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
|
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.
Collapse
|
3
|
Bozzani A, Arici V, Ticozzelli G, Pregnolato S, Boschini S, Fellegara R, Carando S, Ragni F, Sterpetti AV. Intraoperative Cerebral Monitoring During Carotid Surgery: A Narrative Review. Ann Vasc Surg 2021; 78:36-44. [PMID: 34537350 DOI: 10.1016/j.avsg.2021.06.044] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 06/16/2021] [Accepted: 06/22/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Intra-operative neurological monitoring (IONM) during carotid endarterectomy (CEA) aims to reduce neurological morbidity of surgery. OBJECTIVE This narrative review analyses the role and results of different methods of IONM. METHODS review articles on PUBMED and Cochrane Library, by searching key words related to IONM and CEA, from 2000 up to date. RESULTS regional anesthesia in some centers represents the "gold standard". The most often used alternative techniques are: stump pressure, electroencephalogram, somatosensory evoked potentials, transcranical doppler ultrasound, near infrared spectroscopy and routine shunting. Every technique shows limitations. Regional anesthesia can make difficult prompt intubation when needed. Stump pressure shows a wide operative range. Electroencephalogram is unable to detect ischemia in sub-cortical regions of the brain. Somatosensory evoked potentials certainly demonstrate the presence of cerebral ischemia, but are no more specific or sensitive than the electroencephalogram. Transcranical doppler monitoring is undoubtedly operator-dependent and suffers from the limitations that the probe has to be placed relatively near to the surgical site and may impede the operator, especially if it needs constant adjustments; moreover, an acoustic window may not be found in 10% -20% of the subjects. Near infrared spectroscopy appears to have a high negative predictive value for cerebral ischemia, but has a poor positive predictive value and low specificity, because predominantly estimates venous oxygenation as this makes up about 80% of cerebral blood volume. The data on the use of Routine Shunting (RS) from RCTs are limited. CONCLUSIONS currently, with no clear consensus on monitoring technique, choice should be guided by local expertise and complication rates. With reflection, best practice may dictate that a standard technique is selected as suggested above and this remains the default position for individual practice. Nevertheless, current techniques for monitoring cerebral perfusion during CEA are associated with false negative and false positive resulting in inappropriate shunt insertion.
Collapse
Affiliation(s)
- Antonio Bozzani
- Vascular and Endovascular Surgery Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | - Vittorio Arici
- Vascular and Endovascular Surgery Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Giulia Ticozzelli
- Anesthesiology and Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Sandro Pregnolato
- Anesthesiology and Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Stefano Boschini
- Vascular and Endovascular Surgery Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Raffaele Fellegara
- Vascular and Endovascular Surgery Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Simona Carando
- Vascular and Endovascular Surgery Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Franco Ragni
- Vascular and Endovascular Surgery Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | |
Collapse
|
4
|
Comparison of sedoanalgesia versus general anesthesia in surgical resection of carotid body tumors: A retrospective cohort study. JOURNAL OF SURGERY AND MEDICINE 2021. [DOI: 10.28982/josam.904504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
5
|
Cho JW, Jang JS. Near-Infrared Spectroscopy versus Transcranial Doppler-Based Monitoring in Carotid Endarterectomy. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2017; 50:448-452. [PMID: 29234612 PMCID: PMC5716648 DOI: 10.5090/kjtcs.2017.50.6.448] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 06/13/2017] [Accepted: 06/14/2017] [Indexed: 11/16/2022]
Abstract
Background Proper monitoring of cerebral perfusion during carotid artery surgery is crucial for determining if a shunt is needed. We compared the safety and reliability of near-infrared spectroscopy (NIRS) with transcranial Doppler (TCD) for cerebral monitoring. Methods This single-center, retrospective review was conducted on patients who underwent carotid endarterectomy (CEA) using selective shunt-based TCD or NIRS at Daegu Catholic University Medical Center from November 2009 to June 2016. Postoperative complications were the primary outcome, and the distribution of risk factors between the 2 groups was compared. Results The medical records of 74 patients (45 TCD, 29 NIRS) were reviewed. The demographic characteristics were similar between the 2 groups. One TCD patient died within the 30-day postoperative period. Postoperative stroke (n=4, p=0.15) and neurologic complications (n=10, p=0.005) were only reported in the TCD group. Shunt usage was 44.4% and 10.3% in the TCD and NIRS groups, respectively (p=0.002). Conclusion NIRS-based selective shunting during CEA seems to be safe and reliable for monitoring cerebral perfusion in terms of postoperative stroke and neurologic symptoms. It also reduces unnecessary shunt usage.
