1
|
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.
Collapse
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
| | | | | | | |
Collapse
|
2
|
Fleseriu CM, Sultan I, Brown JA, Mina A, Frenchman J, Crammond DJ, Balzer J, Anetakis KM, Subramaniam K, Shandal V, Navid F, Thirumala PD. Role of Intraoperative Neurophysiological Monitoring in Preventing Stroke After Cardiac Surgery. Ann Thorac Surg 2023; 116:623-629. [PMID: 36634835 DOI: 10.1016/j.athoracsur.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 12/09/2022] [Accepted: 01/03/2023] [Indexed: 01/11/2023]
Abstract
BACKGROUND Perioperative stroke after cardiac surgical procedures carries significant morbidity. Dual intraoperative neurophysiological monitoring with electroencephalography (EEG) and somatosensory-evoked potentials detects cerebral hypoperfusion and predicts postoperative stroke in noncardiac procedures. We further evaluated preoperative risk factors and intraoperative neuromonitoring ability to predict postoperative stroke after cardiac operations. METHODS All patients who underwent cardiac operations with intraoperative neurophysiological monitoring from 2009 to 2020 at a single academic medical center were retrospectively analyzed. Patients with circulatory arrest were excluded. Risks factors analyzed were sex, age, tobacco use, hypertension, diabetes mellitus, dyslipidemia, atrial fibrillation, prior cerebrovascular accident, cerebrovascular disease, antiplatelet/anticoagulant use, abnormal somatosensory-evoked potentials and EEG baselines, and significant somatosensory-evoked potentials and EEG change as well as their permanence. Patients were divided into 2 groups by 30-day postoperative stroke occurrence. Univariate and multivariate logistical regressions were used for postoperative stroke significant predictors, and Kaplan-Meier curves estimated survival. RESULTS The study included 620 patients (67.6% men), mean age 65.1 ± 14.1 years, with stroke in 5.32%. In univariate analysis, diabetes (odds ratio [OR], 2.62) and permanence of EEG change (OR, 5.35) were each associated with increased postoperative stroke odds. In multivariate analysis, diabetes (OR, 2.64) and permanent EEG change (OR, 4.22) were independently significantly associated with postoperative stroke. Overall survival was significantly better for patients with no intraoperative neurophysiological monitoring changes (P < .005). CONCLUSIONS Permanent EEG change and diabetes were significant postoperative stroke predictors in cardiac operations. Furthermore, overall survival out to 10 years postoperatively was significantly higher in the group without intraoperative neurophysiological monitoring changes, emphasizing its important predictive role.
Collapse
Affiliation(s)
- Cara M Fleseriu
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ibrahim Sultan
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - James A Brown
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Amir Mina
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jacob Frenchman
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Donald J Crammond
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jeffrey Balzer
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Katherine M Anetakis
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kathirvel Subramaniam
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Varun Shandal
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Forozan Navid
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Parthasarathy D Thirumala
- Center of Clinical Neurophysiology, Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
| |
Collapse
|
3
|
Liu Y, Ma J, Li H, Shi WY, Xiao ZH, Yang Q, Zhao QQ, Wang F, Tao XL, Bai YF. Which sites better represent the sensory function of hands in convalescent stroke patients? A study based on electrophysiological examination. Front Neurosci 2023; 16:1065629. [PMID: 36711129 PMCID: PMC9875544 DOI: 10.3389/fnins.2022.1065629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 12/07/2022] [Indexed: 01/13/2023] Open
Abstract
Background Assessing hand sensation in stroke patients is necessary; however, current clinical assessments are time-consuming and inaccurate. Objective This study aimed to explore the nature of light touch sensation and two-point discrimination (2-PD) of different hand sites in convalescent stroke patients based on somatosensory evoked potentials (SEP). Methods Light touch sensation and 2-PD of the thumb, the index finger, the little finger, thenar, and hypothenar were measured (n = 112) using sensory measurement tools. Sensory differences among the hand sites were then compared. The correlation analysis between SEP and the hemiplegic hand function was made. Sensory functions were divided into three levels: sensory intactness, sensory impairment, and sensory loss. Results Light touch sensations were mainly associated with sensory impairment in the finger and palm region. The 2-PD of the finger region was mainly sensory loss and that of the palm region was mainly sensory impairment. There was no statistical difference in the light touch sensation among the sites of the hand. The correlation coefficients between the 2-PD and SEP N20 amplitudes differed. The correlation coefficients of the thenar and hypothenar were the smallest, and that of the finger was the largest. Light touch sensation and 2-PD in patients with stroke were related to the hemiplegic hand function. Conclusion Any site on the hand could be selected as the measurement site for light touch sensation. The little finger and hypothenar may be appropriate sites when screening for 2-PD. To improve the patient's recovery they could receive more sensory stimulation of the hand.
