1
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Shayesteh-Kheslat R, Lescan M. [Open surgical treatment for carotid stenoses]. RADIOLOGIE (HEIDELBERG, GERMANY) 2024; 64:699-704. [PMID: 38713222 DOI: 10.1007/s00117-024-01307-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/17/2024] [Indexed: 05/08/2024]
Abstract
BACKGROUND Globally, stroke is considered the second most common cause of death. According to the German Federal Statistical Office, 33.6% of mortality was due to cardiovascular diseases, making them the most prevalent cause of death. PROBLEM Specifically, cerebral infarctions were recorded as the cause in over 16,000 cases. These figures underscore the significant role that cerebrovascular diseases play in Germany's mortality statistics. Notably, about 80% of strokes are ischemic. Moreover, one-fifth of all strokes result from extracranial carotid stenosis. The increase in stroke risk with advancing age, especially among men, is particularly striking. This trend highlights the growing importance of efficient stroke prevention and treatment in an aging society. CONCLUSION Open surgical therapy, as a crucial treatment method, is increasingly important, especially as an emergency intervention. Its role in modern medicine emphasizes the urgency of prioritizing this life-saving procedure in healthcare and making it widely available.
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Affiliation(s)
- Roushanak Shayesteh-Kheslat
- Klinik für Allgemeine Chirurgie, Viszeral‑, Gefäß- und Kinderchirurgie, Universitätsklinik des Saarlandes, Kirrberger Straße 100, Geb. 57, 66421, Homburg/Saar, Deutschland.
| | - Mario Lescan
- Klinik für Thorax- Herz- und Gefäßchirurgie, Universitätsklinikum Tübingen, Tübingen, Deutschland
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Plata-Bello J, Pérez-Lorensu PJ, Saponaro-González Á, Darias-Delbey B, Fariña-Jerónimo H, Domínguez-Lorenzo JM, Ucelay-Gómez R, González-Tabares EF, Ibrahim-Achi Z, Guerrero-Ramírez CS, Padrón-Encalada CE, Pérez-Burkhardt JL. Can NIRS be a surrogate indicator of elective shunt in carotid endarterectomy? A single-center observational retrospective study says no. J Clin Monit Comput 2024; 38:631-638. [PMID: 38064136 DOI: 10.1007/s10877-023-01114-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 11/23/2023] [Indexed: 06/11/2024]
Abstract
BACKGROUND Neuromonitoring during carotid endarterectomy (CEA) under general anesthesia is desirable and may be useful for preventing brain ischemia, but the selection of the most appropriate method remains controversial. PURPOSE To determine the effectiveness of near infrared spectroscopy (NIRS) compared to multimodality intraoperative neuromonitoring (IONM) in indicating elective shunts and predicting postoperative neurological status. METHODS This is a retrospective observational study including 86 consecutive patients with CEA under general anesthesia. NIRS and multimodality IONM were performed during the procedure. IONM included electroencephalography (EEG), somatosensory evoked potentials (SSEPs) and transcranial motor-evoked potentials (TcMEPs). Sensitivity, specificity, and positive and negative predictive values (PPV and NPV) were calculated for each neuromonitoring modality. RESULTS NIRS presented a sensitivity and a specificity for detecting brain ischemia of 77.7% and 89.6%, respectively (PPV = 46.6% and NPV = 97.2%). In contrast, a 100% sensitivity and specificity for multimodality IONM was determined (PPV and NPV = 100%). No significant difference (in demographical or clinical data) between "true positive" and "false-positive" patients was identified. Among the methods included in multimodality IONM, EEG showed the best results for predicting postoperative outcome after CEA (PPV and NPV=100%). CONCLUSION NIRS is inferior to multimodality IONM in detecting brain ischemia and predicting postoperative neurological status during CEA under general anesthesia.
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Affiliation(s)
- Julio Plata-Bello
- Department of Neurosurgery, Hospital Universitario de Canarias, Carretera Ofra s/n La Cuesta. CP 38320. La Laguna, S/C de Tenerife, Santa Cruz de Tenerife, Spain.
| | | | | | - Beneharo Darias-Delbey
- Department of Anesthesiology, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain
- Department of Vascular Surgery, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain
| | - Helga Fariña-Jerónimo
- Department of Neurosurgery, Hospital Universitario de Canarias, Carretera Ofra s/n La Cuesta. CP 38320. La Laguna, S/C de Tenerife, Santa Cruz de Tenerife, Spain
| | | | - Roberto Ucelay-Gómez
- Department of Anesthesiology, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain
| | | | - Zena Ibrahim-Achi
- Department of Anesthesiology, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain
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Díaz-Baamonde A, Peláez-Cruz R, Téllez MJ, Lantis J, Ulkatan S. Median nerve somatosensory evoked potential alarm related to head and neck positioning for carotid surgery. J Clin Monit Comput 2023; 37:699-704. [PMID: 35960492 DOI: 10.1007/s10877-022-00904-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 07/27/2022] [Indexed: 11/25/2022]
Abstract
Head positioning in carotid surgery represents an often overlooked but sensitive period in the surgical plan. A 53-year-old male presented a significant decrement in median nerve somatosensory evoked potential (mSEP) following head and neck positioning for carotid pseudoaneurysm repair before skin incision.Neurophysiological monitoring was performed with mSEP and electroencephalography early during the patient's preparation and surgery. Within five minutes after rotation and extension of the head to properly expose the surgical field, the contralateral m-SEP significantly decreased in both cortical (N20/P25) and subcortical (P14/N18) components. Partial neck correction led to m-SEP improvement, allowing to proceed with the carotid repair. We discuss possible underlying pathophysiological mechanisms responsible for these changes and highlight the relevance of an early start on monitoring to avoid neurological deficits.