Collapse
Affiliation(s)
- Jun Woo Cho
- Department of Cardiovascular and Thoracic Surgery, Catholic University of Daegu School of Medicine
| | - Jae Seok Jang
- Department of Cardiovascular and Thoracic Surgery, Catholic University of Daegu School of Medicine
| |
Collapse
|
6
|
Cho JW, Jeon YH, Bae CH. Selective Carotid Shunting Based on Intraoperative Transcranial Doppler Imaging during Carotid Endarterectomy: A Retrospective Single-Center Review. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2016; 49:22-8. [PMID: 26889442 PMCID: PMC4757393 DOI: 10.5090/kjtcs.2016.49.1.22] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 09/16/2015] [Accepted: 09/30/2015] [Indexed: 11/25/2022]
Abstract
Background Carotid endarterectomy (CEA) with selective shunting is the surgical method currently used to treat patients with carotid artery disease. We evaluated the incidence of major postoperative complications in patients who underwent CEA with selective shunting under transcranial Doppler (TCD) at our institution. Methods The records of 45 patients who underwent CEA with TCD-based selective shunting under general anesthesia from November 2009 to June 2015 were reviewed. The risk factors for postoperative complications were analyzed using univariate and multivariate analysis. Results Preoperative atrial fibrillation was observed in three patients. Plaque ulceration was detected in 10 patients (22.2%) by preoperative computed tomography imaging. High-level stenosis was observed in 16 patients (35.5%), and 18 patients had contralateral stenosis. Twenty patients (44.4%) required shunt placement due to reduced TCD flow or a poor temporal window. The 30-day mortality rate was 2.2%. No cases of major stroke were observed in the 30 days after surgery, but four cases of minor stroke were noted. Univariate analysis showed that preoperative atrial fibrillation (odds ratio [OR], 40; p=0.018) and ex-smoker status (OR, 17.5; p=0.021) were statistically significant risk factors for a minor stroke in the 30-day postoperative period. Analogously, multivariate analysis also found that atrial fibrillation (p<0.001) and ex-smoker status (p=0.002) were significant risk factors for a minor stroke in the 30-day postoperative period. No variables were identified as risk factors for 30-day major stroke or death. No wound complications were found, although one (2.2%) of the patients suffered from a hypoglossal nerve injury. Conclusion TCD-based CEA is a safe and reliable method to treat patients with carotid artery disease. Preoperative atrial fibrillation and ex-smoker status were found to increase the postoperative risk of a small embolism leading to a minor neurologic deficit.
