activity in locations distant from the electrodes will
have no impact on the recorded data. Thus, changes in cortical activity that are distant
from the electrodes will be missed. Hence, the EEG is usually recorded using several

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 Intraoperative Neuromonitoring 3

pairs of electrodes over the areas of interest. EEG is recorded using a standard 21-
channel electrode set, with placement based on the 10 to 20 electrode localization
system,7 (Fig. 1), the spatial resolution of each electrode placed on the scalp is
approximately 6 cm.8 A common intraoperative technique is to use 8 electrodes,
which approximate a spatial resolution of approximately 10 to 12 cm (extrapolating
from Gevins and colleagues9), thus focal effects may be missed.
The overall electrical activity of the brain is dependent on the availability of metab-
olites, including oxygen. When these are compromised, it is reflected quickly in loss of
synaptic function. Intraoperative EEG can therefore be an indirect measure of cortical
ischemia (Fig. 2). EEG is also helpful in detecting electrical seizure activity. Thus, the
most common procedures where EEG is used are where the chance of vascular insult
is high and during intracranial motor mapping procedures to identify seizure activity
resulting from cortical stimulation.
As the spectral content of the EEG is critical to localizing insult to the brain, many
systems include tempero/spectral plots to show the energy in the key EEG spectral

Fig. 1. The 10 to 20 location of scalp electrodes for EEG and SSEP recordings. Common place-
ment of SSEP electrodes are at Fp, C30 (about 2 cm behind C3), Cz0 , and C40 , whereas for EEG,
a full set will use all electrodes shown on the right image. MEP stimulation electrodes are
usually placed just in front of C3-C4 or C1-C2.

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4 Wong et al

Fig. 2. An example of cortical ischemia related to a change in blood pressure during a ca-
rotid endarterectomy procedure. (A) The baseline EEG under general anesthesia with no
burst suppression during the surgical exposure. (B) The effect of a reduction in the blood
pressure. Notice the generalized d activity and the loss of higher frequencies (q and a). (C)
A return to baseline activity. The generalized d is gone and the higher frequency q and small
a are coming back.

bands. These bands are: Delta (d), which is 1 to 4 Hz; Theta (q), which is 4 to 8 Hz;
Alpha (a), which is 8 to 12 Hz; and Beta (b), which is usually between 12 and 30 Hz.
a and b are dominant when awake and as anesthesia starts to affect the brain. As un-
consciousness starts, the higher frequency activity is replaced by lower frequency ac-
tivity commonly called “slowing.” In general, critical iatrogenic-induced changes in the
EEG are a reduction in the overall amplitude, a shift to low-frequency activity possible
moving to electrocerebral silence (Fig. 3) due to reductions in the amount of synaptic
activity.10
Inhalational agents at low doses cause an increase in both EEG voltage and fre-
quency.11 In general, as the patient moves to unconsciousness, alpha activity moves
anteriorly, whereas beta activity moves posteriorly.12 This leads to an initial depression
in the overall cortical activity followed by a slowing of the dominant frequency.
Continued depression of activity eventually leads to burst suppression and finally elec-
trocerebral silence at very high doses (see Fig. 3).13 At high doses, this reduction in
EEG activity affects the ability to interpret the EEG. Most importantly, as the reduction
in oxygenation of the brain produces a diffuse slowing of activity, which will eventually
become electrically silent, higher doses of inhalational agents may mimic ischemia.

SENSORY EVOKED POTENTIALS

Sensory evoked potentials monitor sensory pathway integrity by recording at points

cranial and caudal to the surgical field, or in regions that may be indirectly affected
by surgery (ie, aneurysm surgery potentially causing ischemic effects at the sensory
cortex). A distal nerve is stimulated and responses are recorded at specific neural
junctures along the ascending sensory pathway. Given the low amplitude of this
response, it is very difficult to obtain a quality response using a single stimulus, thus

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 Intraoperative Neuromonitoring 5

Fig. 3. A generalized image of the EEG at different anesthetic states. In the awake state, the
EEG shows low-amplitude higher frequency activity (in this case, the EEG is showing a pre-
dominant a activity). As the anesthetic starts to take effect, the a is reduced and the low-
amplitude b activity starts shifting eventually to higher amplitude activity modulated by
some lower frequency q and d activity. As the patient gets deeper, the higher frequencies
are completely lost and the most predominant activity moves from q and d activity to burst
suppression and finally electrocerebral silence. (From Shils JL, Sloan TB. Intraoperative neu-
romonitoring. Int Anesthesiol Clin. 2015;53(1):53 to 73. https://doi.org/10.1097/AIA.
0000000000000043; with permission).

