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Zhao G, Feng G, Zhao L, Feng S, An Y, Kong C, Wang T. Application of quantitative electroencephalography in predicting early cerebral ischemia in patients undergoing carotid endarterectomy. Front Neurol 2023; 14:1159788. [PMID: 37090976 PMCID: PMC10117753 DOI: 10.3389/fneur.2023.1159788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 03/20/2023] [Indexed: 04/09/2023] Open
Abstract
BackgroundQuantitative electroencephalography (QEEG) has emerged as a promising monitoring method in cerebral ischemia, but the feasibility of QEEG in intraoperative cerebral perfusion-related ischemia monitoring is still uncertain. The purpose of this study was to investigate the value of QEEG monitoring in Carotid Endarterectomy (CEA) and the thresholds for intraoperative cerebral perfusion-related ischemia monitoring.MethodsSixty-three patients who underwent carotid endarterectomy with continuous Transcranial Doppler ultrasound (TCD) monitoring and QEEG monitoring at Xuanwu Hospital Capital Medical University from January 2021 to August 2021 were enrolled in this study. Each patient received total intravenous anesthesia. Middle cerebral artery blood flow velocity (V-MCA) was obtained by TCD. Relative alpha percentage (RA) and alpha-delta ratio (ADR) were obtained by QEEG monitoring. Patients were divided into ischemic and non-ischemic groups using a decline of more than 50% in the V-MCA monitored by TCD as the gold standard.ResultsOf the 63 patients, twenty patients were divided into the ischemic group, and forty-three patients into the non-ischemic group. Ipsilateral post-clamp RA and ADR values of QEEG were decreased for all patients in the ischemic group. The optimal threshold for RA and ADR to predict cerebral ischemia was a 14% decrease from baseline (sensitivity 90.0%, specificity 90.7%, Kappa value 0.786), a 21% decrease from baseline (sensitivity 85.0%, specificity 81.4%, Kappa value 0.622), respectively, indicated by TCD monitoring.ConclusionsOur study demonstrated that QEEG is a promising monitoring method undergoing CEA under general anesthesia and has good consistency with TCD.
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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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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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Baek H, Sariev A, Lee S, Dong SY, Royer S, Kim H. Deep Cerebellar Low-Intensity Focused Ultrasound Stimulation Restores Interhemispheric Balance after Ischemic Stroke in Mice. IEEE Trans Neural Syst Rehabil Eng 2020; 28:2073-2079. [PMID: 32746292 DOI: 10.1109/tnsre.2020.3002207] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Ischemic damage after stroke disrupts the complex balance of inhibitory and excitatory activity within cortical network causing brain functional asymmetry. Cerebellar deep nuclei with its extensive projections to cortical regions could be a prospective target for stimulation to restore inter-hemispheric balance and enhance neural plasticity after stroke. In our study, we repeatedly stimulated the lateral cerebellar nucleus (LCN) by low-intensity focused ultrasound (LIFU) for 3 days to enhance rehabilitation after middle cerebral artery occlusion (MCAO) in a mouse stroke model. The neural activity of the mice sensorimotor cortex was measured using epidural electrodes and analyzed with quantified electroencephalography (qEEG). Pairwise derived Brain Symmetry Index (pdBSI) and delta power were used to assess the neurorehabilitative effect of LIFU stimulation. Compared to the Stroke (non-treated) group, the LIFU group exhibited a decrease in cortical pathological delta activity, significant recovery in pdBSI and enhanced performance on the balance beam walking test. These results suggest that cerebellar LIFU stimulation could be a non-invasive method for stroke rehabilitation through the restoration of interhemispheric balance.
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Allen KB, Chhatriwalla AK, Cohen D, Saxon J, Hawa Z, Kennedy KF, Aggarwal S, Davis R, Pak A, Borkon AM. Transcarotid Versus Transapical and Transaortic Access for Transcatheter Aortic Valve Replacement. Ann Thorac Surg 2019; 108:715-722. [DOI: 10.1016/j.athoracsur.2019.02.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 01/18/2019] [Accepted: 02/04/2019] [Indexed: 10/27/2022]
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Fastenberg JH, Garzon‐Muvdi T, Hsue V, Reilly EK, Jabbour P, Rabinowitz MR, Rosen MR, Evans JJ, Nyquist GN, Farrell CJ. Adenosine‐induced transient hypotension for carotid artery injury during endoscopic skull‐base surgery: case report and review of the literature. Int Forum Allergy Rhinol 2019; 9:1023-1029. [DOI: 10.1002/alr.22381] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 05/28/2019] [Accepted: 06/20/2019] [Indexed: 01/10/2023]
Affiliation(s)
- Judd H. Fastenberg
- Department of Otolaryngology–Head & Neck SurgeryThomas Jefferson University Hospitals Philadelphia PA
| | - Tomas Garzon‐Muvdi
- Department of Neurosurgery and Neurological SciencesThomas Jefferson University Hospitals Philadelphia PA
| | | | - Erin K. Reilly
- Department of Otolaryngology–Head & Neck SurgeryThomas Jefferson University Hospitals Philadelphia PA
| | - Pascal Jabbour
- Department of Neurosurgery and Neurological SciencesThomas Jefferson University Hospitals Philadelphia PA
| | - Mindy R. Rabinowitz
- Department of Otolaryngology–Head & Neck SurgeryThomas Jefferson University Hospitals Philadelphia PA
| | - Marc R. Rosen
- Department of Otolaryngology–Head & Neck SurgeryThomas Jefferson University Hospitals Philadelphia PA
| | - James J. Evans
- Department of Neurosurgery and Neurological SciencesThomas Jefferson University Hospitals Philadelphia PA
| | - Gurston N. Nyquist
- Department of Otolaryngology–Head & Neck SurgeryThomas Jefferson University Hospitals Philadelphia PA
| | - Christopher J. Farrell
- Department of Neurosurgery and Neurological SciencesThomas Jefferson University Hospitals Philadelphia PA
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Verkerke G, Van Den Dungen J, Meyer T, Rakhorst G. Flow Analysis in Vascular Shunts that Bypass the Carotid Artery. Int J Artif Organs 2018. [DOI: 10.1177/039139880102400913] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
When blood flow through a carotid artery is impaired and vascular surgery is necessary to restore adequate circulation a vascular shunt can be applied to maintain cerebral blood flow. Several vascular shunts are commercially available, but there is only limited test data on their flow capacity. The purpose of this study is to determine the flow capacity of three vascular shunt systems. A theoretical model has been developed for this purpose. To validate the model, in vitro flow measurements were taken. Application of the model showed that all shunts cause a decrease in blood flow. The amount of flow decrease varied widely from 13% (Javid shunt) to 55% (Pruitt-Inahara). In vitro measurements confirmed the validity of the model. In conclusion, it is important for the vascular surgeon to realise that vascular shunts show large differences in flow capacity. Of the three investigated shunts, the Javid has the highest flow capacity.