Collapse
Affiliation(s)
- Yu Liu
- Department of Rehabilitation Medicine, Shijiazhuang People’s Hospital, Shijiazhuang, China
| | - Jiang Ma
- Department of Rehabilitation Medicine, Shijiazhuang People’s Hospital, Shijiazhuang, China,*Correspondence: Jiang Ma,
| | - Hong Li
- Department of Rehabilitation Medicine, Shijiazhuang People’s Hospital, Shijiazhuang, China,Physical Education College, Hebei Normal University, Shijiazhuang, China
| | - Wan-ying Shi
- Department of Rehabilitation Medicine, Shijiazhuang People’s Hospital, Shijiazhuang, China
| | - Zheng-hua Xiao
- Physical Education College, Hebei Normal University, Shijiazhuang, China
| | - Qian Yang
- Department of Electrophysiology, Shijiazhuang People’s Hospital, Shijiazhuang, Hebei, China
| | - Qing-qing Zhao
- School of Nursing and Rehabilitation, North China University of Science and Technology, Tangshan, Hebei, China
| | - Fang Wang
- Physical Education College, Hebei Normal University, Shijiazhuang, China
| | - Xiao-lin Tao
- Department of Rehabilitation Medicine, Shijiazhuang People’s Hospital, Shijiazhuang, China
| | - Yun-fei Bai
- Department of Rehabilitation Medicine, Shijiazhuang People’s Hospital, Shijiazhuang, China
| |
Collapse
|
4
|
Moehl K, Shandal V, Anetakis K, Paras S, Mina A, Crammond D, Balzer J, Thirumala PD. Predicting transient ischemic attack after carotid endarterectomy: The role of intraoperative neurophysiological monitoring. Clin Neurophysiol 2022; 141:1-8. [DOI: 10.1016/j.clinph.2022.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 05/17/2022] [Accepted: 06/07/2022] [Indexed: 11/16/2022]
|
5
|
Paras S, Mina A, Crammond DJ, Visweswaran S, Anetakis KM, Balzer JR, Shandal V, Thirumala PD. Cardiovascular-related mortality after intraoperative neurophysiologic monitoring changes during carotid endarterectomy. Clin Neurophysiol 2022; 139:43-48. [DOI: 10.1016/j.clinph.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 04/10/2022] [Accepted: 04/11/2022] [Indexed: 11/03/2022]
|
6
|
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.
