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Electrical promontory stimulation in patients with intact cochlear nerve and anacusis following acoustic neuroma surgery.

Anacusis following hearing preservation surgery for acoustic neuroma removal in which the cochlear nerve was preserved has been explained on the basis of neural or vascular compromise. In the absence of pathologic evidence for either theory, a physiologic model was chosen. Electrical promontory stimulation with monitoring of subjective and electrically evoked auditory brainstem responses was undertaken. A positive response to stimulation suggests a vascular impairment of the cochlea sparing the cochlear nerve and spiral ganglion. The absence of response suggests loss of neural integrity at the level of the spiral ganglion or cochlear nerve. Six patients who suffered anacusis following hearing preservation surgery for acoustic neuroma were studied. Data regarding electrical promontory stimulation, auditory brainstem responses, and implications of the possible role of cochlear implantation are discussed.

California↗

The fine structure of acoustic ganglia in the rat.

Nerve cell bodies in the spiral and vestibular ganglia of the adult rat are surrounded by thin (about ten lamellae) myelin sheaths which differ in several respects from typical axonal myelin. In some instances lamellae surrounding perikarya appear as typical major dense lines, and in others as thin Schwann cell sheets in which cytoplasm persists. Discontinuities and irregularities appear in the structure of perikaryal myelin. Lamellae may terminate anywhere within the sheaths; they may bifurcate; they may reverse their direction; or they may merge with each other. The number of lamellae varies from one part of a sheath to another. In addition, the myelin of a single perikaryal sheath may receive contributions from more than one Schwann cell, which overlap and interleave with each other. The ganglion cells are of two types: those which are densely packed with the usual cytoplasmic organelles but have few neurofilaments (granular neurons), and those which exhibit large areas containing few organelles but have a high concentration of neurofilaments (filamented neurons). The latter cell type is ensheathed by myelin which is generally more compact that that surrounding the former. The formation and the physiologic significance of perikaryal myelin are discussed.

Animals↗

Effect of partial neuromuscular blockade on intraoperative electromyography in patients undergoing resection of acoustic neuromas.

Intraoperative electromyographic monitoring of the facial nerve during acoustic neuroma excision provides early detection of nerve injury and improved outcome. To determine whether a useful level of peripheral neuromuscular blockade could be achieved without compromise of facial electromyographic monitoring, we studied 10 patients undergoing resection of acoustic neuroma. Facial nerve monitoring was accomplished by placement of wire electrodes in the orbicularis oris, orbicularis occuli, and mentalis muscles. Peripheral neuromuscular blockade was assessed by recording unprocessed hypothenar compound muscle action potentials (CMAPs). After induction of anesthesia, an infusion of atracurium (1.0 micrograms.kg-1.min-1) accompanied by a bolus dose of 50 micrograms/kg was administered. The infusion was then increased in increments of 0.5 micrograms.kg-1.min-1 until a 50% reduction in hypothenar single-twitch CMAP was obtained. Facial nerve function was continuously monitored by comparison of facial CMAPs produced by stimulation of the nerve proximal and distal to the tumor bed. The mean (+/- SD) infusion rate of atracurium was 2.55 +/- 0.75 micrograms.kg-1.min-1. Decrements in facial nerve CMAPs were detected in 6 of 10 patients, and all demonstrated moderate to severe facial nerve dysfunction. In no patient was an unexpected deficit present postoperatively. Moderate degrees of peripheral neuromuscular blockade can be achieved without compromising facial nerve electromyographic monitoring.

Action Potentials↗

Distribution of VIII nerve excitation by pure tones, derived by electrical stimulation and acoustic masking.

VIII nerve compound action potentials evoked by electrical stimulation are decomposed in series of pure-tone derived potentials using masking. These potentials are in turn decomposed in a series of contributions from various frequency bands by adding high-pass masking noises. The amplitudes of the derived signals are thought to be proportional to the number of fibres activated by the masking acoustical stimulations. Thus the density of nerve fibres stimulated along the basilar membrane by pure tones as a function of frequency and intensity can be estimated.

Animals↗

Response of cochlear nerve fibers to brief acoustic stimuli: role of discharge-history effects.

The probability that a cochlear nerve fiber spike discharge occurs during a time interval delta t depends on both the acoustic stimulus and on aftereffects from earlier spike discharges. We have examined the influence of discharge-history on post-stimulus time (PST) histogram responses to acoustic click and tone-burst stimuli. Discharge-history effects were found to include the modification of observed interpeak times of PST responses to clicks, a loss of distinct peaks in the click response of high characteristic frequency (CF greater than 5 kHz) fibers, and changes in the ratio of initial to steady-state response portions of tone-burst responses. The method used to separate discharge-history from stimulus-related factors is based on a model developed in Gaumond et al. [J. Neurophysiol. 48, 856-873 (1982)]. The results are in general agreement with those obtained by the method of Peter Gray [Biophys. J. 7, 759-777 (1967)], which discards from consideration those portions of the response record not preceded by a silent interval of 20 or 25 ms or more. Our method requires more assumptions about the spike train, but produces less variable results by utilizing more of the spike train data.