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Affiliation(s)
- G.J. Verkerke
- Department of Biomedical Engineering, Faculty of Medical Sciences, University of Groningen, Groningen - The Netherlands
| | | | - T. Meyer
- Department of Biomedical Engineering, Faculty of Medical Sciences, University of Groningen, Groningen - The Netherlands
| | - G. Rakhorst
- Department of Biomedical Engineering, Faculty of Medical Sciences, University of Groningen, Groningen - The Netherlands
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Kim CS. Analysis of the Continuous Monitored Electroencephalogram Patterns in Intensive Care Unit. KOREAN JOURNAL OF CLINICAL LABORATORY SCIENCE 2017. [DOI: 10.15324/kjcls.2017.49.3.294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Cheon-Sik Kim
- Departments of Neurology, Asan Medical Center, 05505, Seoul, Korea
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Knappich C, Kuehnl A, Tsantilas P, Schmid S, Breitkreuz T, Kallmayer M, Zimmermann A, Eckstein HH. Intraoperative Completion Studies, Local Anesthesia, and Antiplatelet Medication Are Associated With Lower Risk in Carotid Endarterectomy. Stroke 2017; 48:955-962. [DOI: 10.1161/strokeaha.116.014869] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 01/21/2017] [Accepted: 01/27/2017] [Indexed: 01/05/2023]
Abstract
Background and Purpose—
In Germany, all surgical and endovascular procedures on the carotid bifurcation must be documented in a statutory nationwide quality assurance database. We aimed to analyze the association between procedural and perioperative variables and in-hospital stroke or death rates after carotid endarterectomy.
Methods—
Between 2009 and 2014, overall 142 074 elective carotid endarterectomy procedures for asymptomatic or symptomatic carotid artery stenosis were documented in the database. The primary outcome of this secondary data analysis was in-hospital stroke or death. Major stroke or death, stroke, and death, each until discharge were secondary outcomes. Adjusted relative risks (RRs) were assessed by multivariable multilevel regression analyses.
Results—
The primary outcome occurred in 1.8% of patients, with a rate of 1.4% in asymptomatic and 2.5% in symptomatic patients, respectively. In the multivariable analysis, lower risks of stroke or death were independently associated with local anesthesia (versus general anesthesia: RR, 0.85; 95% confidence interval [CI], 0.75–0.95), carotid endarterectomy with patch plasty compared with primary closure (RR, 0.71; 95% CI, 0.52–0.97), intraoperative completion studies by duplex ultrasound (RR, 0.74; 95% CI, 0.63–0.88) or angiography (RR, 0.80; 95% CI, 0.71–0.90), and perioperative antiplatelet medication (RR, 0.83; 95% CI, 0.71–0.97). No shunting and a short cross-clamp time were also associated with lower risks; however, these are suspected to be confounded.
Conclusions—
Local anesthesia, patch plasty compared with primary closure, intraoperative completion studies by duplex ultrasound or angiography, and perioperative antiplatelet medication were independently associated with lower in-hospital stroke or death rates after carotid endarterectomy.
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Affiliation(s)
- Christoph Knappich
- From the Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany (C.K., A.K., P.T., S.S., M.K., A.Z., H.-H.E.); and AQUA-Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen GmbH, Göttingen, Germany (T.B.)
| | - Andreas Kuehnl
- From the Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany (C.K., A.K., P.T., S.S., M.K., A.Z., H.-H.E.); and AQUA-Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen GmbH, Göttingen, Germany (T.B.)
| | - Pavlos Tsantilas
- From the Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany (C.K., A.K., P.T., S.S., M.K., A.Z., H.-H.E.); and AQUA-Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen GmbH, Göttingen, Germany (T.B.)
| | - Sofie Schmid
- From the Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany (C.K., A.K., P.T., S.S., M.K., A.Z., H.-H.E.); and AQUA-Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen GmbH, Göttingen, Germany (T.B.)
| | - Thorben Breitkreuz
- From the Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany (C.K., A.K., P.T., S.S., M.K., A.Z., H.-H.E.); and AQUA-Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen GmbH, Göttingen, Germany (T.B.)
| | - Michael Kallmayer
- From the Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany (C.K., A.K., P.T., S.S., M.K., A.Z., H.-H.E.); and AQUA-Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen GmbH, Göttingen, Germany (T.B.)
| | - Alexander Zimmermann
- From the Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany (C.K., A.K., P.T., S.S., M.K., A.Z., H.-H.E.); and AQUA-Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen GmbH, Göttingen, Germany (T.B.)
| | - Hans-Henning Eckstein
- From the Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany (C.K., A.K., P.T., S.S., M.K., A.Z., H.-H.E.); and AQUA-Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen GmbH, Göttingen, Germany (T.B.)
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Gardner PA, Snyderman CH, Fernandez-Miranda JC, Jankowitz BT. Management of Major Vascular Injury During Endoscopic Endonasal Skull Base Surgery. Otolaryngol Clin North Am 2016; 49:819-28. [DOI: 10.1016/j.otc.2016.03.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Consensus statement on continuous EEG in critically ill adults and children, part I: indications. J Clin Neurophysiol 2016; 32:87-95. [PMID: 25626778 DOI: 10.1097/wnp.0000000000000166] [Citation(s) in RCA: 382] [Impact Index Per Article: 47.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Critical Care Continuous EEG (CCEEG) is a common procedure to monitor brain function in patients with altered mental status in intensive care units. There is significant variability in patient populations undergoing CCEEG and in technical specifications for CCEEG performance. METHODS The Critical Care Continuous EEG Task Force of the American Clinical Neurophysiology Society developed expert consensus recommendations on the use of CCEEG in critically ill adults and children. RECOMMENDATIONS The consensus panel recommends CCEEG for diagnosis of nonconvulsive seizures, nonconvulsive status epilepticus, and other paroxysmal events, and for assessment of the efficacy of therapy for seizures and status epilepticus. The consensus panel suggests CCEEG for identification of ischemia in patients at high risk for cerebral ischemia; for assessment of level of consciousness in patients receiving intravenous sedation or pharmacologically induced coma; and for prognostication in patients after cardiac arrest. For each indication, the consensus panel describes the patient populations for which CCEEG is indicated, evidence supporting use of CCEEG, utility of video and quantitative EEG trends, suggested timing and duration of CCEEG, and suggested frequency of review and interpretation. CONCLUSION CCEEG has an important role in detection of secondary injuries such as seizures and ischemia in critically ill adults and children with altered mental status.
