Comparison Between Conventional Flash and Off-Response Intraoperative Visual Evoked Potential Monitoring for Endoscopic Endonasal Surgery

Abstract

BACKGROUND Intraoperative flash stimulation visual evoked potential (VEP) monitoring has been used for endoscopic endonasal approach (EEA). Recently, off-response VEP, which is recorded when the light stimulus is turned off, was introduced to monitor visual function intraoperatively. OBJECTIVE To evaluate off-response VEP monitoring in comparison with the conventional flash stimulation VEP monitoring for EEA. METHODS From March 2015 to March 2020, 70 EEA surgeries with intraoperative VEP monitoring (140 eyes) were performed. Light stimuli were delivered by a pair of goggle electrodes. Recording electrodes were placed on the scalp over the occipital region. The warning signal was prompted by a reduction of the peak-to-peak amplitude of the VEP by more than 50% compared to the initial amplitude. Visual function was assessed pre- and postoperatively. Results of flash and off-response VEP monitoring were compared. RESULTS VEP was recorded in 134 eyes. Warning signal occurred in 23 eyes (transient in 17 eyes and permanent in 6 eyes). Two eyes showed permanent VEP attenuation for flash VEP monitoring, in which one patient had postoperative visual function deterioration. Four eyes showed permanent VEP attenuation for off-response VEP monitoring, where 2 patients had postoperative visual function deterioration. Sensitivity, specificity, positive predictive value, and negative predictive value were 100%, 98.9%, 50%, and 100%, respectively, for flash stimulation VEP, and 100%, 97.8%, 50%, and 100%, respectively, for off-response VEP. CONCLUSION VEP monitoring was useful to monitor visual function in EEA surgery. Off-response VEP monitoring was not inferior to conventional flash stimulation VEP monitoring.

Commentary: Comparison Between Conventional Flash and Off-Response Intraoperative Visually Evoked Potential Monitoring for Endoscopic Endonasal Surgery

“…Clinically, the sensitivity, specificity, positive predictive value, and negative predictive value of off-response monitoring, as it related to postoperative visual outcomes, suggests that it provides clinically relevant, real-time feedback for optic nerve function during surgery for resection of pathology of the suprasellar space. 3 The authors should be commended for their work in applying a useful technology in a rapidly expanding field. Postoperative visual decline remains one of the most feared complications of endoscopic endonasal surgery.…”

“…Clinically, the sensitivity, specificity, positive predictive value, and negative predictive value of off-response monitoring, as it related to postoperative visual outcomes, suggests that it provides clinically relevant, real-time feedback for optic nerve function during surgery for resection of pathology of the suprasellar space. 3…”