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An Alternative Position for the BIS-Vista Montage in Frontal Approach Neurosurgical Cases

Nelson, Priscilla MD*; Nelson, Jonas A. MD; Chen, Alexander J. MD; Kofke, W. Andrew MD, MBA*

Journal of Neurosurgical Anesthesiology: April 2013 - Volume 25 - Issue 2 - p 135–142
doi: 10.1097/ANA.0b013e31826ca3a0
Clinical Investigations

Background: Appropriate placement of the bispectral index (BIS)-vista montage for frontal approach neurosurgical procedures is a neuromonitoring challenge. The standard bifrontal application interferes with the operative field; yet to date, no other placements have demonstrated good agreement. The purpose of our study was to compare the standard BIS montage with an alternate BIS montage across the nasal dorsum for neuromonitoring.

Materials and Methods: The authors performed a prospective study, enrolling patients and performing neuromonitoring using both the standard and the alternative montage on each patient. Data from the 2 placements were compared and analyzed using a Bland-Altman analysis, a Scatter plot analysis, and a matched-pair analysis.

Results: Overall, 2567 minutes of data from each montage was collected on 28 subjects. Comparing the overall difference in score, the alternate BIS montage score was, on average, 2.0 (6.2) greater than the standard BIS montage score (P<0.0001). The Bland-Altman analysis revealed a difference in score of −2.0 (95% confidence interval, −14.1, 10.1), with 108/2567 (4.2%) of the values lying outside of the limit of agreement. The scatter plot analysis overall produced a trend line with the equation y=0.94x+0.82, with an R2 coefficient of 0.82.

Conclusions: We determined that the nasal montage produces values that have slightly more variability compared with that ideally desired, but the variability is not clinically significant. In cases where the standard BIS-vista montage would interfere with the operative field, an alternative positioning of the BIS montage across the nasal bridge and under the eye can be used.

*Department of Anesthesiology and Critical Care

Division of Plastic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA

Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA

The authors have no funding or conflicts of interest to disclose.

Reprints: W.A. Kofke, MD, MBA, Department of Anesthesiology and Critical Care, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104 (e-mail:

Received April 19, 2012

Accepted July 31, 2012

© 2013 by Lippincott Williams & Wilkins