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Affiliation(s)
- Alba Díaz-Baamonde
- Mount Sinai Roosevelt, Mount Sinai West Medical Center, New York, NY, USA.
| | | | - Maria J Téllez
- Mount Sinai Roosevelt, Mount Sinai West Medical Center, New York, NY, USA
| | - John Lantis
- Mount Sinai Roosevelt, Mount Sinai West Medical Center, New York, NY, USA
| | - Sedat Ulkatan
- Mount Sinai Roosevelt, Mount Sinai West Medical Center, New York, NY, USA
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4
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Silverstein JW, Doron O, Ellis JA. Temporary vessel occlusion in cerebral aneurysm surgery guided by direct cortical motor evoked potentials. Acta Neurochir (Wien) 2023; 165:645-646. [PMID: 36534185 DOI: 10.1007/s00701-022-05447-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 11/24/2022] [Indexed: 12/23/2022]
Affiliation(s)
- Justin W Silverstein
- Department of Neurology, Lenox Hill Hospital, Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
- Neuro Protective Solutions, New York, NY, USA
| | - Omer Doron
- Department of Neurosurgery, Lenox Hill Hospital, Zucker School of Medicine at Hofstra/Northwell, 130 East 77Th Street, Black Hall Bldg, Third Floor, New York, NY, 10075, USA
- Biomedical Engineering Department, The Iby and Aladar, Fleischman Faculty of Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Jason A Ellis
- Department of Neurosurgery, Lenox Hill Hospital, Zucker School of Medicine at Hofstra/Northwell, 130 East 77Th Street, Black Hall Bldg, Third Floor, New York, NY, 10075, USA.
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5
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Abstract
Stroke is the second leading cause of death worldwide. One of the main causes of stroke is carotid artery stenosis. Stenosis with atherosclerosis in the carotid artery can cause stroke by hemodynamic ischemia or artery to artery embolism. A most common surgical intervention for carotid artery stenosis is carotid endarterectomy (CEA). Many studies on CEA have been reported and suggested medical indications. For symptomatic carotid stenosis, generally, CEA may be indicated for patients with more than 50% stenosis and is especially beneficial in men, patients aged 75 years or older, and patients who underwent surgery within 2 weeks of their last symptoms. For asymptomatic carotid stenosis, CEA may be indicated for those with more than 60% stenosis, though each guideline has different suggestions in detail. In order to evaluate the indication for CEA in each case, it is important to assess risks for CEA carefully including anatomical factors and comorbidities, and to elaborate each strategy for each operation based on preoperative imaging studies including carotid ultrasonography, magnetic resonance imaging and angiography. In surgery there are many tips on operative position, procedure, shunt usage and monitoring to perform a safe and smooth operation. Now that carotid artery stenting has been rapidly developed, better understanding for CEA is required to treat carotid artery stenosis adequately. This chapter must be a good help to understand CEA well.
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Affiliation(s)
- Takayuki Hara
- Department of Neurosurgery, Toranomon Hospital, Minato-ku, Tokyo, Japan.
| | - Yurie Rai
- Department of Neurosurgery, Toranomon Hospital, Minato-ku, Tokyo, Japan
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6
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Abstract
Cerebral ischemia during carotid endarterectomy occurs via several mechanisms: inadequate collateral blood flow during carotid cross-clamping, thromboembolism due to carotid manipulation, and/or rethrombosis at the surgical site. Perioperative strokes increase not only the morbidity of endarterectomy but also its short- and long-term mortality. However, while several predictors of cerebral ischemia have been identified, precise individual risk is hard to assess. Since nonselective shunting during carotid cross-clamping is neither risk-free nor eliminates perioperative stroke, it is advisable to apply intraoperative monitoring techniques for detection and reversal of cerebral ischemia, which may occur at various stages of the procedure. This chapter addresses the methods available for monitoring, with an emphasis on neurophysiologic techniques, which are preferable given their direct assessment of how a decrease in cerebral blood flow impacts brain function. These include electroencephalography, somatosensory evoked potentials, and transcranial motor evoked potentials. Details regarding the methodology, advantages, disadvantages, and interpretation of these tests will be discussed within the anatomic, physiologic, surgical, and anesthetic contexts.
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Affiliation(s)
- Mirela V Simon
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States.