multiple trials are performed and the results of those trials are averaged to remove the
noise and enhance the signal.
The location of the surgery dictates the stimulus and recording locations. Common
SSEP stimulation sites are as follows: (1) posterior tibial nerve at the medial ankle; (2)
the common peroneal nerve behind the knee; (3) the median nerve at the wrist; (4) the
ulnar nerve at the wrist; and (5) the ulnar nerve at the cubital tunnel in the elbow.
Recording electrodes are placed at peripheral locations (popliteal fossa and Erb’s
point), along the spine (cervical spine [C7] and/or thoracolumbar spine [T12]), and
over the sensory cortex [Fpz and C30 , C40 , Cz0 ] [see ]).
Multiple factors affect the transmission of these signals, such as height, tempera-
ture, nerve compression, neural perfusion, anesthetic type, and dose, as well as
some metabolic diseases. Given the primary effect of anesthetic agents is on synaptic
transmission, the greater the number of synapses between the stimulus and recording
sites the greater the effect of the anesthetic agent on that response.

ELECTROMYOGRAPHY

Electromyography monitors the spontaneous (background) (fEMG) or “triggered”

(tEMG) activity in muscles by placing 2 electrodes into the body of the muscle

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6 Wong et al

approximately 1 cm apart. The fEMG method allows for continuous monitoring of any
mechanical or metabolic iatrogenic irritation of nerves without the need for the sur-
geon to use an instrument to stimulate the nerve. In some surgical procedures, the sur-
geon needs to be able to accurately locate nervous tissue that may not easily be
differentiated in the surgical field or to “map” the nervous structures in the surgical
field. This is done using a probe that applies a focused stimulus (“trigger”) to the tissue
while monitoring for time-locked responses that indicate the nervous tissue was acti-
vated. Procedures where this technique is invaluable include skull base and/or ENT
procedures where cranial, and most commonly, the facial nerves may not be easily
identified or entry points may need to be localized. Using variations in stimulus inten-
sity needed to activate the nerve, response amplitude, and response delay help deter-
mine the relative position of the nerve to the stimulator probe.
The EMG requires the neural signal to pass through the neuromuscular junction
which is where the muscle relaxants block nerve transmission. The most common
method to assess the degree of neuromuscular blockade is the train-of-four (TOF)
response where 4 stimuli are applied at 2 Hz and the number of responses and their
amplitudes are analyzed. To assure the best possible EMG response, a majority of
groups recommend that the TOF response should be 4 of 4.14 To get the most appro-
priate TOF result, the test should be performed in the muscles where the critical EMG
response is being observed.14

MOTOR EVOKED POTENTIALS

MEPs monitor the efferent motor pathways from the motor cortex and fibers in the in-
ternal capsule to the muscle via the largest 1% to 2% of axons in corticospinal (or cor-
ticobulbar) tracts.15 To evoke the MEP, transcranial electrical stimulation using a
cathode (electrode) placed on the ipsilateral scalp overlying the motor strip refer-
enced to an anode (1electrode) placed on the contralateral scalp. Transcranial motor
evoked potentials are produced when stimuli directly activate the axons of the large
Betz cells located in the motor cortex, not the cell bodies. This fact is important
because stronger stimulation activates the motor pathway deeper in the brain. Hence
for monitoring when the motor cortex is at risk, “large” stimulation amplitude may acti-
vate corticospinal axons by jumping over the actual area of surgical interest to deeper
structures, thus missing iatrogenic injury in the cortex15,16 (Fig. 4). During open cranial
procedures, MEPs may also be generated by directly stimulating the cortex and/or
subcortical white matter.
Once an action potential is initiated, the activity travels down the corticospinal tract
to activate the alpha-motor neurons (aMN) in laminae IX of the spinal cord to produce
muscle compound action potentials (Fig. 5).
The effect of anesthetics on the motor pathway at the aMN is sufficient to prevent
the recording of myogenic MEPs with a single transcranial stimulation pulse. To over-
come this problem, a multipulse technique consisting of a train of 3 to 9 pulses with an
interstimulus interval between 1 and 4 milliseconds17,18 is used. This multipulse tech-
nique can cause significant patient movement. In most cases, this movement is
acceptable yet, a key precaution is the addition of bite blocks to minimize tongue
and lip lacerations.19

BRAINSTEM AUDITORY EVOKED RESPONSES

BAERs monitor the auditory pathway from the distal VIIIth to the auditory radiations
although for cranial surgery applications monitoring is done to the inferior colliculus
(see Fig. 5). This response is also known as the auditory brainstem response and

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 Intraoperative Neuromonitoring 7

Fig. 4. The left image shows the penetration of the stimulation current into the brain (rep-
resented by the thickness of the red current lines). As can be seen, most of the energy is lost
in the scalp and skull. This is about 80% of the stimulation current. As one looks deeper in
the brain, the current becomes much less. There is a specific threshold that the axons will fire
at. As the current increases, the location of the activation will be deeper in the brain. The
image on the right demonstrates this. The most likely activation point is at bends in the
axon. If the current reaching the deeper structure is strong enough that is the point of acti-
vation irrespective of what happens above that point.