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Diagnostic accuracy of EEG changes during carotid endarterectomy in predicting perioperative strokes. J Clin Neurosci 2016; 25:1-9. [DOI: 10.1016/j.jocn.2015.08.014] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 08/14/2015] [Indexed: 11/22/2022]
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Malek BN, Mohrhaus CA, Sheth AK. Use of Multi-Modality Intraoperative Monitoring during Carotid Endarterectomy Surgery: A Case Study. ACTA ACUST UNITED AC 2015. [DOI: 10.1080/1086508x.2011.11079799] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Affiliation(s)
- Andrew C. Schomer
- Neurocritical Care, Department of Neurology, University of Virginia, Charlottesville, VA, , Phone/Fax: 434-924-2706
| | - Khalid Hanafy
- Harvard Medical School, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical, School, Boston, MA, , Phone/Fax: 617-667-5853/617-667-2987
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Gardner PA, Tormenti MJ, Pant H, Fernandez-Miranda JC, Snyderman CH, Horowitz MB. Carotid artery injury during endoscopic endonasal skull base surgery: incidence and outcomes. Neurosurgery 2014; 73:ons261-9; discussion ons269-70. [PMID: 23695646 DOI: 10.1227/01.neu.0000430821.71267.f2] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Injury to the internal carotid artery (ICA) during endoscopic endonasal skull base surgery is a feared complication that is not well studied or reported. OBJECTIVE To evaluate the incidence, to identify potential risk factors, and to present management strategies and outcomes of ICA injury during endonasal skull base surgery at our institution. METHODS We performed a retrospective review of all endoscopic endonasal operations performed at our institution between 1998 and 2011 to examine potential factors predisposing to ICA injury. We also documented the perioperative management and outcomes after injury. RESULTS There were 7 ICA injuries encountered in 2015 endonasal skull base surgeries, giving an incidence of 0.3%. Most injuries (5 of 7) involved the left ICA, and the most common diagnosis was chondroid neoplasm (chordoma, chondrosarcoma; 3 of 7 [2% of 142 cases]). Two injuries occurred during 660 pituitary adenoma resections (0.3%). The paraclival ICA segment was the most commonly injured site (5 of 7), and transclival and transpterygoid approaches had a higher incidence of injury, although neither factor reached statistical significance. Four of 7 injured ICAs were sacrificed either intraoperatively or postoperatively. No patient suffered a stroke or neurological deficit. There were no intraoperative mortalities; 1 patient died postoperatively of cardiac ischemia. One of the 3 preserved ICAs developed a pseudoaneurysm over a mean follow-up period of 5 months that was treated endovascularly. CONCLUSION ICA injury during endonasal skull base surgery is an infrequent and manageable complication. Preservation of the vessel remains difficult. Chondroid tumors represent a higher risk and should be resected by surgical teams with significant experience.
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Affiliation(s)
- Paul A Gardner
- *Department of Neurological Surgery and §Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania ‡Department of Medicine, University of Adelaide, Adelaide, Australia
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Outcomes of Combined Somatosensory Evoked Potential, Motor Evoked Potential, and Electroencephalography Monitoring during Carotid Endarterectomy. Ann Vasc Surg 2014; 28:665-72. [DOI: 10.1016/j.avsg.2013.09.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Revised: 09/06/2013] [Accepted: 09/18/2013] [Indexed: 11/17/2022]
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Mauermann WJ, Crepeau AZ, Pulido JN, Lynch JJ, Lobbestael A, Oderich GS, Worrell GA. Comparison of Electroencephalography and Cerebral Oximetry to Determine the Need for In-Line Arterial Shunting in Patients Undergoing Carotid Endarterectomy. J Cardiothorac Vasc Anesth 2013; 27:1253-9. [DOI: 10.1053/j.jvca.2013.02.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Indexed: 11/11/2022]
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Importance of Technical Preparation of Intraarterial Shunts to Prevent Iatrogenic Arterial Injury During Urgent Procedures. Vasc Endovascular Surg 2013; 47:106-8. [DOI: 10.1177/1538574412474498] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Aburahma AF, Mousa AY, Stone PA. Shunting during carotid endarterectomy. J Vasc Surg 2011; 54:1502-10. [PMID: 21906905 DOI: 10.1016/j.jvs.2011.06.020] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2011] [Revised: 06/02/2011] [Accepted: 06/08/2011] [Indexed: 11/25/2022]
Abstract
BACKGROUND The use of shunting during carotid endarterectomy (CEA) is controversial. While some surgeons advocate routine shunting, others prefer selective shunting or no shunting. Several large series have documented excellent results of CEA with routine shunting or without shunts. Others reported similar results with selective shunting using transcranial Doppler (TCD), electroencephalogram (EEG) monitoring, carotid stump pressure (SP), cervical block anesthesia (CBA), and somatosensory evoked potential (SSEP). In this study, we review the available evidence supporting shunting, nonshunting, and selective shunting during CEA. METHODS An electronic PubMed/MEDLINE search was conducted to identify all published CEA studies between January 1990 and December 2010, that analyzed the perioperative outcome of routine shunting, routine nonshunting, routine versus selective shunting, selecting shunting versus avoiding a shunt, and selective shunting based on EEG, TCD, SP, CBA, and SSEP. RESULTS The mean reported perioperative stroke rate for CEAs with routine shunting was 1.4% and for routine nonshunt was 2%. Meanwhile, the mean perioperative stroke rates for selecting shunting were 1.6% using EEG, 4.8% using TCD, 1.6% using SP, 1.8% using SSEP, and 1.1% for CBA. Similar results were noted for perioperative stroke and death rates. CONCLUSIONS The use of routine shunting and selective shunting was associated with a low stroke rate. Both methods are acceptable, and the individual surgeon should select the method with which they are more comfortable.
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Affiliation(s)
- Ali F Aburahma
- Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, WV 25304, USA.
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Tambakis CL, Papadopoulos G, Sergentanis TN, Lagos N, Arnaoutoglou E, Labropoulos N, Matsagkas MI. Cerebral oximetry and stump pressure as indicators for shunting during carotid endarterectomy: comparative evaluation. Vascular 2011; 19:187-94. [DOI: 10.1258/vasc.2010.oa0277] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The purpose of this work is to investigate the correlation between regional oxygen saturation (rSO2) changes and stump pressure (SP) during cross-clamping of the internal carotid artery in carotid endarterectomy (CEA) and verify the perspectives of rSO2 to become a criterion for shunting. Sixty consecutive CEAs under general anesthesia were studied prospectively. Selective shunting was based on SP ≤40 mmHg exclusively. Regression analysis with high order terms and receiver operating characteristic analysis were performed to investigate the association between ΔrSO2(%) and SP and to determine an optimal ΔrSO2(%) threshold for shunt insertion. A quadratic association between ΔrSO2(%) and SP was documented regarding the baseline to one and five minutes after cross-clamping intervals. A cut-off of 21 and 10.1% reduction from the baseline recording was identified as optimal for the distinction between patients needed or not a shunt regarding the first and fifth minute after cross-clamping, respectively. In conclusion, cerebral oximety reflects sufficiently cerebral oxygenation during CEA compared with SP, providing a useful mean for cerebral monitoring.
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Affiliation(s)
| | - George Papadopoulos
- Department of Anesthesiology, School of Medicine, University of Ioannina, Ioannina 45110
| | - Theodoros N Sergentanis
- 1st Department of Propaedeutic Surgery, Hippokration Hospital, Medical School, University of Athens, Athens 11527, Greece
| | - Nikolaos Lagos
- Department of Anesthesiology, School of Medicine, University of Ioannina, Ioannina 45110
| | - Eleni Arnaoutoglou
- Department of Anesthesiology, School of Medicine, University of Ioannina, Ioannina 45110
| | - Nicos Labropoulos
- Division of Vascular Surgery, Stony Brook University Medical Center, Stony Brook, NY 11794-8191, USA
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Electroencephalogram monitoring during intracranial surgery for moyamoya disease. Pediatr Neurol 2011; 44:427-32. [PMID: 21555053 DOI: 10.1016/j.pediatrneurol.2011.01.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2010] [Revised: 11/23/2010] [Accepted: 01/03/2011] [Indexed: 11/21/2022]
Abstract
We describe our experience with intraoperative electroencephalography in moyamoya surgery, a method to monitor for ischemic changes during the procedure and to minimize the risk of intraoperative and perioperative stroke. Case records and intraoperative electroencephalography recordings of all patients (n=220) treated with surgical revascularization for moyamoya (pial synangiosis) performed for 14 years (1994-2008) were reviewed. Electroencephalographic slowing occurred in 100 cases (45.5%), and was persistent in nine cases (9%). Slowing coincided with specific operative manipulations, most commonly while suturing the donor vessel to the pia, and during closure of the craniotomy. Slowing generally occurred bilaterally, independently of the side of intervention. The presence, length, and severity of slowing were not predictive of perioperative ischemic events. We present additional data on intraoperative electroencephalography with a modified montage to accommodate the craniotomy. Although not predictive of perioperative ischemic events in this series, electroencephalographic changes were correlated with specific operative interventions, and revealed global responses to unilateral manipulation. These findings suggest that prospective analyses of this technique may elucidate additional methods of predicting (and possibly preventing) perioperative ischemic events.
