Multimodal neuromonitoring during aortic arch surgeries: A prospective study of neurologic outcomes and postoperative recovery.

OBJECTIVE: Neurologic complications remain a major cause of morbidity after aortic arch repair despite advances in cerebral protection. Multimodal intraoperative neurophysiological monitoring (IONM) offers real-time assessment and opportunities for intervention but is underused. We evaluated its impact on neurologic outcomes in patients undergoing major aortic surgeries. METHODS: We retrospectively enrolled 134 adults undergoing consecutive aortic arch surgery with circulatory arrest (February 2018 to July 2024). Patients were stratified by IONM use and surgical urgency. The multimodal IONM protocol included electroencephalography, somatosensory-evoked potentials, brainstem auditory-evoked potentials, transcranial motor-evoked potentials, transcranial Doppler, and near-infrared spectroscopy. Primary outcome was a major intraoperative neurologic complication. Logistic and log-linear regression models adjusted for age, sex, and urgency assessed associations between IONM use and postoperative outcomes. RESULTS: Of 134 patients, 78 (58%) received IONM. Monitored patients had significantly lower neurologic complication rates (13% vs 39%; P < .001), shorter hospital stays (9 vs 13 days; P = .017), and reduced intubation duration (20 vs 46 hours; P = .007). Rates of major intraoperative neurologic complications were significantly lower in the monitored group (3.8% vs 29%; P < .001) but no differences were observed in the rates of postoperative neurologic complications (2.6% vs 7.1%; P = .2). IONM was associated with reduced risk of major neurologic complications (odds ratio [OR], 0.31; P = .02) and prolonged ventilation >48 hours (OR, 0.38; P = .03). IONM was associated with lower odds of neurologic complications in both emergent (OR, 0.17; P < .001) and elective (OR, 0.30; P = .01) surgeries. CONCLUSIONS: IONM during major aortic surgeries was associated with fewer adverse neurologic events and faster recovery, supporting its integration for improved cerebral protection across elective and emergent operations.