Collapse
Affiliation(s)
- Jun Woo Cho
- Department of Cardiovascular and Thoracic Surgery, Catholic University of Daegu School of Medicine
| | - Yun-Ho Jeon
- Department of Cardiovascular and Thoracic Surgery, Catholic University of Daegu School of Medicine
| | - Chi Hoon Bae
- Department of Cardiovascular and Thoracic Surgery, Catholic University of Daegu School of Medicine
| |
Collapse
|
7
|
De Santis F, Chaves Brait CM, Pattaro C, Cesareo V, Di Cintio V. A Prospective Nonrandomized Study on Carotid Surgery Performed under General Anesthesia without Intraoperative Cerebral Monitoring. J Stroke Cerebrovasc Dis 2015; 25:136-43. [PMID: 26493333 DOI: 10.1016/j.jstrokecerebrovasdis.2015.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 08/27/2015] [Accepted: 09/09/2015] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND The purpose of this study was to assess our experience of carotid surgery habitually performed under general anesthesia without intraoperative intracerebral monitoring, and following a pre-established perioperative protocol, which includes extensive use of an intraoperative shunt (IOS). METHODS This study included 311 consecutive carotid operations performed over 32 months. This patient cohort represents 14% of our total experience in carotid surgery (2219 operations, major stroke/mortality rate: 1.4%). The IOS was inserted routinely in the presence of intraoperative blood pressure instability during cross-clamping and when the predictable clamping time might have exceeded 20 minutes. A moderate and stable hypertension was maintained throughout surgery without IOS. RESULTS Overall, 120 (38.6%) endarterectomies were performed with primary closure, 73 (23.5%) with eversion technique, 113 (36.3%) with patch angioplasty, and 5 (1.6%) with other techniques. Out of 113 patch angioplasties, 111 (98.2%) were performed with an IOS. This was utilized in only 3 cases of direct carotid reconstructions or other carotid endarterectomy techniques (1.5%). Overall, the IOS placement rate was 36.7%. Postoperatively, 2 major strokes (.64%), 2 minor strokes (.64%), 4 hyperperfusion syndromes (1.3%), and no mortality were recorded. No cases of cross-clamp ischemia/shunt-related perioperative strokes were observed. CONCLUSIONS The low perioperative stroke rate reported in this prospective study proves the advantages of wide use of IOS during carotid surgery. This coupled with a large experience in carotid surgery and close monitoring and support of blood pressure, are the major determinants of these results that demonstrate the low risk of shunt-related complications for surgeons who regularly utilize an IOS.
Collapse
Affiliation(s)
| | | | - Cristian Pattaro
- Institute of Genetic Medicine, European Academy of Bolzano/Bozen (EURAC), Italy
| | | | | |
Collapse
|
8
|
Kacprzak M, Liebert A, Staszkiewicz W, Gabrusiewicz A, Sawosz P, Madycki G, Maniewski R. Application of a time-resolved optical brain imager for monitoring cerebral oxygenation during carotid surgery. JOURNAL OF BIOMEDICAL OPTICS 2012; 17:016002. [PMID: 22352652 DOI: 10.1117/1.jbo.17.1.016002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Recent studies have shown that time-resolved optical measurements of the head can estimate changes in the absorption coefficient with depth discrimination. Thus, changes in tissue oxygenation, which are specific to intracranial tissues, can be assessed using this advanced technique, and this method allows us to avoid the influence of changes to extracerebral tissue oxygenation on the measured signals. We report the results of time-resolved optical imaging that was carried out during carotid endarterectomy. This surgery remains the "gold standard" treatment for carotid stenosis, and intraoperative brain oxygenation monitoring may improve the safety of this procedure. A time-resolved optical imager was utilized within the operating theater. This instrument allows for the simultaneous acquisition of 32 distributions of the time-of-flight of photons at two wavelengths on both hemispheres. Analysis of the statistical moments of the measured distributions of the time-of-flight of photons was applied for estimating changes in the absorption coefficient as a function of depth. Time courses of changes in oxy- and deoxyhemoglobin of the extra- and intracerebral compartments during cross-clamping of the carotid arteries were obtained. A decrease in the oxyhemoglobin concentration and an increase in the deoxyhemoglobin concentrations were observed in a large area of the head. Large changes were observed in the hemisphere ipsilateral to the site of clamped carotid arteries. Smaller amplitude changes were noted at the contralateral site. We also found that changes in the hemoglobin signals, as estimated from intracerebral tissue, are very sensitive to clamping of the internal carotid artery, whereas its sensitivity to clamping of the external carotid artery is limited. We concluded that intraoperative multichannel measurements allow for imaging of brain tissue hemodynamics. However, when monitoring the brain during carotid surgery, a single-channel measurement may be sufficient.