Acoustic Stimulation↗

Contrast-enhanced magnetic resonance imaging of the cranial nerves in patients with acoustic schwannoma: correlation with surgical findings.

Eighteen patients with acoustic schwannoma were examined on a 1.5-T magnetic resonance imaging (MRI) unit with precontrast and postcontrast T1-weighted spin-echo sequences. Each abnormality was assessed in terms of the size, location, extensions and signal intensity of the lesions. If a nerve was enhanced and was involved by the tumor around the fundus of the internal auditory canal (IAC), the nerve was interpreted to be the originating nerve. The postcontrast T1-weighted images revealed enhanced masses of the cerebellopontine angle and/or the IAC in all cases. In 11 of the 19 operated patients with shwannomas, the site of tumor origin (or origin nerve) was confirmed by surgery. In 2 of the 11 cases (18%), surgical findings coincided with the T1-weighted image findings. Facial nerve enhancement on the ipsilateral side of the tumor was noted in 10 cases (53%) and the contralateral facial nerve enhancement was demonstrated in 7 (70%). The enhancement of facial nerve associated with acoustic schwannoma was not correlated to the degree of nerve compression by the tumor. These results demonstrate that it was possible, although infrequent, to predict the site of origin of acoustic schwannoma before surgery in some patients. Improvement of the imaging matrix or multiplanar reconstruction techniques with three-dimensional data acquisition may make it possible to overcome the limitations of MRI.

Adult↗

Stochastic properties of cat auditory nerve responses to electric and acoustic stimuli and application to intensity discrimination.

Statistical properties of electrically stimulated (ES) and acoustically stimulated (AS) auditory nerve fiber responses were assessed in undeafened and short-term deafened cats, and a detection theory approach was used to determine fibers' abilities to signal intensity changes. ES responses differed from AS responses in several ways. Rate-level functions were an order of magnitude steeper, and discharge rate normally saturated at the stimulus pulse rate. Dynamic ranges were typically 1-4 dB for 200 pps signals, as compared with 15-30 dB for AS signals at CF, and they increased with pulse rate without improving threshold or changing absolute rate-level function slopes. For both ES and AS responses, variability of spike counts elicited by repeated trials increased with level in accord with Poisson-process predictions until the discharge rate exceeded 20-40 spikes/s. AS variability continued increasing monotonically at higher discharge rates, but more slowly. In contrast, maximum ES variability was usually attained at 100 spikes/s, and at higher discharge rates variability reached a plateau that was either maintained or decreased slightly until discharge rate approached the stimulus pulse rate. Variability then decreased to zero as each pulse elicited a spike. Increasing pulse rate did not substantially affect variability for rates up to 800 pps; rather, higher pulse rates simply extended the plateau region. Spike count variability was unusually high for some ES fibers. This was traced to response nonstationarities that stemmed from two sources, namely level-dependent fluctuations in excitability that occurred at 1-3 s intervals and, for responses to high-rate, high-intensity signals, fatigue that arose when fibers discharged at their maximum possible rates. Intensity discrimination performance was assessed using spike count as the decision variable in a simulated 2IFC task. Neurometric functions (percent correct versus intensity difference) were obtained at several levels of the standard (I), and the intensity difference (delta I) necessary for 70% correct responses was estimated. AS Weber fractions (10 log delta I/I) averaged +0.2 dB (delta IdB = 3.1 dB) for 50 ms tones at CF. ES Weber fractions averaged -12.8 dB (delta IdB = 0.23 dB) for 50 ms, 200 pps signals, and performance was approximately constant between 100 and 1000 pps. Intensity discrimination by single cells in ES conditions paralleled human psychophysical performance for similar signals. High ES sensitivity to intensity changes arose primarily from steeper rate-level functions and secondarily from reduced spike count variability.

Acoustic Stimulation↗

Monitoring of facial nerve function during removal of acoustic tumor.

A method for locating the facial nerve during removal of medium to large acoustic tumors is described. The method consists of stimulating the tumor mass with short rectangular pulses of monopolar, constant voltage and then presenting the electrical responses from the facial muscles through a loudspeaker. In this way, regions of the tumor where there is no nerve present can be identified and large parts of the tumor removed safely and quickly. Monitoring spontaneous electromyogram (EMG) activity was used to reduce the risk of damaging the facial nerve when parts of medium to large acoustic tumors adhering to the nerve were removed from 20 patients operated upon consecutively by the same surgeon. Only 1 patient lost facial function with the nerve intact anatomically. Nine patients had normal function immediately after the operation and had no detectable weakness upon discharge 6-8 days later, 4 patients had weakness which was resolved, and 6 patients had partial loss of facial function at the time of discharge. The same method may be used to identify the facial nerve during other operations in which this structure is at risk.

