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Carotid endarterectomies: who are the candidates at risk?
1Christian Medical College Hospital, Vellore, India.
Insights
Preoperative symptoms and contralateral or bilateral vertebral stenosis increase the risk of clamp-induced ischemia during carotid endarterectomy (CEA). However, severe ipsilateral carotid stenosis reduces this risk.
Area of Science:
- Neurology
- Vascular Surgery
- Neurophysiology
Background:
- Carotid endarterectomy (CEA) is a procedure to remove plaque from carotid arteries.
- Electroencephalograms (EEG) are used during CEA to monitor for cerebral ischemia.
- Identifying predictors of EEG changes can optimize patient management and reduce stroke risk.
Purpose of the Study:
- To identify predictors of clamp-induced electroencephalogram (EEG) changes during carotid endarterectomy (CEA).
- To test the hypothesis that age, preoperative symptoms, contralateral carotid stenosis, and bilateral vertebral stenosis increase the likelihood of clamp-induced EEG changes.
- To determine if ipsilateral carotid stenosis influences the probability of clamp-induced EEG changes.
Main Methods:
- Observational cohort study of 299 patients undergoing CEA with EEG monitoring.
- Univariate and multivariate logistic regression analyses were employed.
- Data collected included patient demographics, preoperative symptoms, and degree of carotid and vertebral stenosis.
Main Results:
- Preoperative neurologic symptoms, ≥70% contralateral carotid stenosis, and bilateral vertebral stenosis were independently associated with increased odds of clamp-induced EEG changes.
- ≥70% ipsilateral carotid stenosis was associated with decreased odds of clamp-induced neurophysiologic dysfunction.
- Age ≥70 years did not significantly impact the odds of clamp-induced EEG changes.
Conclusions:
- Intraoperative EEG monitoring during CEA can detect cerebral ischemia.
- Preoperative symptoms, contralateral carotid stenosis, and bilateral vertebral stenosis are risk factors for clamp-induced ischemia.
- Severe ipsilateral carotid stenosis appears protective against clamp-induced ischemia detected by EEG.
Abstract Of Reviewed Article:
Predictors of clamp-induced electroencephalographic changes during carotid endarterectomies.Simon MV, Chiappa KH, Kilbride RD, Rordorf GA, Cambria RP, et al.J Clin Neurophysiol 2012t;29:462-467.
Objective:
Electroencephalograms detect clamp-induced cerebral ischemia during carotid endarterectomy, and thus impact management and minimize the risk of perioperative stroke. We hypothesized that age, preoperative neurologic symptoms, ≥70% contralateral carotid, and bilateral vertebral stenosis increase the probability of clamp-induced electroencephalogram changes, whereas ≥70% unilateral carotid stenosis does not.
Methods:
This is an observational cohort study of 299 patients who underwent carotid endarterectomy with electroencephalogram monitoring at a single large urban academic medical center in 2009. Univariate and multivariate logistic regression analyses were used.
Results:
Seventy percent or greater ipsilateral carotid stenosis decreases the odds of clamp-induced neurophysiologic dysfunction (odds ratio = 0.43, 95% confidence interval [0.18-0.99], P = 0.04) after adjustment for symptomatic status, degree contralateral carotid or vertebral stenosis, and age. Preoperative neurologic symptoms, ≥70% contralateral carotid stenosis, and bilateral extracranial vertebral stenosis independently increase these odds (odds ratio 2.62, 95% confidence interval [1.32-5.18], P = 0.005; odds ratio 2.84, 95% confidence interval [1.27-6.34], P = 0.01; and odds ratio 3.58, 95% confidence interval [1.02-12.53], P = 0.04, respectively), after adjustment for the other factors. Age ≥70 years has no significant impact.
Conclusions:
Preoperative neurologic symptoms, ≥70% contralateral carotid, and bilateral vertebral stenosis increase the probability of clamp-induced ischemia as detected by intraoperative electroencephalogram, whereas ≥70% ipsilateral carotid stenosis decreases it.
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