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Shang Y, Cheng R, Dong L, Ryan SJ, Saha SP, Yu G. Cerebral monitoring during carotid endarterectomy using near-infrared diffuse optical spectroscopies and electroencephalogram. Phys Med Biol 2011; 56:3015-32. [PMID: 21508444 DOI: 10.1088/0031-9155/56/10/008] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Intraoperative monitoring of cerebral hemodynamics during carotid endarterectomy (CEA) provides essential information for detecting cerebral hypoperfusion induced by temporary internal carotid artery (ICA) clamping and post-CEA hyperperfusion syndrome. This study tests the feasibility and sensitivity of a novel dual-wavelength near-infrared diffuse correlation spectroscopy technique in detecting cerebral blood flow (CBF) and cerebral oxygenation in patients undergoing CEA. Two fiber-optic probes were taped on both sides of the forehead for cerebral hemodynamic measurements, and the instantaneous decreases in CBF and electroencephalogram (EEG) alpha-band power during ICA clamping were compared to test the measurement sensitivities of the two techniques. The ICA clamps resulted in significant CBF decreases (-24.7 ± 7.3%) accompanied with cerebral deoxygenation at the surgical sides (n = 12). The post-CEA CBF were significantly higher (+43.2 ± 16.9%) than the pre-CEA CBF. The CBF responses to ICA clamping were significantly faster, larger and more sensitive than EEG responses. Simultaneous monitoring of CBF, cerebral oxygenation and EEG power provides a comprehensive evaluation of cerebral physiological status, thus showing potential for the adoption of acute interventions (e.g., shunting, medications) during CEA to reduce the risks of severe cerebral ischemia and cerebral hyperperfusion syndrome.
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Affiliation(s)
- Yu Shang
- Center for Biomedical Engineering, University of Kentucky, KY, USA
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Ballotta E, Saladini M, Gruppo M, Mazzalai F, Da Giau G, Baracchini C. Predictors of Electroencephalographic Changes Needing Shunting During Carotid Endarterectomy. Ann Vasc Surg 2010; 24:1045-52. [DOI: 10.1016/j.avsg.2010.06.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2010] [Revised: 06/08/2010] [Accepted: 06/23/2010] [Indexed: 10/18/2022]
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Cerebral embolism during elective carotid endarterectomy treated with tissue plasminogen activator: Utility of intraoperative EEG monitoring. Clin Neurol Neurosurg 2010; 112:446-9. [DOI: 10.1016/j.clineuro.2010.01.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2008] [Revised: 10/14/2009] [Accepted: 01/22/2010] [Indexed: 11/24/2022]
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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.
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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.
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Isley MR, Edmonds HL, Stecker M. Guidelines for intraoperative neuromonitoring using raw (analog or digital waveforms) and quantitative electroencephalography: a position statement by the American Society of Neurophysiological Monitoring. J Clin Monit Comput 2009; 23:369-90. [DOI: 10.1007/s10877-009-9191-y] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2009] [Accepted: 07/02/2009] [Indexed: 10/20/2022]
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Predictors of shunt during carotid endarterectomy with routine electroencephalography monitoring. J Vasc Surg 2009; 49:1374-8. [DOI: 10.1016/j.jvs.2009.02.206] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2008] [Revised: 02/06/2009] [Accepted: 02/12/2009] [Indexed: 11/20/2022]
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Linear and non-linear parameterization of EEG during monitoring of carotid endarterectomy. Comput Biol Med 2009; 39:512-8. [DOI: 10.1016/j.compbiomed.2009.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2007] [Revised: 08/25/2008] [Accepted: 03/10/2009] [Indexed: 11/22/2022]
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One Patent Intracranial Collateral Predicts Tolerance of Flow Reversal during Carotid Angioplasty and Stenting. Ann Vasc Surg 2009; 23:32-8. [DOI: 10.1016/j.avsg.2008.04.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2007] [Revised: 02/24/2008] [Accepted: 04/28/2008] [Indexed: 01/18/2023]
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Cerebrovascular Disease. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_63] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Woodworth GF, McGirt MJ, Than KD, Huang J, Perler BA, Tamargo RJ. SELECTIVE VERSUS ROUTINE INTRAOPERATIVE SHUNTING DURING CAROTID ENDARTERECTOMY. Neurosurgery 2007; 61:1170-6; discussion 1176-7. [DOI: 10.1227/01.neu.0000306094.15270.40] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE
The use of intraluminal shunting during carotid endarterectomy (CEA) remains controversial. Over the years, different shunting strategies have been used. More recently, the use of intraoperative electroencephalography and somatosensory evoked potential monitoring with selective intraluminal shunting has been explored. No studies have assessed the independent association of selective versus routine intraluminal shunting to outcomes after CEA.
METHODS
The clinical and radiological records of all patients undergoing CEA from 1994 to 2006 at an academic institution were reviewed retrospectively to assess outcomes at 72 hours. The independent association of selective intraluminal carotid artery shunting during CEA and perioperative stroke within 72 hours was assessed through multivariate logistic regression analysis.
RESULTS
In 1411 patients with both symptomatic and asymptomatic extracranial carotid artery disease, there were a total of 49 (3.5%) perioperative strokes after CEA. There were two (1%) cases of perioperative strokes among 194 patients in the selective shunting group compared with 47 out of 1217 (4%) in the routine shunting group (P = 0.04). Symptomatic carotid artery disease was associated with a twofold increase in the odds of experiencing perioperative stroke (odds ratio, 1.95; 95% confidence interval, 1.08–3.52; P = 0.03). Patients undergoing electrophysiological monitoring with selective intraluminal carotid artery shunting were more than seven times less likely to experience a perioperative stroke (odds ratio, 0.05; 95% confidence interval, 0.01–0.40; P < 0.01). Increasing cumulative surgical volume, particularly more than 200 total cases, was associated with more than a twofold decrease in perioperative stroke (odds ratio, 0.38; 95% confidence interval, 0.20–0.74; P < 0.01).
CONCLUSION
Regardless of symptomatic carotid artery disease or cumulative surgical volume, patients undergoing CEA with intraoperative electroencephalography and somatosensory evoked potential monitoring with selective intraluminal carotid artery shunting had a stroke rate lower than that of the routine shunting group. Selective shunting based on electroencephalography and somatosensory evoked potential monitoring may be superior to the nonselective strategy.