Fig. 5. A graphical representation of the brainstem auditory response with the location of
the peak generators. Using this information, the IONM team can determine the potential
location of the iatrogenic injury to the system.

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8 Wong et al

the brainstem auditory evoked potentials. BAERs are performed by applying a full
band click to the patient and recording responses from the distal VIIIth nerve (wave
I), the proximal VIIIth nerve and the cochlear nucleus (wave II), the cochlear nucleus
(wave III), the superior olivary nucleus and the nuclei of the lateral lemniscus (wave
IV), and the lateral lemniscus and inferior colliculus (wave V). It should be noted that
the actual location of each peak is still debated so you may find different generators
in different texts. Waves I through III are recorded from the ipsilateral nerve and brain-
stem nuclei, whereas waves IV and V are recorded from the contralateral brainstem. It
is also possible to record directly from the VIIIth nerve. BAER can be used to monitor
the integrity of the VIIIth nerve, the integrity of the labyrinthian artery, and segments of
the brainstem.
The applied clicks are usually of 100 to 200 microseconds in duration and 130 dB
normal hearing level and a rate of 0.5 to 100 clicks per second (although a 11–
13 Hz is what is commonly used in the operating room). In some cases, masking noise
is used in the contralateral ear to minimize the effects from that ear on the recordings
but many times in the OR masking noise is not used. The clicks can either be rarefac-
tion (initial portion of the click “pulls” the eardrum), condensation (the initial click
“pushes” the eardrum), or alternating which can be used to help minimize the stimu-
lation artifact. Each of these polarities can affect the latency and shape of the re-
sponses, which need to be taken into account when switching between them in the
operating room. Changing the polarity can help minimize noise that obscures the
results.
Waves I, III, and V are the most prominent waves and are thus the primary waves
used in evaluating potential iatrogenic injury. Both amplitude and latency changes
are indicators of potential injury to some part of the system. Changes in the latency
between waves I and III can indicate a problem in the VIIIth nerve, whereas changes
in the latency between waves III and V can indicate issues in the brainstem. The tem-
perature has a significant effect on the BAER latency with colder temperatures
increasing the latency of each wave, thus this would not be related to iatrogenic injury.
Latency and interpeak intervals increase by about 7% for each 1 C drop in temper-
ature.20 Traction or compression of the VIIIth nerve usually show as progressive
changes over time with an increase in latency between waves I and III with little to
no change in the latency between waves III and V.20 These changes can be reversible.
Damage to the labyrinthian artery or anterior inferior cerebellar artery on the other hand
is usually not reversible and can show as a quick loss of all responses (waves I through
V). In a systematic review of the literature, Thirumala and colleagues showed that
specificity was high (98%), indicating that patients who woke with a deficit had a
change in the BAER, whereas sensitivity was low (74%), indicating that even with a
change in the OR some patient still woke with hearing intact.21 Loss of wave V alone
does not necessarily mean hearing will be lost at the end of surgery because tempo-
rary dispersion of responses do inflict minor mechanical injury.20,21

DIRECT CORTICAL STIMULATION

Intracranial surgery requires intimate knowledge of cortical and subcortical function to

minimize postoperative neurologic deficits. Understanding the anatomic relationship
of these areas with both surface and deep landmarks allows the surgeon to determine
the safety of a planned resection. However, even with an extensive understanding of
such relationships, individual variations in functional arrangement exist.22–27 Further-
more, pathologic distortion of cortical eloquence either through mass effect or func-
tional rearrangement often makes reliance on normal anatomic functional

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 Intraoperative Neuromonitoring 9

arrangement unacceptably inaccurate.28–30 Though advanced imaging such as func-

tional MRI, tractography, and magnetoencephalography provides patient-specific
anatomic and functional detail, the lack of adequate granularity in such data often pre-
cludes them from being authoritative methods in determining surgical approaches and
influencing intraoperative decision making. Direct cortical stimulation and mapping
provide real-time information regarding the cortical or subcortical region of interest
allowing for informed decision making by the surgeon. In this section, we will discuss
the indications and benefits of this intraoperative neuromonitoring technique as well as
its limitations.