| | - Michael Malcharek
- Division of Neuroanesthesia and Intraoperative Neuromonitoring, Department of Anesthesia, Intensive Care and Pain Therapy, Klinikum St. Georg, Hospital of the University of Leipzig, Leipzig, Germany
| | - Sedat Ulkatan
- Department of Neurosurgery, Mount Sinai Hospital, New York, NY, United States
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7
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The Application of Regional Cerebral Oxygenation Monitoring in the Prediction of Cerebral Hypoperfusion During Carotid Endarterectomy. J Neurosurg Anesthesiol 2022; 34:29-34. [PMID: 32379101 DOI: 10.1097/ana.0000000000000690] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 04/02/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aim of this study was to assess the diagnostic ability of near-infrared spectroscopy-monitored regional cerebral oxygen saturation (rSO2) to detect cerebral hypoperfusion during internal carotid artery (ICA) clamping compared with motor and somatosensory evoked potential (EP) monitoring. METHODS This prospective study recruited consecutive patients undergoing carotid endarterectomy under general anesthesia. Significant EP changes (defined as >50% decrease in ipsilateral somatosensory EP amplitude or disappearance of contralateral motor EP on >2 consecutive stimulations) during ICA clamping were considered a warning sign for cerebral hypoperfusion. If significant EP changes occurred, the amplitude of the EPs and simultaneous rSO2 values were recorded before therapeutic intervention. The relationship between reductions in rSO2 and EP amplitudes was analyzed using Spearman rank-correlation analysis. Receiver operating characteristic curve analysis was used to calculate the optimal cutoff value for the relative reduction in rSO2. False-positive rates were evaluated according to immediate postoperative motor outcomes. RESULTS A total of 203 patients were included for analysis, of whom 23 developed significant EP changes during ICA clamping. There was a positive relationship between decreases in EP amplitude and rSO2 (R2=0.15, P=0.02). A rSO2 reduction ≥16% from baseline had the optimal diagnostic performance for the detection of cerebral hypoperfusion (area under the receiver operating characteristic curve=0.82; 95% confidence interval: 0.76-0.87). The false-positive rate was 8.9%. CONCLUSIONS Decreases in rSO2 correlated with decreases in EP amplitude during ICA clamping. A relative reduction in rSO2 ≥16% could serve as a warning for clamping-associated cerebral hypoperfusion. The 8.9% false-positive rate is a potential clinical limitation of the use of rSO2 to predict postoperative neurological deficits.
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8
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Surve RM, Bharadwaj S, Srinivas D, Anju JL. Pre-emptive diagnosis of cerebral ischemia during carotid endarterectomy with transcranial motor evoked potential monitoring under general anesthesia. Saudi J Anaesth 2021; 15:471-473. [PMID: 34658748 PMCID: PMC8477767 DOI: 10.4103/sja.sja_259_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 04/11/2021] [Indexed: 11/04/2022] Open
Affiliation(s)
- Rohini M Surve
- Department of Neruroanesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Suparna Bharadwaj
- Department of Neruroanesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Dwarakanath Srinivas
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - J L Anju
- Department of Neruroanesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
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Wang J, Guo L, Holdefer RN, Zhang Y, Liu Q, Gai Q, Zhang W. Intraoperative Neurophysiology and Transcranial Doppler for Detection of Cerebral Ischemia and Hyperperfusion During Carotid Endarterectomy. World Neurosurg 2021; 154:e245-e253. [PMID: 34271149 DOI: 10.1016/j.wneu.2021.07.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 07/05/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To evaluate and compare efficacy of intraoperative neurophysiological monitoring (IONM) and intraoperative transcranial Doppler (TCD) techniques for identification of hypoperfusion during carotid artery clamp and hyperperfusion after release of occlusion during carotid endarterectomy. METHODS This was a retrospective, consecutive case series of 152 patients undergoing carotid endarterectomy between June 2018 and March 2020. Somatosensory evoked potentials, motor evoked potentials, electroencephalogram, and TCD were obtained. RESULTS Three patient cohorts were observed after clamping the carotid artery: A, in 132 of 152 patients (87%), TCD blood flow velocity decreased by <50% and there were no changes in IONM; B, in 5 of 152 (3%) patients, TCD blood flow rate was reduced 50%-100% with no changes in IONM; C, in 15 patients (10%), blood flow velocity was reduced by 50%-100% and all IONM modalities met warning criteria. With increased blood pressure, IONM and blood flow velocities improved to less than warning criteria in 8 of 15 patients. In 6 of the 7 remaining patients, IONM modalities recovered to baseline immediately after clamps were removed from the carotid artery. The 1 patient with persistent motor evoked potential deterioration experienced postoperative proximal muscle weakness, which recovered 48 hours later. In 22 patients, TCD detected hyperperfusion at the moment of clamp release. CONCLUSIONS TCD blood flow velocity is correlated with motor evoked potential and somatosensory evoked potential amplitude changes after clamping. After declamping, TCD can detect hyperperfusion and help regulate blood pressure to prevent hyperperfusion.
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Affiliation(s)
- Jinfeng Wang
- Department of Electrophysiology, Cangzhou Central Hospital, Cangzhou, China
| | - Lanjun Guo
- Surgical Neuromonitoring Service, University of California San Francisco, San Francisco, California, USA.
| | - Robert N Holdefer
- Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Yansheng Zhang
- Department of Electrophysiology, Cangzhou Central Hospital, Cangzhou, China
| | - Qin Liu
- Department of Electrophysiology, Cangzhou Central Hospital, Cangzhou, China
| | - Qing Gai
- Department of Electrophysiology, Cangzhou Central Hospital, Cangzhou, China
| | - Wengao Zhang
- Department of Neurosurgery, Cangzhou Central Hospital, Cangzhou, China
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10
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Mirallave Pescador A, Pérez Lorensu PJ, Saponaro González Á, Darias Delbey B, Pérez Burkhardt JL, Ucelay Gómez R, González Tabares EF, Ibrahim Achi Z, Guerrero Ramírez CS, Padrón Encalada CE, Jiménez Sosa A, Plata Bello J. Anaesthesia and multimodality intraoperative neuromonitoring in carotid endarterectomy. Chronological evolution and effects on intraoperative neurophysiology. J Clin Monit Comput 2021; 35:1429-1436. [PMID: 33389357 DOI: 10.1007/s10877-020-00621-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 11/18/2020] [Indexed: 10/22/2022]
Abstract
Contingency data was retrospectively collected to evaluate the historical and current ability to provide multimodality intraoperative neurophysiological monitoring during carotid endarterectomy under two conditions: total intravenous anaesthesia (TIVA) and low dose halogenated anaesthesia (SEVO). 229 patients were monitored during carotid endarterectomy procedures under general anaesthesia between 2012 and 2020. 121 Patients were monitored with SEVO at a minimum alveolar concentration less than 0.7 and 108 were monitored using TIVA, according to common anaesthetic practice standards in our hospital across the years. Multimodality IONM was established with electroencephalography, somatosensory evoked potentials and motor evoked potentials. As compared to TIVA, patients monitored with SEVO showed significantly higher motor evoked potential thresholds (313.52 ± 77.74 SEVO and 218.93 V ± 103.2 V TIVA p < 0.05) and lower reproducibility. Electroencephalography and somatosensory evoked potentials showed no significant differences among the groups. When using SEVO, multimodality intraoperative neurophysiological monitoring during carotid endarterectomy could mask or miss a motor isolated change in patients in spite of low dose minimum alveolar concentration and of apparently adequate electroencephalography and somatosensory evoked potentials for monitoring. Given these difficulties, we believe the chronological transfer to TIVA could have improved our ability to establish multimodality intraoperative neurophysiological monitoring during carotid endarterectomy in recent times.