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Affiliation(s)
| | - Matthew J. McGirt
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Khoi D. Than
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Bruce A. Perler
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Rafael J. Tamargo
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland
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van Putten MJAM. The revised brain symmetry index. Clin Neurophysiol 2007; 118:2362-7. [PMID: 17888719 DOI: 10.1016/j.clinph.2007.07.019] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2007] [Revised: 07/02/2007] [Accepted: 07/28/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Recently, the extended brain symmetry index (BSI) was introduced to assist the visual interpretation of the EEG, in particular to quantify both the spatial (left-right) and the temporal spectral characteristics. The BSI has found application in monitoring during carotid endarterectomy, acute stroke and focal seizure detection. Here, we present additional relevant characteristics and a slightly modified version of this index, simulating its behavior as may occur in various clinical conditions, with an emphasis on the detection of cerebral ischaemia. METHODS The behavior of the revised and standard sBSI and tBSI is illustrated using random noise signals to simulate various changes in the EEG. The indices are evaluated as a function of spatial and temporal changes, and as a function of the number of channels. RESULTS The r-sBSI and the r-tBSI are normalized in the range [0-1] with sensitivities of about 0.05 for a 10% difference in signal amplitude, either spatial or temporal. The baseline value of the sBSI shows a modest dependence on the number of channels used. CONCLUSIONS The revised BSI has an improved sensitivity (about two times) to detect interhemispheric asymmetry and diffuse changes. The modified expression of the tBSI is more compact and allows a more intuitive understanding than previously proposed. SIGNIFICANCE qEEG assists in a more objective interpretation of the EEG, and is relevant in neuromonitoring.
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Affiliation(s)
- Michel J A M van Putten
- Institute of Technical Medicine, Faculty of Science and Technology, Biomedical Signals and Systems Group, Faculty of Electrical Engineering, Mathematics and Computer Science, University of Twente, Enschede, The Netherlands.
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Hans SS, Jareunpoon O. Prospective evaluation of electroencephalography, carotid artery stump pressure, and neurologic changes during 314 consecutive carotid endarterectomies performed in awake patients. J Vasc Surg 2007; 45:511-5. [PMID: 17275248 DOI: 10.1016/j.jvs.2006.11.035] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2006] [Accepted: 11/13/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVE This study attempted to correlate neurologic changes in awake patients undergoing carotid endarterectomy (CEA) under cervical block anesthesia (CBA) with electroencephalography (EEG) and measurement of carotid artery stump pressure (SP). METHODS Continuous EEG and SP monitoring was measured prospectively in 314 consecutive patients undergoing CEA between April 1, 2003, and July 30, 2006, under CBA. Indications for CEA were asymptomatic 70% to 99% internal carotid artery stenosis in 242 (77.1%), transient ischemic attacks (including transient monocular blindness) in 45 (14.3%), and prior stroke in 27 (8.6%). Mean common carotid artery pressure before clamping, mean SP after carotid clamping, and intraarterial pressure were continuously monitored in all patients. An indwelling shunt was placed when neurologic events (contralateral motor weakness, aphasia, loss of consciousness, or seizures) occurred, regardless of SP or EEG changes. RESULTS Shunt placement was necessary because of neurologic changes in 10% (32/314) of all CEAs performed under CBA. Only 3 patients (1.4%) of 216 required shunt placement if SP was 50 mm Hg or more, vs 29 (29.6%) of 98 if SP was less than 50 mm Hg (P < .00001; sensitivity, 29.8%; specificity, 98.6%). In patients with SP of 40 mm Hg or more, 7 (2.6%) of 270 required shunt placement, vs 25 (56.8%) of 44 if SP was less than 40 mm Hg (P < .00001; sensitivity, 56.8%; specificity, 97.4%). Ischemic EEG changes were observed in 19 (59.4%) of 32 patients (false-negative rate, 40.6%) requiring shunt placement under CBA. Three patients had false-positive EEG results and did not require shunt placement (false-positive rate, 1.0%). The perioperative stroke/death rate was 4 (1.2%) in 314. All strokes occurred after surgery and were unrelated to cerebral ischemia or lack of shunt placement. CONCLUSIONS Ten percent of patients required a shunt placement during CEA under CBA. Shunt placement was necessary in 56.8% of patients with SP less than 40 mm Hg. EEG identified cerebral ischemia in only 59.4% of patients needing shunt placement, with a false-positive rate of 1.0% and a false-negative rate of 40.6%. Both SP and EEG as a guide to shunt placement have poor sensitivity. Intraoperative monitoring of the awake patients under regional anesthesia (CBA) is the most sensitive and specific method to identify patients requiring shunt placement.
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Baracchini C, Ballotta E. Routine electroencephalographic monitoring for selective shunting in carotid surgery. Am J Surg 2006; 192:409-10. [PMID: 16920443 DOI: 10.1016/j.amjsurg.2005.05.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2005] [Revised: 03/31/2005] [Accepted: 05/10/2005] [Indexed: 11/16/2022]
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McGirt MJ, Woodworth GF, Brooke BS, Coon AL, Jain S, Buck D, Huang J, Clatterbuck RE, Tamargo RJ, Perler BA. Hyperglycemia independently increases the risk of perioperative stroke, myocardial infarction, and death after carotid endarterectomy. Neurosurgery 2006; 58:1066-73; discussion 1066-73. [PMID: 16723885 DOI: 10.1227/01.neu.0000215887.59922.36] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Clinical and experimental evidence suggests that hyperglycemia lowers the neuronal ischemic threshold, potentiates stroke volume in focal ischemia, and is associated with morbidity and mortality in the surgical critical care setting. It remains unknown whether hyperglycemia during carotid endarterectomy (CEA) predisposes patients to perioperative stroke and operative related morbidity and mortality. METHODS The clinical and radiological records of all patients undergoing CEA and operative day glucose measurement from 1994 to 2004 at an academic institution were reviewed and 30-day outcomes were assessed. The independent association of operative day glucose before CEA and perioperative morbidity and mortality were assessed via multivariate logistic regression analysis. RESULTS One thousand two hundred and one patients with a mean age of 72 +/- 10 years (748 men, 453 women) underwent CEA (676 asymptomatic, 525 symptomatic). Overall, stroke occurred in 46 (3.8%) patients, transient ischemic attack occurred in 19 (1.6%), myocardial infarction occurred in 19 (1.6%), and death occurred in 17 (1.4%). Increasing operative day glucose was independently associated with perioperative stroke or transient ischemic attack (Odds ratio [OR], 1.005; 95% confidence interval [CI], 1.00-1.01; P = 0.03), myocardial infarction (OR, 1.01; 95% CI, 1.004-1.016; P = 0.017), and death (OR, 1.007; 95% CI, 1.00-1.015; P = 0.04). Patients with operative day glucose greater than 200 mg/dl were 2.8-fold, 4.3-fold, and 3.3-fold more likely to experience perioperative stroke or transient ischemic attack (OR, 2.78; 95% CI, 1.37-5.67; P = 0.005), myocardial infarction (OR, 4.29; 95% CI, 1.28-14.4; P = 0.018), or death (OR, 3.29; 95% CI, 1.07-10.1; P = 0.037), respectively. Median and interquartile range length of hospitalization was greater for patients with operative day glucose greater than 200 mg/dl (4 d [interquartile range, 2-15 d] versus 3 d [interquartile range, 2-7 d]; P < 0.05). CONCLUSION Independent of previous cardiac disease, diabetes, or other comorbidities, hyperglycemia at the time of CEA was associated with an increased risk of perioperative stroke or transient ischemic attack, myocardial infarction, and death. Strict glucose control should be attempted before surgery to minimize the risk of morbidity and mortality after CEA.
