Selective shunting based on somatosensory evoked potential monitoring during carotid endarterectomy

Somatosensory Evoked Potentials (SEPs), to median nerve stimulation, were continuously monitored in 58 patients undergoing carotid endarterectomy A first group of patients was shunted routinely; in a second group the shunt was selectively applied when inadequacy of collateral circulation was suspected based on stump pressure values and SEP changes. Both amplitude and latency modifications of SEPs occurred during surgery; however no post-operative neurological deficit was seen unless there was a complete flattening of cortical waves, even a transitory one. Inadequate collateral circulation and embolic ischemia affected SEPs differently. While the latter produced a disappearance of all cortical waves, the former led first to a progressive flattening of later cortical waves and then of N20 as well. For values of stump pressure ranging between 20 and 50 mmHg SEPs were unchanged in some patients and altered in others. These findings may explain the controversies existing about the usefulness of stump pressure for predicting tolerance to carotid clamping.