Collapse
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
| |
Collapse
|
7
|
Sultan I, Brown JA, Serna-Gallegos D, Thirumala PD, Balzer JR, Paras S, Fleseriu C, Crammond DJ, Anetakis KM, Kilic A, Navid F, Gleason TG. Intraoperative neurophysiologic monitoring during aortic arch surgery. J Thorac Cardiovasc Surg 2021; 165:1971-1981.e2. [PMID: 34384591 DOI: 10.1016/j.jtcvs.2021.07.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 06/16/2021] [Accepted: 07/09/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To evaluate the ability of intraoperative neurophysiologic monitoring (IONM) during aortic arch reconstruction with hypothermic circulatory arrest (HCA) to predict early (<48 hours) adverse neurologic events (ANE; stroke or transient ischemic attack) and operative mortality. METHODS This was an observational study of aortic arch surgeries requiring HCA from 2010 to 2018. Patients were monitored with electroencephalogram (EEG) and somatosensory evoked potentials (SSEP). Baseline characteristics and postoperative outcomes were compared according to presence or absence of IONM changes, which were defined as any acute variation in SSEP or EEG, compared with baseline. Multivariable logistic regression analysis was used to assess the association of IONM changes with operative mortality and early ANE. RESULTS A total of 563 patients underwent aortic arch reconstruction with HCA and IONM. Of these, 119 (21.1%) patients had an IONM change, whereas 444 (78.9%) did not. Patients with IONM changes had increased operative mortality (22.7% vs 4.3%) and increased early ANE (10.9% vs 2.9%). In multivariable analysis, SSEP changes were correlated with early ANE (odds ratio [OR], 4.68; 95% confidence interval [CI], 1.51-14.56; P = .008), whereas EEG changes were not (P = .532). Permanent SSEP changes were correlated with early ANE (OR, 4.56; 95% CI, 1.51-13.77; P = .007), whereas temperature-related SSEP changes were not (P = .997). Finally, any IONM change (either SSEP or EEG) was correlated with operative mortality (OR, 5.82; 95% CI, 2.72-12.49; P < .001). CONCLUSIONS Abnormal IONM events during aortic arch reconstruction with HCA portend worse neurologic outcomes and operative mortality and have a negative predictive value of 97.1%. SSEP might be more sensitive than EEG for predicting early ANE, especially when SSEP changes are permanent.
Collapse
Affiliation(s)
- Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
| | - James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | | | - Jeffrey R Balzer
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Stephanie Paras
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Cara Fleseriu
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Donald J Crammond
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pa
| | | | - Arman Kilic
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Forozan Navid
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Thomas G Gleason
- Division of Cardiac Surgery, Department of Surgery, University of Maryland, College Park, Md
| |
Collapse
|
8
|
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.
Collapse
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
| |
Collapse
|
9
|
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.
Collapse
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
| | | |
Collapse
|
10
|
Temporary Reversal of Blood Flow During Transcarotid Artery Revascularization Does Not Change Brain Electrical Activity in Lead-In Cases of the ROADSTER 1 Multicenter Trial. J Endovasc Ther 2018; 25:773-778. [DOI: 10.1177/1526602818797986] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: To evaluate any intraoperative electroencephalographic (EEG) changes accompanying reversed flow with the ENROUTE Transcarotid Neuroprotection System during transcarotid artery revascularization (TCAR). Methods: A post hoc analysis was performed of the first 81 consecutive lead-in patients (mean age 72.8±8 years; 61 men) enrolled in the ROADSTER 1 trial at 5 participating institutions. All patients had high-grade carotid artery stenosis [53 (59.3%) left sided; 12 (14.8%) contralateral occlusions] and high-risk criteria for carotid endarterectomy. A third had symptoms of either stroke (13, 16.0%) or transient ischemic attack (14, 17.3%). This subset of early patients underwent EEG monitoring to detect any cerebral changes during reversed flow as an added safety measure mandated by the ROADSTER 1 trial protocol. Results: Mean flow reversal time was 12.9±8.2 minutes. The goal mean arterial pressure during reversed flow was 100 mm Hg, but 7 (8.6%) patients suffered hypotension. One (1.2%) patient had slight EEG changes secondary to blood pressure fluctuation; these resolved with blood pressure elevation. No other EEG changes were noted. One (1.2%) patient had a postoperative stroke and another (1.2%) had postoperative myocardial infarction (MI), leading to 2.5% 30-day stroke/death/MI rate. Conclusion: Temporary reversal of blood flow during TCAR is a safe maneuver and does not cause cerebral ischemia in the vast majority of patients, including those with contralateral carotid occlusion. Carotid stenting performed with reversed blood flow mitigates cerebral embolization and periprocedural stroke without concern for brain ischemia.
Collapse
|
11
|
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: 16] [Impact Index Per Article: 2.3] [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.
Collapse
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
| |
Collapse
|