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Affiliation(s)
- Matthew J McGirt
- Department of Neurosurgery, The Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Rigamonti A, Scandroglio M, Minicucci F, Magrin S, Carozzo A, Casati A. A clinical evaluation of near-infrared cerebral oximetry in the awake patient to monitor cerebral perfusion during carotid endarterectomy. J Clin Anesth 2006; 17:426-30. [PMID: 16171662 DOI: 10.1016/j.jclinane.2004.09.007] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2003] [Accepted: 09/09/2004] [Indexed: 11/28/2022]
Abstract
STUDY OBJECTIVE To evaluate the relationship between continuous noninvasive monitoring of cerebral saturation (regional cerebral oxygen saturation [rSo2]) and occurrence of clinical and electroencephalographic (EEG) signs of cerebral ischemia during carotid cross-clamping. DESIGN Prospective clinical study. SETTING University hospital. PATIENTS Fifty ASA physical status II and III inpatients undergoing elective carotid endarterectomy with a cervical plexus block. INTERVENTIONS rSo2 was continuously monitored throughout surgery, while an independent neurologist evaluated the occurrence of both clinical and EEG signs of cerebral ischemia induced during carotid cross-clamping. MEASUREMENTS AND MAIN RESULTS rSo2 was recorded 1 and 3 minutes after clamping the carotid artery during a 3-minute clamping test. In 5 patients (10%), the carotid clamping test was associated with the occurrence of clinical and EEG signs of cerebral ischemia. All these patients were treated with the placement of a Javid shunt, which completely resolved the symptoms. In no patient was permanent neurological injury reported at hospital discharge. In 4 of these patients, EEG signs of cerebral ischemia were present at both observation times, and in one of them, the duration of cerebral ischemia was less than 2 minutes. The percentage rSo2 reduction from baseline during the carotid clamping test was 17% +/- 4% in patients requiring shunt placement and only 8% +/- 6% in those who did not require it (P = .01). A decrease in rSo2 15% or greater during the carotid clamping test was associated with a 20-fold increase in the odd for developing severe cerebral ischemia (odds ratio, 20; 95% confidence interval, 6.7-59.2) (P = .001); however, this threshold had a 44% sensitivity and 82% specificity, with only 94% negative predictive value. CONCLUSIONS Continuous rSo2 monitoring is a simple and noninvasive method that correlates with the development of clinical and EEG signs of cerebral ischemia during carotid cross-clamping; however, we could not identify an rSo2 threshold that can be used alone to predict the need for shunt placement because of the low sensitivity and specificity.
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Affiliation(s)
- Andrea Rigamonti
- Department of Anesthesiology, Vita-Salute University of Milan, IRCCS San Raffaele Hospital, 20132 Milan, Italy
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Clair DG, Ouriel K. Carotid endarterectomy versus carotid angioplasty and stenting: a critical appraisal. Adv Surg 2005; 39:35-55. [PMID: 16250545 DOI: 10.1016/j.yasu.2005.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Daniel G Clair
- Department of Vascular Surgery, The Cleveland Clinic, Cleveland, Ohio, USA
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Laman DM, Wieneke GH, van Duijn H, Veldhuizen RJ, van Huffelen AC. QEEG changes during carotid clamping in carotid endarterectomy: spectral edge frequency parameters and relative band power parameters. J Clin Neurophysiol 2005; 22:244-52. [PMID: 16093896 DOI: 10.1097/01.wnp.0000167931.83516.cf] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Intraoperative monitoring is needed to identify accurately those patients in need of a shunt during carotid endarterectomy. EEG can be used for this purpose, but there is no consensus on the variables to use. Using a database consisting of 149 EEGs recorded from patients during carotid endarterectomy under isoflurane (n=61) or propofol (n=88) anesthesia and who did or did not receive a shunt, the authors investigated which of 16 derivations (common reference, Cz) and 12 parameters (relative and absolute powers and spectral edge frequencies [SEFs]) singly or in combination could best distinguish between the shunt and the nonshunt groups for the two anesthesia regimens. Receiver operating characteristic curves were used to select derivation/parameter combinations for three types of trend computation: (1) values of relative powers and SEFs during clamping (C) only, (2) clamp minus preclamp (baseline) differences (C-B), and (3) C-B differences in absolute logarithmic power (DeltalogP). For both anesthesia regimens, C-B computation distinguished best between the shunt and nonshunt groups. For isoflurane anesthesia, SEF parameters were the best, and for propofol anesthesia the relative power parameters. Discriminant analysis, in which additional derivation/parameter combinations were added, increased the discriminative power of the DeltalogP computation but not of the C or C-B computations. For isoflurane anesthesia, SEF 90% was the best single parameter for distinguishing between patients who did and did not need a shunt and the four best derivations were F3-Cz, P4-Cz, C4-Cz, and F7-Cz. For the propofol anesthesia, the relative power (C or C-B computations) of the delta band was the best and the four best derivations were F8-Cz, T4-Cz, C4-Cz, and F4-Cz.
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Affiliation(s)
- David M Laman
- Department of Clinical Neurophysiology, St. Lucas Andreas Hospital, Amsterdam, and Department of Clinical Neurophysiology, University Medical Center and Rudolf Magnus Institute for Neuroscience, Utrecht, The Netherlands.
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Deogaonkar A, Vivar R, Bullock RE, Price K, Chambers I, Mendelow AD. Bispectral index monitoring may not reliably indicate cerebral ischaemia during awake carotid endarterectomy † †This study was conducted in the Department of Neurosurgery, Newcastle General Hospital, Newcastle Upon Tyne NE4 6BE, UK. Preliminary results were presented at the British Neurosurgery Research Group Meeting, Sheffield, March 29–30, 2001. Br J Anaesth 2005; 94:800-4. [PMID: 15778269 DOI: 10.1093/bja/aei115] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Intraoperative ischaemia during carotid cross-clamping in patients undergoing carotid endarterectomy (CEA) is a major complication and prompt recognition of insufficient collateral blood supply is crucial. Electroencephalogram (EEG) is believed to be one of the useful forms of monitoring cerebrovascular insufficiency during CEA. The aim of this study was to evaluate the utility of bispectral index (BIS) monitoring, a processed EEG parameter, for the reliable detection of intraoperative cerebral ischaemia during awake CEA. METHODS We monitored 52 patients continuously with the BIS monitor together with assessment of neurological function (contralateral upper and lower limb strength and the verbal component of the Glasgow Coma Scale for speech) in patients undergoing awake CEA. RESULTS Overall mean BIS value in all patients was 96 (SD 2.9). In five patients who showed clinical evidence of cortical ischaemia during carotid cross-clamping, there was no change in the original range of BIS values throughout the procedure (96.7 [3.2]). In one patient BIS values decreased to 38 about 5 min after the incision and recovered within the next 10 min. The mean BIS value in the remaining 46 patients who did not develop clinical signs of ischaemia was 95.4 (2.6). Three cases are presented which demonstrate the inability of the BIS monitor to detect cerebral ischaemia. CONCLUSIONS Lack of correlation of BIS with the signs of cerebral ischaemia during CEA makes it unreliable for detection of cerebrovascular insufficiency. We conclude that awake neurological testing is the preferred method of monitoring in these patients.