Cranial Nerve Neoplasms↗

The limitations of hearing preservation in acoustic neuroma surgery: histological study of the interface between the eighth cranial nerve and the tumor.

The interface between the eighth cranial nerve and acoustic neuroma was investigated by light microscopy and immunohistochemistry in paraffin sections in 13 patients, and in Epon sections in 19 patients. The cochlear nerve was severely invaded by tumor cells in two of six specimens examined, moderately invaded in two specimens, and not invaded in two specimens. Gliosis was frequently found within the cochlear and vestibular nerve. Hemangioma-like tissue was occasionally found attached to the cochlear and vestibular nerve adjacent to the tumor. These findings were considered to be related to difficulty in hearing preservation in some patients although acoustic neuroma surgery was successful.

Adult↗

The benefits of VII-VII neuroanastomosis in acoustic tumor surgery.

Division of the seventh nerve during acoustic tumor removal cannot always be avoided. Direct VII-VII neuroanastomosis is superior to any other neuroanastomosis for facial reanimation. Rerouting of the seventh nerve from the mastoid and neuroanastomosis can be accomplished primarily at the initial surgery. This study reviews 19 patients with a follow-up of greater than 18 months who underwent the procedure at the time of tumor removal because of seventh nerve involvement by tumor, intentional sacrifice or, rarely, unintentional division. A House class IV result or better, without the twelfth nerve neurological deficit produced by a VII-XII neuroanastomosis, was achieved in 16 of 19 patients. Although the technique is not new, surgeons unprepared to manage this surgical complication at primary tumor removal should either learn the technique, work with an associate who can do so, or be prepared to call in someone else to do it.

Adipose Tissue↗

Nerve origin of the acoustic neuroma.

Two hundred and seventy-one Japanese patients who underwent surgical removal of neuroma from the cerebello-pontine angle using the translabyrinthine approach were retrospectively reviewed in order to investigate the nerve origin on an anatomical basis. In 269 out of the 271 cases, the origin of the neuromas was identified. Among these cases, 84.8 per cent of tumours originated from the inferior vestibular nerve (IVN), followed by the superior vestibular nerve (SVN) (8.9 per cent). Of the 5.6 per cent of tumours arising from the vestibular nerve, however, it could not be determined whether they originated from the SVN or IVN. Two cases of neuromas originating from the facial nerve were seen (0.7 per cent). No neuroma arose from the cochlear nerve. Currently, the diagnosis of acoustic neuromas is best made with Gd-enhanced magnetic resonance imaging (MRI). However, our data indicate that the development of a functional test of the individual IVN can be useful for screening most cases of acoustic neuroma and in facilitating their early diagnosis.

Cerebellar Neoplasms↗

Ultrastructural localization of nerve growth factor receptor in acoustic neurinoma.

Light and electron microscopic immunohistochemical studies on nerve growth factor (NGF) receptors in acoustic neurinoma cases were made using a monoclonal antibody to human NGF receptor. Immunoreactivity of the NGF receptor was found exclusively on the cytoplasmic membrane of schwannoma cells. Reaction product was highly concentrated at the interdigitated distal end of the cell processes, but it was discontinuous in the perinuclear area of the cell body. Basal lamina was located outside the immunoreacted cytoplasmic membrane of the cell body, but it was not observed at the tip of the interdigitated cell processes. These findings suggest that NGF receptor expression has some relationship with the formation of interdigitated schwannoma cell processes. Other possibilities for the functional significance of the schwannoma NGF receptor are also discussed.

Antibodies, Monoclonal↗

Facial nerve dissection by use of acoustic (loudspeaker) facial EMG monitoring.

The development of the surgical microscope in 1953, and the subsequent development of microsurgical instrumentation, signaled the beginning of modern-day acoustic neuroma surgery. Preservation of facial nerve function and total tumor removal is the goal of all acoustic neuroma surgery. The refinement of the translabyrinthine removal of acoustic neuromas by Dr. William House significantly improved preservation of facial nerve function. This is made possible by the anatomic identification of the facial nerve at the lateral end of the internal auditory canal. When the surgery is accomplished from a suboccipital or retrosigmoid approach, the facial nerve may be identified at the brain stem or within the internal auditory canal. Identifying the facial nerve from the posterior approach is not as anatomically precise as from the lateral approach through the labyrinth. The use of a facial nerve stimulator can greatly facilitate identification of the facial nerve in these procedures.

Acoustics↗