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Affiliation(s)
| | - Pedro Javier Pérez Lorensu
- Unidad de Monitorización Neurofisiológica Intraoperatoria, Hospital Universitario de Canarias, Santa Cruz de Tenerife, España
| | - Ángel Saponaro González
- Unidad de Monitorización Neurofisiológica Intraoperatoria, Hospital Universitario de Canarias, Santa Cruz de Tenerife, España
| | - Beneharo Darias Delbey
- Servicio de Anestesia, Hospital Universitario de Canarias, Santa Cruz de Tenerife, España
| | | | - Roberto Ucelay Gómez
- Servicio de Cirugía Vascular, Hospital Universitario de Canarias, Santa Cruz de Tenerife, España
| | | | - Zeina Ibrahim Achi
- Servicio de Cirugía Vascular, Hospital Universitario de Canarias, Santa Cruz de Tenerife, España
| | | | | | - Alejandro Jiménez Sosa
- Unidad de Investigación, Hospital Universitario de Canarias, Santa Cruz de Tenerife, España
| | - Julio Plata Bello
- Servicio de Neurocirugía, Hospital Universitario de Canarias, Santa Cruz de Tenerife, España
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11
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Uno M, Yagi K, Takai H, Oyama N, Yagita Y, Hazama K, Nakatsuka H, Matsubara S. Comparison of Single and Dual Monitoring during Carotid Endarterectomy. Neurol Med Chir (Tokyo) 2020; 61:124-133. [PMID: 33390558 PMCID: PMC7905295 DOI: 10.2176/nmc.oa.2020-0286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
We compared the rate of selective shunt and pattern of monitoring change between single and dual monitoring in patients undergoing carotid endarterectomy (CEA). A total of 121 patients underwent 128 consecutive CEA procedures. Excluding five procedures using internal shunts in a premeditated manner, we classified patients according to the monitoring: Group A (n = 72), patients with single somatosensory evoked potential (SSEP) monitoring; and Group B (n = 51), patients with dual SSEP and motor evoked potential (MEP). Among the 123 CEAs, an internal shunt was inserted in 12 procedures (9.8%) due to significant changes in monitoring (Group A 5.6%, Group B 15.7%, p = 0.07). The rate of shunt use was significantly higher in patients with the absence of contralateral proximal anterior cerebral artery (A1) on magnetic resonance angiography (MRA) than in patients with other types of MRA (p <0.001). Significant monitor changes were seen in 16 (12.5%) in both groups. In four of nine patients in Group B, SSEP and MEP changes were synchronized, and in the remaining five patients, a time lag was evident between SSEP and MEP changes. In conclusion, the rate of internal shunt use tended to be more frequent in patients with dual monitoring than in patients with single SSEP monitoring, but the difference was not significant. Contralateral A1 absence may predict the need for a shunt and care should be taken to monitor changes throughout the entire CEA procedure. Use of dual monitoring can capture ischemic changes due to the complementary relationship, and may reduce the rate of false-negative monitor changes during CEA.
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Affiliation(s)
- Masaaki Uno
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Kenji Yagi
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Hiroyuki Takai
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Naoki Oyama
- Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Yoshiki Yagita
- Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Keita Hazama
- Department of Anesthesiology and Intensive Care Medicine, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Hideki Nakatsuka
- Department of Anesthesiology and Intensive Care Medicine, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Shunji Matsubara
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
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12
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Silverstein JW, Ellis JA, Langer DJ. Loss of Motor Evoked Potentials Due to Carotid Artery Retraction in an Exoscopic Clipping of a Basilar Tip Aneurysm. Neurodiagn J 2020; 60:289-299. [PMID: 33197217 DOI: 10.1080/21646821.2020.1810520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The internal carotid artery (ICA) may inhibit visualization of a basilar tip aneurysm during an orbitozygomatic craniotomy. Retraction of the ICA may be warranted for better visualization; however, it may lead to impending neurological sequelae. Impending neurological injury due to ICA retraction may be mitigated if multi-modal neuromonitoring techniques are employed. The authors present a case report showing the contemporaneous loss of transcranial motor evoked potentials and direct cortical motor evoked potentials during an exoscopic clipping of a basilar tip aneurysm due to ICA retraction and subsequent loss of perfusion to the vascular territory supplied by ICA. The motor evoked potentials immediately returned after retraction was removed and the patient awoke neurologically intact.