Collapse
Affiliation(s)
- Michal Kacprzak
- Nalecz Institute of Biocybernetics and Biomedical Engineering PAS, Trojdena 4, 02-109 Warsaw, Poland.
| | | | | | | | | | | | | |
Collapse
|
9
|
Vetrugno L, Di Luca E, Drigo D, Fregonese V, Gonano N, Giordano F. Wake-up test decrease shunts insertion during carotid endarterectomy under general anesthesia. Vasc Endovascular Surg 2010; 44:174-8. [PMID: 20150229 DOI: 10.1177/1538574409359428] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The use of locoregional anesthesia versus general anesthesia (GE) in carotid endarterectomy (CEA) has been a debatable issue in clinical studies for the past several years. In our study, GE with wake-up tests (WUTs) during carotid cross-clamping was used instead of stump pressure (SP) to directly assess the neurological status of the patient to determine whether shunting was needed. Our study assessed the percentage of patients under light sedation and mechanically ventilated needing shunting based on WUT compared to a systolic stump pressure (SPs) cutoff value of <or=40 mm Hg. DESIGN Retrospective, observational study. SETTING University hospital clinic. PARTICIPANTS Three hundred fifty-one patients (American Society of Anesthesiologists physical class II-III) with carotid artery stenosis scheduled for CEA under GE. INTERVENTIONS The WUT was used to assess the neurological status in patients undergoing CEA, which involved the gradual reduction of depth of anesthesia until the patient was capable of responding to a verbal stimulus and provide full collaboration while only receiving remifentanil. A positive WUT indicated that patient was not able to carry out the order. MEASUREMENTS AND MAIN RESULTS Of 343 patients, 20 (5.8%) were shunted due to a positive WUT after cross-clamping in comparison to 45 patients (12.8%) based on the SPs <or=40 mm Hg criteria. CONCLUSION Wake-up test can be used to directly assess the neurological status in patients undergoing CEA to determine whether shunting is required. Our results showed that less patients required shunting based on WUT compared to the SP criteria.
Collapse
Affiliation(s)
- Luigi Vetrugno
- Cardiothoracic and Vascular Anesthesia, University-Hospital of Udine, Udine, Italy.
| | | | | | | | | | | |
Collapse
|
10
|
Estruch-Pérez MJ, Ausina-Aguilar A, Barberá-Alacreu M, Sánchez-Morillo J, Solaz-Roldán C, Morales-Suárez-Varela MM. Bispectral index changes in carotid surgery. Ann Vasc Surg 2009; 24:393-9. [PMID: 19932952 DOI: 10.1016/j.avsg.2009.08.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2009] [Revised: 05/27/2009] [Accepted: 08/09/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Intraoperative monitoring of cerebral ischemia with shunting during carotid endarterectomy (CEA) remains controversial. Our objective was to evaluate the sensitivity and specificity of BIS changes during carotid clamping in relation to shunted patients in awake CEA. METHODS Eighty CEAs under cervical block were included. There were two patient groups: with clinical signs of cerebral ischemia (shunted patients) and without signs of cerebral ischemia (nonshunted patients). Data were based on bispectral index (BIS) values and neurological monitoring at different surgery time points, with special attention paid during carotid clamping. BIS values were compared between shunted and nonshunted patients. Sensitivity and specificity, along with positive and negative predictive values of a percentage BIS value decrease during carotid clamping from baseline BIS values, were calculated in both patient groups. RESULTS Shunting was performed in 11 patients with cerebral ischemia at carotid clamping. Mean BIS values were 82.82+/-11.98 in shunted patients and 92.31+/-5.42 in nonshunted patients at carotid clamping (p<0.001). Relative decreased BIS values in relation to basal BIS values were 13.57% in shunted patients and 3.68% in nonshunted patients (p<0.05). The percentage decrease in BIS was 14%, sensitivity was 81.8% (95% CI 49.9-96.8), and specificity was 89.7% (95% CI 79.3-95.4). CONCLUSION BIS monitoring during carotid clamping is an easy, noninvasive method which correlates with cerebral ischemia in patients undergoing CEA. A decrease>or=14% from the basal BIS value presents a high negative predictive value, and ischemia is unlikely without a decrease. Nonetheless, a decrease may not always indicate cerebral ischemia with a low positive predictive value.
Collapse
Affiliation(s)
- M J Estruch-Pérez
- Anesthesiology and Critical Care Department, Dr. Peset University Hospital, and Department of Preventive Medicine, University of Valencia, Valencia, Spain.
| | | | | | | | | | | |
Collapse
|