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Affiliation(s)
- A Deogaonkar
- Department of General Anesthesiology, Cleveland Clinic Foundation, Cleveland, OH, USA
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Schneider JR, Novak KE. Carotid endarterectomy with routine electroencephalography and selective shunting. Semin Vasc Surg 2004. [DOI: 10.1053/j.semvascsurg.2004.06.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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van Putten MJAM, Peters JM, Mulder SM, de Haas JAM, Bruijninckx CMA, Tavy DLJ. A brain symmetry index (BSI) for online EEG monitoring in carotid endarterectomy. Clin Neurophysiol 2004; 115:1189-94. [PMID: 15066544 DOI: 10.1016/j.clinph.2003.12.002] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2003] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Carotid endarterectomy is a common procedure as a secondary prevention of stroke, and one of the early controversies in carotid surgery is centered around whether a shunt should be used during this procedure. Although various EEG parameters have been proposed to determine if the brain is at risk during carotid artery clamping, the common procedure is still the visual assessment of the EEG. We propose a brain symmetry index (BSI), that has been implemented as an on-line quantitative EEG parameter, as an additional criterion for shunt need in carotid endarterectomy. METHODS The BSI captures a particular asymmetry in spectral power between the two cerebral hemispheres, and is normalized between 0 (perfect symmetry) and 1 (maximal asymmetry). The index was evaluated retrospectively in a group of 57 operations in which the EEG and the transcranial Doppler were used as criteria for shunt insertion. In addition, after online implementation of the algorithm, several patients have been evaluated prospectively. RESULTS If no visual EEG changes were detected, it was found that the change in BSI from baseline, DeltaBSI<or=0.03 in all patients. In none of these patients shunting was performed, except for 11 in whom shunting was advised based on changes in the transcranial Doppler signal. None of these patients suffered from neurological complications. In those operations with visual EEG changes during test-clamping and selective shunting, we found that DeltaBSI>or=0.06. In this group, one patient suffered from intraoperative stroke and one patient died, most likely from a hyperperfusion syndrome. CONCLUSIONS The BSI may assist in the visual EEG analysis during carotid endarterectomy and provides a quantitative measure for electroencephalographic asymmetry due to cerebral hypo-perfusion. In patients with a change in the BSI (DeltaBSI) smaller than 0.03 during test clamping, visual EEG analysis showed no changes, whereas if visual EEG analysis did warrant shunting, it was found that DeltaBSI>or=0.06.
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Affiliation(s)
- Michel J A M van Putten
- Department of Neurology and Clinical Neurophysiology, Ziekenhuis Leyenburg, Leyweg 275, 2545 CH The Hague, The Netherlands.
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Roseborough GS. Pro: routine shunting is the optimal management of the patient undergoing carotid endarterectomy. J Cardiothorac Vasc Anesth 2004; 18:375-80. [PMID: 15232821 DOI: 10.1053/j.jvca.2004.03.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Glen S Roseborough
- Division of Vascular Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.
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Blanco-Cañibano E, Reina-Gutiérrez T, Serrano-Hernando F, Martín-Conejero A, Ponce-Cano A, Vega de Céniga M, Aguilar-Lloret C. Endarterectomía carotídea con anestesia locorregional. Estudio de factores clínicos y arteriográficos de riesgo de isquemia cerebral durante el clampaje carotídeo. ANGIOLOGIA 2004. [DOI: 10.1016/s0003-3170(04)74857-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Bond R, Rerkasem K, Rothwell PM. Systematic review of the risks of carotid endarterectomy in relation to the clinical indication for and timing of surgery. Stroke 2003; 34:2290-301. [PMID: 12920260 DOI: 10.1161/01.str.0000087785.01407.cc] [Citation(s) in RCA: 170] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Reliable data on the risk of carotid endarterectomy (CEA) in relation to clinical indication and timing of surgery are necessary to target CEA more effectively, to inform patients, to adjust risks for case mix, and to understand the mechanisms of operative stroke. METHODS We performed a systematic review of all studies published from 1980 to 2000 inclusive that reported the risk of stroke and death resulting from CEA. Pooled estimates of risk by type of presenting ischemic event and time since the last event were obtained by Mantel-Haenszel meta-analysis. RESULTS Of 383 published studies, only 103 stratified risk by indication. Although the operative risk for symptomatic stenosis overall was higher than for asymptomatic stenosis (odds ratio [OR], 1.62; 95% confidence interval [CI], 1.45 to 1.81; P<0.00001; 59 studies), risk in patients with ocular events only tended to be lower than for asymptomatic stenosis (OR, 0.75, 95% CI, 0.50 to 1.14; 15 studies). Operative risk was the same for stroke and cerebral transient ischemic attack (OR, 1.16; 95% CI, 0.99 to 1.35; P=0.08; 23 studies) but higher for cerebral transient ischemic attack than for ocular events only (OR, 2.31; 95% CI, 1.72 to 3.12; P<0.00001; 19 studies) and for CEA for restenosis than primary surgery (OR, 1.95; 95% CI, 1.21 to 3.16; P=0.018; 6 studies). Urgent CEA for evolving symptoms had a much higher risk (19.2%, 95% CI, 10.7 to 27.8) than CEA for stable symptoms (OR, 3.9; 95% CI, 2.7 to 5.7; P<0.001; 13 studies), but there was no difference between early (<3 to 6 weeks) and late (>3 to 6 weeks) CEA for stroke in stable patients (OR, 1.13; 95% CI, 0.79 to 1.62; P=0.62; 11 studies). All observations were highly consistent across studies. CONCLUSIONS Risk of stroke and death resulting from CEA is highly dependent on the clinical indication. Audits of risk should be stratified accordingly, and patients should be informed of the risk that relates to their presenting event.
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Affiliation(s)
- R Bond
- Stroke Prevention Research Unit, University Department of Clinical Neurology, Radcliffe Infirmary, Oxford, UK
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Gervitz LM, Davies DG, Omidvar K, Fowler JC. The effect of acute hypoxemia and hypotension on adenosine-mediated depression of evoked hippocampal synaptic transmission. Exp Neurol 2003; 182:507-17. [PMID: 12895463 DOI: 10.1016/s0014-4886(03)00160-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The present study was designed to investigate the relative contributions of arterial P(O(2)), local cerebral blood flow, and oxygen delivery to the adenosine A(1) receptor-mediated depression of evoked synaptic transmission recorded in the rat hippocampus. Urethane-anesthetized rats were given a unilateral common carotid artery occlusion and then placed in a stereotaxic apparatus for stimulation and recording of bilateral hippocampal field excitatory postsynaptic potentials (fEPSPs). Arterial blood gases, mean arterial blood pressure (MAP), and bilateral hippocampal blood flow (HBF) were also measured. Arterial P(O(2)), HBF, and oxygen delivery were manipulated using normoxic hypotension, hypoxic hypotension, and hypoxic normotension. Both hypoxic hypotension and normoxic hypotension resulted in decreased HBF, decreased oxygen delivery, and a depression of the evoked fEPSP limited to the hippocampus ipsilateral to the occlusion. The enhanced HBF and oxygen delivery associated with increased MAP resulted in a restoration and maintenance of hippocampal fEPSPs despite sustained hypoxemia. The adenosine A(1) receptor-mediated depression of the fEPSP was more strongly correlated with changes in HBF and oxygen delivery than with arterial P(O(2)). We propose that adenosine plays an important role mediating the depression of neuronal activity associated with reduced oxygen delivery characteristically observed in ischemic brain tissue.