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Affiliation(s)
- Justin W Silverstein
- Neuro Protective Solutions ,New York, New York.,Department of Neurology, Lenox Hill Hospital Northwell Health ,New York, New York
| | - Jason A Ellis
- Department of Neurosurgery, Lenox Hill Hospital Northwell Health ,New York, New York.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell ,New York, New York
| | - David J Langer
- Department of Neurosurgery, Lenox Hill Hospital Northwell Health ,New York, New York.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell ,New York, New York
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13
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Uno M, Takai H, Yagi K, Matsubara S. Surgical Technique for Carotid Endarterectomy: Current Methods and Problems. Neurol Med Chir (Tokyo) 2020; 60:419-428. [PMID: 32801277 PMCID: PMC7490601 DOI: 10.2176/nmc.ra.2020-0111] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Over the last 60 years, many reports have investigated carotid endarterectomy (CEA) and techniques have thus changed and improved. In this paper, we review the recent literature regarding operational maneuvers for CEA and discuss future problems for CEA. Longitudinal skin incision is common, but the transverse incision has been reported to offer minimal invasiveness and better cosmetic effects for CEA. Most surgeons currently use microscopy for dissection of the artery and plaque. Although no monitoring technique during CEA has been proven superior, multiple monitors offer better sensitivity for predicting postoperative neurological deficit. To date, data are lacking regarding whether routine shunt or selective shunt is better. Individual surgeons thus need to select the method with which they are more comfortable. Many surgical techniques have been reported to obtain distal control of the internal carotid artery in patients with high cervical carotid bifurcation or high plaque, and minimally invasive techniques should be considered. Multiple studies have shown that patch angioplasty reduces the risks of stroke and restenosis compared with primary closure, but few surgeons in Japan have been performing patch angioplasty. Most surgeons thus experience only a small volume of CEAs in Japan, so training programs and development of in vivo training models are important.
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Affiliation(s)
- Masaaki Uno
- Department of Neurosurgery, Kawasaki Medical School
| | - Hiroki Takai
- Department of Neurosurgery, Kawasaki Medical School
| | - Kenji Yagi
- Department of Neurosurgery, Kawasaki Medical School
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14
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Yang Y, Cao TT, Tian ZM, Gao H, Wen HQ, Pang M, He WJ, Wang NX, Chen YY, Wang Y, Li H, Lin JW, Kang Z, Li MM, Liu B, Rong LM. Subarachnoid transplantation of human umbilical cord mesenchymal stem cell in rodent model with subacute incomplete spinal cord injury: Preclinical safety and efficacy study. Exp Cell Res 2020; 395:112184. [PMID: 32707134 DOI: 10.1016/j.yexcr.2020.112184] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 07/13/2020] [Accepted: 07/17/2020] [Indexed: 12/22/2022]
Abstract
Functional multipotency renders human umbilical cord mesenchymal stem cell (hUC-MSC) a promising candidate for the treatment of spinal cord injury (SCI). However, its safety and efficacy have not been fully understood for clinical translation. In this study, we performed cellular, kinematic, physiological, and anatomical analyses, either in vitro or in vivo, to comprehensively evaluate the safety and efficacy associated with subarachnoid transplantation of hUC-MSCs in rats with subacute incomplete SCI. Concerning safety, hUC-MSCs were shown to have normal morphology, excellent viability, steady proliferation, typical biomarkers, stable karyotype in vitro, and no tumorigenicity both in vitro and in vivo. Following subarachnoid transplantation of hUC-MSCs in the subject rodents, the biodistribution of hUC-MSCs was restricted to the spinal cord, and no toxicity to immune system or organ function was observed. Body weight, organ weight, and the ratio of the latter upon the former between stem cell-transplanted rats and placebo-injected rats revealed no statistical differences. Regarding efficacy, hUC-MSCs could differentiate into osteoblasts, chondrocytes, adipocytes and neural progenitor cells in vitro. While in vivo studies revealed that subarachnoid transplantation of stem cells resulted in significant improvement in locomotion, earlier automatic micturition recovery and reduced lesion size, which correlated with increased regeneration of tracking fiber and reduced parenchymal inflammation. In vivo luminescence imaging showed that a few of the transplanted luciferase-labeled hUC-MSCs tended to migrate towards the lesion epicenter. Shortened latency and enhanced amplitude were also observed in both motor and sensory evoked potentials, indicating improved signal conduction in the damaged site. Immunofluorescent staining confirmed that a few of the administrated hUC-MSCs integrated into the spinal cord parenchyma and differentiated into astrocytes and oligodendrocytes, but not neurons. Moreover, decreased astrogliosis, increased remyelination, and neuron regeneration could be observed. To the best of our knowledge, this preclinical study provides detailed safety and efficacy evidence regarding intrathecal transplantation of hUC-MSCs in treating SCI for the first time and thus, supports its initiation in the following clinical trial.
