Total Intravenous Anesthesia Protocol for Decreasing Unacceptable Movements during Cerebral Aneurysm Clipping with Motor-Evoked Potential Monitoring: A Historical Control Study and Meta-Analysis

Injury can occur during intraoperative transcranial motor-evoked potential (MEP) monitoring caused by patient movement related to insufficient neuromuscular blocking agent use. Here, we evaluated the incidence of unacceptable movements in patients undergoing intraoperative MEP monitoring following our anesthetic protocol. We reviewed the anesthesia records of 419 patients who underwent unruptured cerebral aneurysm clipping with intraoperative MEP monitoring. The anesthetic protocol included target-controlled infusion with a fixed effect-site propofol concentration of 3 mu g/mL and an adjustable effect-site remifentanil concentration of 10-12 ng/mL. We compared our findings of the intraoperative parameters and incidence of spontaneous movement and respiration with those of published meta-analysis studies. Spontaneous movement and respiration occurred in one (0.2%) patient each. The meta-analysis included six studies. The pooled proportions of spontaneous movement and respiration were 6.9% (95% confidence interval [CI], 1.3-16.5%) and 4.1% (95% CI, 0.5-14.1%), respectively. The proportion of spontaneous movement in our study was significantly lower than that in previous studies (p = 0.013), with no significant difference in spontaneous respiration (p = 0.097). Following our center's anesthesia protocol during cerebral aneurysm clipping resulted in a low incidence of spontaneous respiration and movement, indicating its safety for patients undergoing intraoperative MEP monitoring.