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Affiliation(s)
- L M Gervitz
- Department of Physiology, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA.
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Abstract
The efficacy of continuous intraoperative electroencephalographic (EEG) monitoring as a criterion for selective shunt use during carotid endarterectomy is evaluated in a group of 1661 operations in which the EEG was the sole criterion for shunt insertion. EEG monitoring is measured by the intraoperative stroke rate. Carotid stump pressure measurements were recorded as an additional observation in 1517 operations and represent a subset of the study group allowing comparison of this technique with EEG. Intraoperative stroke rate for the 1661 operations in the study group was 0.03% (five strokes). A statistically significant increase in intraoperative stroke rate was associated with the development of an abnormal EEG (1.1%), contralateral internal carotid artery occlusion (1.8%), and the combination of both abnormal EEG and contralateral internal carotid occlusion (3.3%). The EEG remained normal in 1295 operations including 75 operations with contralateral internal carotid artery occlusion. One minor intraoperative stroke (0.08%) which resolved in 1 week occurred in the absence of an EEG change with no intraoperative strokes in the 75 operations in which the contralateral internal carotid artery was occluded. Intraoperative EEG monitoring accurately (99.92%) identified patients who may safely have carotid endarterectomy without the need of a shunt.
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Affiliation(s)
- Joe A Pinkerton
- School Of Medicine, University of Missouri at Kansas City, 4320 Wornall Road, Suite 308, Kansas City, MO 64111, USA.
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Abstract
BACKGROUND Intraoperative neuromonitoring (IONM) has been a valuable part of surgical procedures for over 25 years. Insight into the nervous system during surgery provides critical information to the surgeon allowing reversal or avoidance of neural insults. REVIEW SUMMARY Electrophysiological tests including electroencephalography, electromyography, and multiple types of evoked potentials (somatosensory, auditory, and motor) are monitored during surgeries that involve risk to the nervous system. Deterioration of signals suggests a surgical insult and is associated with an increased risk of postoperative deficit. Intraoperative identification of this risk allows corrective action. In addition, IONM teams make use of their armamentarium of tests to evaluate anatomy or function of the nervous system in response to specific questions posed by the surgical team. CONCLUSIONS Intraoperative recordings are now a routine part of many surgical procedures. Their correct application leads to improved surgical outcome.
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Affiliation(s)
- Robert E Minahan
- Department of Neurology, Johns Hopkins University, Baltimore, Maryland 21287, USA.
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Schneider JR, Droste JS, Schindler N, Golan JF, Bernstein LP, Rosenberg RS. Carotid endarterectomy with routine electroencephalography and selective shunting: Influence of contralateral internal carotid artery occlusion and utility in prevention of perioperative strokes. J Vasc Surg 2002; 35:1114-22. [PMID: 12042721 DOI: 10.1067/mva.2002.124376] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Carotid endarterectomy (CEA) is associated with a risk of cerebral ischemia during carotid clamping, particularly in the face of contralateral internal carotid artery (ICA) occlusion. We examined the results of CEA with continuous electroencephalography in patients without and with contralateral ICA occlusion. DESIGN AND SETTING We reviewed 564 primary CEAs with routine electroencephalography and general anesthesia performed between April 1, 1989, and March 31, 1999, in a community teaching medical center. Main outcome measures were perioperative stroke, temporary lateralizing neurologic deficit, and death. Shunts were placed primarily for significant electroencephalographic changes after carotid clamping but also selectively for contralateral ICA occlusion, prior stroke, or surgeon choice. CEA was performed for asymptomatic disease in 35% of cases. RESULTS Significant electroencephalographic changes occurred in 16% versus 39% (P <.001) and shunts were placed in 13% versus 55% (P <.001) of patients with patent (n = 507) versus occluded contralateral ICA (n = 57), respectively. The fraction of CEAs with significant electroencephalographic changes during clamping was stable, but shunt use declined slightly over time as our confidence in electroencephalography increased. Patches were placed more often (86% versus 65%; P =.002), but other operative details were similar when the contralateral ICA was occluded. Five early (30 days) strokes (0.9%) and eight early temporary postoperative neurologic events (1.4%) occurred, all ipsilateral to CEA and all after the patient left the operating room with none in patients with contralateral ICA occlusion. Two perioperative deaths occurred, one in a patient without and one in a patient with contralateral ICA occlusion. Neither of these deaths was related to ipsilateral stroke. No increase in stroke rate with decreased shunt use over time was seen. CONCLUSION Routine use of electroencephalography was associated with apparent complete elimination of intraoperative strokes and less than 1% risk of perioperative strokes. These observations appear to be true even in the face of contralateral ICA occlusion. Electroencephalography is a sensitive detector of cerebral ischemia and a valuable tool for determination of need for shunting during CEA. Surgeons should consider routine use of electroencephalography and selective shunting for significant electroencephalographic changes with clamping.
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Affiliation(s)
- Joseph R Schneider
- Division of Vascular Surgery, Department of Neurology, Northwestern University Medical School, 9977 Woods Drive, Skokie, IL 60077, USA.
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Illig KA, Sternbach Y, Zhang R, Burchfiel J, Shortell CK, Rhodes JM, Davies MG, Lyden SP, Green RM. EEG changes during awake carotid endarterectomy. Ann Vasc Surg 2002; 16:6-11. [PMID: 11904797 DOI: 10.1007/s10016-001-0135-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
To determine the reason for differing shunt rates based on electroencephalographic (EEG) and neurologic changes during general and regional anesthetic, respectively, we compared simultaneous EEG tracings and neurologic status in 135 patients undergoing carotid endarterectomy (CEA) under cervical block over a 30-month period. The decision to shunt in these patients was made on the basis of neurologic changes only irrespective of EEG findings. This group was then compared to the 288 patients undergoing CEA under general anesthetic with EEG monitoring over the same period. EEG changes occurred in 7.4% of awake patients and 15.3% of asleep patients (p < 0.03). The rates of ipsilateral hemispheric changes were similar, but no awake patient manifested global EEG changes with clamping while 3.5% of patients under general anesthesia did (p < 0.04). Global, but not hemispheric, changes were correlated with systolic blood pressure variability during clamping. This implies that global EEG changes in anesthetized patients may be the result of the anesthetic technique itself, and that cervical block may in fact be cerebroprotective.
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Affiliation(s)
- Karl A Illig
- Division of Vascular Surgery, University of Rochester Medical Center, NY 14642, USA.
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