Indication and Patient Selection

When eloquent regions of the brain are suspected to be intimately involved in the path-
ologic process, direct intraoperative cortical mapping should be considered. Cortical
mapping is particularly informative when delineating areas involved in motor, sensory,
and speech functions. Although advanced imaging modalities are often not detailed
enough to direct operative decision making, they nevertheless are useful in approxi-
mating these eloquent areas and determining the need for cortical mapping. There-
fore, cortical mapping is not a replacement for these preoperative investigations but
rather a consequence of them. Although mapping of the motor cortex can be done
with the patient fully anesthetized, mapping of the sensory and language cortex
must be done with the patient awake. As such, the capacity of the patient’s ability
to tolerate an awake craniotomy should be assessed when considering sensory and
language mapping. Extensive neuropsychiatric testing of language function must
also be completed as language mapping requires adequate baseline function to pro-
vide a reliable and reproducible reference.

Surgical Considerations
Intraoperative cortical mapping requires considerable coordination among many
different teams, including neurosurgeon, anesthesiologists, neurophysiologists,
speech therapists, operating room nurses, and surgical technicians. The expectations
and goals of surgery should be thoroughly reviewed with all teams involved to ensure
optimal surgical outcomes. Premedication with an anxiolytic is typically given in the
preoperative area before arrival in the operating room. A local anesthetic is then
injected subcutaneously circumferentially in the scalp. If frameless intraoperative neu-
ronavigation is used, the patient is placed in a skull clamp for rigid fixation with a
further local anesthetic injected at the pin sites. After the surgical site is prepped
and sterilized, the surgical drapes are placed in a fashion that allows ancillary staff
to access the patient’s face and contralateral extremities for assessment of function.

Stimulation Mapping
Identification of the central sulcus
An important landmark in many intracranial surgeries is the central sulcus as it defines
the sensory and motor cortices. Although preoperative imaging and intraoperative ob-
servations of gyri and sulci can provide an approximation of the central sulcus, defin-
itive identification is sometimes needed. SSEPs using a cortical electrode strip can be
used in such situations to identify the central sulcus.31,32 After identification of the Syl-
vian fissure, the electrode strip is placed over the cortical surface perpendicular to the
presumed central sulcus approximately 3 cm above the Sylvian. An N20 wave is
recorded using a stimulus to the contralateral median nerve. A phase reversal in the
wave is seen in the recordings from the sensory cortex to the motor cortex, identifying
the central sulcus (Fig. 6). This process is repeated 2 to 3 times moving rostrally to

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10 Wong et al

Fig. 6. Phase reversal across channels 2 and 3 seen as a deflection and inversion of the waves
as you move sequentially across the electrode strip that is placed perpendicularly and
traversing across the presumed central sulcus.

further delineate the central sulcus, which is then labeled for identification (Fig. 7).
Phase reversal is particularly useful in identifying the central sulcus when there is dis-
torting pathology and is a technique that can be done in a fully anesthetized or awake
patient.

Fig. 7. Mapping of the central sulcus laterally using phase reversal by sequentially moving
the electrode strip laterally (as represented by the colored dots).

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 Intraoperative Neuromonitoring 11

Sensorimotor stimulation
After the central sulcus is determined through phase reversal on SSEP recordings,
direct cortical stimulation can then be used for specific mapping of functional regions
of the sensory and motor cortex. This is particularly of use when pathology has caused
distortion in the normal anatomy. Stimulation of the sensory cortex begins in the
suprasylvian area and must be done while the patient is awake. A unipolar or bipolar
stimulator is used to provide a 1 to 2 mA stimulus at a 60 Hz frequency and 0.5 to 1 ms
pulse duration. The cortex in question is sequentially stimulated in w1 cm2 plots
where the stimulator is placed for 3 seconds and the patient is asked to report
changes in sensation such as paresthesias. This can be repeated to map out the
tongue, lip, and hand somatotopic areas. To map lower extremity cortical representa-
tion, an electrode strip may be used to stimulate the difficult-to-reach interhemispheric
fissure.
Mapping of the motor cortex can be done with the patient awake or fully anesthe-
tized.33 Stimulation is conducted in a similar fashion beginning at the suprasylvian
area of the precentral gyrus. Higher amplitudes of stimulation may be required in a fully
anesthetized patient to reach the threshold for response, though amplitudes above
6 mA are not recommended. The amplitude is increased gradually until movement
in the contralateral limb is noted. Alternatively, changes in electromyography record-
ings of the contralateral limb can be noted for response.
After discharges immediately following stimulus should be carefully monitored and
treated. Focal or generalized seizures as a result of intraoperative cortical mapping
occur with an incidence of 8.8% to 35%.34,35 These can typically be terminated by irri-
gating the cortex with chilled Ringer’s solution for 5 to 10 seconds. If this does not
terminate the seizures, a bolus of propofol can be given followed by methohexital
for continued refractory seizures.36 As with the treatment of any seizures, careful
and continued assessment for the need to secure the patient’s airway via intubation
is paramount.

