Monitoring in carotid endarterectomy
Mirela V Simon1, Michael Malcharek2, Sedat Ulkatan3
1Department of Neurology, Massachusetts General Hospital, Boston, MA, United States.
Insights
Cerebral ischemia during carotid endarterectomy poses risks. Intraoperative neurophysiologic monitoring, including electroencephalography and evoked potentials, helps detect and reverse brain function changes, improving patient outcomes.
Area of Science:
- Neurology
- Neurosurgery
- Anesthesiology
Background:
- Cerebral ischemia during carotid endarterectomy stems from poor collateral flow, thromboembolism, or rethrombosis.
- Perioperative strokes elevate morbidity and mortality rates associated with endarterectomy.
- Assessing individual stroke risk is challenging despite identified predictors.
Purpose of the Study:
- To review intraoperative monitoring techniques for detecting and reversing cerebral ischemia during carotid endarterectomy.
- To emphasize the advantages of neurophysiologic monitoring for assessing brain function impact.
- To discuss the methodology, pros, cons, and interpretation of specific neurophysiologic tests.
Main Methods:
- Focus on neurophysiologic monitoring techniques.
- Includes electroencephalography (EEG).
- Includes somatosensory evoked potentials (SSEPs) and transcranial motor evoked potentials (TMEPs).
Main Results:
- Nonselective shunting is not risk-free and does not eliminate stroke risk.
- Neurophysiologic monitoring directly assesses the impact of reduced cerebral blood flow on brain function.
- These techniques allow for timely detection and potential reversal of ischemia.
Conclusions:
- Intraoperative monitoring is advisable for managing cerebral ischemia during carotid endarterectomy.
- Neurophysiologic monitoring offers direct assessment of brain function.
- Understanding these techniques within surgical and anesthetic contexts is crucial for patient safety.
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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