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Affiliation(s)
- Yang Yang
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Road, Tianhe District, Guangzhou, Guangdong Province, People's Republic of China
| | - Ting-Ting Cao
- Department of Cell Biology, School of Basic Medical Sciences, Southern Medical University, 1023 Shatai South Road, Baiyun District, Guangzhou, Guangdong Province, People's Republic of China
| | - Zhen-Ming Tian
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Road, Tianhe District, Guangzhou, Guangdong Province, People's Republic of China
| | - Han Gao
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Road, Tianhe District, Guangzhou, Guangdong Province, People's Republic of China
| | - Hui-Quan Wen
- Department of Radiology, The Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Road, Tianhe District, Guangzhou, Guangdong Province, People's Republic of China
| | - Mao Pang
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Road, Tianhe District, Guangzhou, Guangdong Province, People's Republic of China
| | - Wei-Jie He
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Road, Tianhe District, Guangzhou, Guangdong Province, People's Republic of China
| | - Nan-Xiang Wang
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Road, Tianhe District, Guangzhou, Guangdong Province, People's Republic of China
| | - Yu-Yong Chen
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Road, Tianhe District, Guangzhou, Guangdong Province, People's Republic of China
| | - Yang Wang
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Road, Tianhe District, Guangzhou, Guangdong Province, People's Republic of China
| | - He Li
- Department of Physiology, School of Basic Medical Sciences, Southern Medical University, 1023 Shatai South Road, Baiyun District, Guangzhou, Guangdong Province, People's Republic of China
| | - Jun-Wei Lin
- Department of Obstetrics, The Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Road, Tianhe District, Guangzhou, Guangdong Province, People's Republic of China
| | - Zhuang Kang
- Department of Radiology, The Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Road, Tianhe District, Guangzhou, Guangdong Province, People's Republic of China
| | - Mang-Mang Li
- Department of Cell Biology, School of Basic Medical Sciences, Southern Medical University, 1023 Shatai South Road, Baiyun District, Guangzhou, Guangdong Province, People's Republic of China.
| | - Bin Liu
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Road, Tianhe District, Guangzhou, Guangdong Province, People's Republic of China.
| | - Li-Min Rong
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Road, Tianhe District, Guangzhou, Guangdong Province, People's Republic of China.
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Chang R, Reddy RP, Sudadi S, Balzer J, Crammond DJ, Anetakis K, Thirumala PD. Diagnostic accuracy of various EEG changes during carotid endarterectomy to detect 30-day perioperative stroke: A systematic review. Clin Neurophysiol 2020; 131:1508-1516. [DOI: 10.1016/j.clinph.2020.03.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 03/01/2020] [Accepted: 03/23/2020] [Indexed: 10/24/2022]
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16
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Warning criteria for MEP monitoring during carotid endarterectomy: a retrospective study of 571 patients. J Clin Monit Comput 2019; 34:589-595. [DOI: 10.1007/s10877-019-00345-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 06/27/2019] [Indexed: 10/26/2022]
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Sugiyama T, Nakamura T, Ito Y, Tokairin K, Kazumata K, Nakayama N, Houkin K. A Pilot Study on Measuring Tissue Motion During Carotid Surgery Using Video-Based Analyses for the Objective Assessment of Surgical Performance. World J Surg 2019; 43:2309-2319. [DOI: 10.1007/s00268-019-05018-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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MacDonald D, Dong C, Quatrale R, Sala F, Skinner S, Soto F, Szelényi A. Recommendations of the International Society of Intraoperative Neurophysiology for intraoperative somatosensory evoked potentials. Clin Neurophysiol 2019; 130:161-179. [DOI: 10.1016/j.clinph.2018.10.008] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 09/27/2018] [Accepted: 10/21/2018] [Indexed: 11/25/2022]
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19
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Reddy RP, Brahme IS, Karnati T, Balzer JR, Crammond DJ, Anetakis KM, Thirumala PD. Diagnostic value of somatosensory evoked potential changes during carotid endarterectomy for 30-day perioperative stroke. Clin Neurophysiol 2018; 129:1819-1831. [DOI: 10.1016/j.clinph.2018.05.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 04/25/2018] [Accepted: 05/09/2018] [Indexed: 11/24/2022]
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20
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Comparing the efficacy of shunting approaches and cerebral monitoring during carotid endarterectomy using a national database. J Vasc Surg 2018; 68:416-425. [DOI: 10.1016/j.jvs.2017.11.077] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 11/10/2017] [Indexed: 11/20/2022]
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21
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Intraoperative Neurological Monitoring With Evoked Potentials During Carotid Endarterectomy Versus Cooperative Patients Under General Anesthesia Technique: A Retrospective Study. J Neurosurg Anesthesiol 2018; 30:258-264. [DOI: 10.1097/ana.0000000000000430] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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22
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Norton JA, Peeling L, Meguro K, Kelly M. Phenomenology of neurophysiologic changes during surgical treatment of carotid stenosis using signal analysis. Clin Neurophysiol Pract 2018; 3:28-32. [PMID: 30215004 PMCID: PMC6133780 DOI: 10.1016/j.cnp.2017.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 12/12/2017] [Accepted: 12/20/2017] [Indexed: 11/02/2022] Open
Abstract
Objective To describe the changes in the shape and topology of the somatosensory evoked potential (SSEP) during carotid endarterectomy, with particular reference to the time of clamping. Methods Routine intraoperative monitoring was performed on 30 patients undergoing carotid endarterectomy (15) or undergoing stenting (15) using median nerve SSEPs. Post-operatively the first and second derivatives of the potential were examined. Separate analysis of the SSEP using wavelets was also performed. Results In no instances did changes in the SSEP reach clinical significance. The first derivative showed significant changes that were temporally related to the clamp period. After clamping the 'velocity' was higher than baseline. There were changes in the wavelets related to the clamp period with more marked spectral edges at the conclusion of the procedure than baseline. In all instances the patient had a good clinical outcome. Conclusions Wavelet and derivative analysis of evoked potentials show changes that are not apparent with measures of amplitude and latency. The clinical relevance of these changes remains uncertain and await larger studies. Significance Increased velocity and spectral edges may be markers of increased cerebral blood flow, at least in the setting of pre-existing carotid stenosis.