Language mapping
Language mapping is used in patients with pathology in the region of the dominant
perisylvian frontotemporal lobes. Like sensory mapping, language mapping must be
done in an awake patient. As it requires constant assessment of the patient’s language
function, extensive preoperative testing of the patient’s baseline language function
must be conducted. Patients with existing significant language deficits or those who
cannot tolerate a physically demanding awake surgery would not benefit from lan-
guage mapping.
Both unipolar and bipolar stimulation has been described though recent trends have
shifted toward the former. Although bipolar stimulation is considered more sensitive in
detecting clinically eloquent areas, unipolar stimulation has demonstrated a lower inci-
dence of seizure induction. After discharges induced by stimulation, as measured by
an electrocorticography grid, can lead to false-positive readings. Stimulation typically
begins with an amplitude of 1 mA at 60 Hz with a pulse duration of 1 millisecond and is
carried out in a similar fashion to sensory mapping wherein the stimulus is applied for
approximately 3 seconds and speech arrest is monitored. Stimulus amplitude should
be tailored such that it remains just below levels that would induce after discharges.
Each cortical plot is stimulated 3 times. Counting, object naming, and word reading
are tested with each sequential stimulus application. If the patient is unable to com-
plete these tasks for 2 of 3 stimuli, the cortical plot is considered eloquent and positive
for language function.37 As opposed to sensory or motor mapping, the cortex is map-
ped out in comparatively smaller 3 mm2 plots.

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12 Wong et al

Once mapping is completed and all relevant cortical areas are labeled, resection
can commence in a cortically “silent” area. All areas positive for language function
should be avoided with a 1 cm margin or up to an adjacent sulcus. Anterior temporal
lobe resections of the dominant hemisphere within 2 cm of identified language areas
may result in mild aphasia that tends to improve over time.38–40
Should no surgically exposed area test positive for language function, a consensus
should be reached among the neurosurgeon, anesthesiologist, and neurophysiologist
that all aspects of mapping from sedation level to technique and equipment function-
ality were satisfactory and appropriate. It is also critical in such scenarios to have
determined the after-discharge threshold as a positive control and to identify the
maximal safe stimulus amplitude.
Subcortical stimulation mapping
Some intracranial procedures require exploration beyond the cortical surface, partic-
ularly in tumor resection surgery. Subcortical white matter tracts can be just as clini-
cally relevant as the cortex and, when suspected, their preservation should be of equal
importance. Mapping of the subcortical white matter can be completed in a similar
fashion to determine eloquence before surgical manipulation or resection. Subcortical
mapping is often carried out using unipolar stimulation and requires higher amplitude
stimulation when compared with cortical mapping.
Subcortical mapping
As the surgical dissection and resection continues beyond the cortical surface and
gray matter, it is critical to maintain an understanding of the eloquent deep white mat-
ter tracts. In fact, successful cortical mapping-directed dissection can be undermined
if deeper subcortical tracts are disrupted. Subcortical stimulation mapping refers to
the stimulation of subcortical white matter to identify descending or ascending white
matter tracts that connect cortical gray matter with deep gray nuclei. Pathologic
distortion in normal anatomy holds especially true within the more grossly homoge-
nous subcortical white matter, making subcortical stimulation mapping and intraoper-
ative neuronavigation especially important in identifying and maintaining the integrity
of important subcortical pathways.41 The technical aspects of subcortical stimulation
mapping are much the same as cortical mapping though typically entails higher stim-
ulation parameters and requires incremental resection and frequent confirmation with
stimulation and neuronavigation before proceeding.

CLINICS CARE POINTS

The use of intraoperative neuromonitoring must be tailored for each case.

Prior to the utilization of any intraoperative neuromonitoring modality, careful
consideration should be paid to its specific clinical utility, if any, and how it may affect
operative decision making.

A team-based approach among the neurosurgeon, anesthesiologist, neuromonitoring
technician, and neurologist is key to the successful implementation and use of
intraoperative neuromonitoring.

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