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Affiliation(s)
- Jonathan A Norton
- Division of Neurosurgery, Department of Surgery, University of Saskatchewan, Canada
| | - Lissa Peeling
- Division of Neurosurgery, Department of Surgery, University of Saskatchewan, Canada
| | - Kotoo Meguro
- Division of Neurosurgery, Department of Surgery, University of Saskatchewan, Canada
| | - Mike Kelly
- Division of Neurosurgery, Department of Surgery, University of Saskatchewan, Canada
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Domenick Sridharan N, Thirumala P, Chaer R, Balzer J, Long B, Crammond D, Makaroun M, Avgerinos E. Predictors of cross-clamp-induced intraoperative monitoring changes during carotid endarterectomy using both electroencephalography and somatosensory evoked potentials. J Vasc Surg 2017; 67:191-198. [PMID: 28688529 DOI: 10.1016/j.jvs.2017.04.064] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 04/30/2017] [Indexed: 01/26/2023]
Abstract
OBJECTIVE The efficacy of selective shunting during carotid endarterectomy (CEA) using intraoperative monitoring (IOM) for detection of cerebral ischemia is well established. There is mounting evidence that monitoring of both electroencephalography (EEG) and somatosensory evoked potentials (SSEPs) increases the sensitivity of cerebral ischemia detection. Predictors of cerebral ischemia requiring selective shunt placement using IOM of both EEG and SSEPs have not been previously identified. METHODS Consecutive patients who underwent CEA between January 1, 2000, and December 31, 2010, were retrospectively analyzed. Primary end points were IOM changes at any time during the operation or IOM changes with carotid cross-clamping. Risk factors assessed included demographics; baseline comorbidities; severity of ipsilateral and contralateral disease; symptomatic status; and use of statin, antiplatelet, and beta-blocker medications. Univariate and multivariate logistic regression was used for analysis. RESULTS During the 11-year study period, a total of 758 patients underwent 804 CEAs (mean age, 70.6 ± 9.5 years; 59.8% male; 39.2% symptomatic) using IOM of both SSEPs and EEG for selective shunting guidance. Postoperative stroke rate was 1.37%; 27.1% of patients had significant SSEP or EEG changes, and 49.1% of these were clamp induced (within 5 minutes of cross-clamping). Of these patients, 83.2% received a shunt (11.4% overall). The most common reason that a shunt was not placed after cross-clamp-induced changes was that the changes resolved with further blood pressure elevation (8 of 17 patients). Clamp-induced IOM changes were predictive of postoperative stroke (odds ratio [OR], 5.5; P = .005). Risk factors for clamp-induced IOM changes were contralateral carotid occlusion (OR, 2.5; P = .01), symptomatic stenosis (OR, 1.8; P = .006), and diabetes (OR, 1.6; P = .03), whereas there was a trend toward increased risk with female sex (OR, 1.5; P = .08). Risk factors for any IOM change (clamp and nonclamp induced) were symptomatic carotid stenosis (OR, 1.8; P < .001), use of beta blockers (OR, 1.5; P = .03), and female sex (OR, 1.5; P = .02). CONCLUSIONS Whereas some patients can be expected to experience IOM changes by monitoring of SSEPs and EEG, a much smaller percentage will receive a shunt. Contralateral carotid occlusion, symptomatic stenosis, diabetes, and female sex increase the risk of clamp-induced IOM changes and should be anticipated to need a shunt. Patients receiving beta blockers are likely to experience IOM changes during the operation that are not associated with clamping.
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Affiliation(s)
| | - Partha Thirumala
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Rabih Chaer
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Jeffrey Balzer
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Becky Long
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Donald Crammond
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Michel Makaroun
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Efthymios Avgerinos
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
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Thirumala PD, Natarajan P, Thiagarajan K, Crammond DJ, Habeych ME, Chaer RA, Avgerinos ED, Friedlander R, Balzer JR. Diagnostic accuracy of somatosensory evoked potential and electroencephalography during carotid endarterectomy. Neurol Res 2016; 38:698-705. [PMID: 27342607 DOI: 10.1080/01616412.2016.1200707] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND PURPOSE Perioperative stroke risk following carotid endarterectomy (CEA) is reported to be approximately 2-3%. The diagnostic accuracies of intraoperative EEG and SSEP monitoring during CEA have been studied separately. However, to date, the effectiveness of simultaneous EEG and SSEP monitoring during CEA has only been evaluated in small study populations. This study examined the diagnostic accuracy of combined EEG and SSEP monitoring in a large (N = 1165) patient population. METHODS This study included 1165 patients who underwent CEA from 2000 to 2012 at the University of Pittsburgh Medical Center. The sensitivities, specificities, and diagnostic odds ratio of EEG and SSEP monitoring methods were examined separately and together. Receiver operating characteristic curves were plotted to assess sensitivity and specificity of single and combined Intraoperative monitoring (IONM) methods. RESULTS Maximum sensitivity was obtained with multimodality monitoring with an IONM change in either EEG or SSEP of 50.00 (95% CI, 30.66-69.34). The specificity of simultaneous EEG and SSEP changes was 93.95 (95% CI, 92.28-95.35%). Maximum area under ROC curve obtained for IONM change in either EEG or SSEP was 0.660 (95% CI, 0.547-0.773, p-value 0.004). CONCLUSION The diagnostic accuracy of multimodality IONM during CEA is higher than an approach using single modality IONM. Simultaneous EEG and SSEP monitoring improves the likelihood of detecting periprocedural strokes after CEA. Neuro protective therapies to prevent periprocedural strokes can be based on changes in SSEP and EEG during CEA.
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Affiliation(s)
- Parthasarathy D Thirumala
- a Department of Neurological Surgery , Universityof Pittsburgh Medical Center , Pittsburgh , PA , USA.,b Department of Neurology , University of Pittsburgh Medical Center , Pittsburgh , PA , USA
| | - Piruthiviraj Natarajan
- a Department of Neurological Surgery , Universityof Pittsburgh Medical Center , Pittsburgh , PA , USA
| | - Karthy Thiagarajan
- a Department of Neurological Surgery , Universityof Pittsburgh Medical Center , Pittsburgh , PA , USA
| | - Donald J Crammond
- a Department of Neurological Surgery , Universityof Pittsburgh Medical Center , Pittsburgh , PA , USA
| | - Miguel E Habeych
- a Department of Neurological Surgery , Universityof Pittsburgh Medical Center , Pittsburgh , PA , USA
| | - Rabih A Chaer
- c Division of Vascular Surgery , University of Pittsburgh Medical Center , Pittsburgh , PA , USA
| | - Efthymios D Avgerinos
- c Division of Vascular Surgery , University of Pittsburgh Medical Center , Pittsburgh , PA , USA
| | - Robert Friedlander
- a Department of Neurological Surgery , Universityof Pittsburgh Medical Center , Pittsburgh , PA , USA
| | - Jeffrey R Balzer
- a Department of Neurological Surgery , Universityof Pittsburgh Medical Center , Pittsburgh , PA , USA
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Adhikari RB, Takeda M, Kolakshyapati M, Sakamoto S, Morishige M, Kiura Y, Okazaki T, Shinagawa K, Ichinose N, Yamaguchi S, Kurisu K. Somatosensory evoked potentials in carotid artery stenting: Effectiveness in ascertaining cerebral ischemic events. J Clin Neurosci 2016; 30:71-76. [PMID: 27291465 DOI: 10.1016/j.jocn.2016.01.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 01/04/2016] [Accepted: 01/17/2016] [Indexed: 11/16/2022]
Abstract
Somatosensory evoked potentials (SSEP) have been used in various endovascular procedures and carotid endarterectomy, but to our knowledge no literature deals exclusively with the utility of SSEP in carotid artery stenting (CAS). The purpose of this study was to evaluate the efficacy of SSEP in detecting cerebral ischemic events during CAS. We conducted a prospective study in 35 CAS procedures in 31 patients during an 18month period. Thirty-three patients without near occlusion underwent stenting using dual protection (simultaneous flow reversal and distal filter) combined with blood aspiration, while two patients with near occlusion underwent stenting without dual protection. All 35 patients underwent SSEP monitoring. SSEP were generated by stimulating median and/or tibial nerves and recorded by scalp electrodes. During the aspiration phase post-dilation, seven patients (20%) exhibited SSEP changes with a mean duration of 11.3±8.5minutes (range: 3-25minutes), three of whom later developed minor stroke/transient ischemic attack. Diffusion-weighted imaging showed new lesions in 10 patients (28.6%). Change in SSEP exhibited mean sensitivity of 100% (95% confidence interval, 0.29-1.0) and specificity of 88% (95% confidence interval, 0.71-0.96) in predicting clinical stroke post-CAS. Intra-procedural SSEP change was predictive of post-procedural complications (p=0.005, Fisher's exact test). Longer span of SSEP change was positively correlated with complications (p=0.032, Mann-Whitney test). Intra-procedural SSEP changes are highly sensitive in predicting neurological outcome following CAS. Chances of complications are increased with prolongation of such changes. SSEP allows for prompt intra-procedural ischemia prevention measures and stratification to pursue an aggressive peri-procedural protocol for high risk patients to mitigate neurological deficits.
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Affiliation(s)
- Rupendra Bahadur Adhikari
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan.
| | - Masaaki Takeda
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan
| | - Manish Kolakshyapati
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan
| | - Shigeyuki Sakamoto
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan
| | - Mizuki Morishige
- Clinical Engineer Section, Clinical Support Department, Hiroshima University Hospital, Hiroshima, Japan
| | - Yoshihiro Kiura
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan
| | - Takahito Okazaki
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan
| | - Katsuhiro Shinagawa
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan
| | - Nobuhiko Ichinose
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan
| | - Satoshi Yamaguchi
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan
| | - Kaoru Kurisu
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan
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Hybrid treatment of symptomatic chronic isolated carotid bifurcation. Ann Vasc Surg 2014; 28:1795.e7-1795.e10. [PMID: 24858588 DOI: 10.1016/j.avsg.2014.04.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2014] [Revised: 03/19/2014] [Accepted: 04/01/2014] [Indexed: 11/22/2022]
Abstract
Total chronic occlusion of the common carotid artery with patent internal and external carotid arteries can induce cerebral embolism and hypoperfusion. We report a hybrid approach that was used to treat 2 patients presented with symptomatic chronic occlusion of the common carotid artery and ipsilateral internal carotid stenosis. Antegrade recanalization and retrograde stenting of the common carotid artery was performed in both patients associated to carotid bulb endarterectomy. Fresh thrombus observed in the distal common carotid stump was responsible for the embolic cerebral lesions and patients' previous symptoms. Patients remain asymptomatic at the 23rd- and 18th-month follow-up, respectively.
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