[Thoughts about brain protection in carotid surgery]

Brain protective measures and monitoring devices in carotid surgery tend towards absolute prevention of strokes without totally achieving this objective. When a post-operative stroke occurs, the question is: is it a brain protection failure, a technical fault or an ill-advised indication? However, apart from massive stroke, other significant disorders may occur especially affecting higher functions. We studied a series of 126 patients with a mean age of 68.4 years who underwent 140 carotid repairs. The average clamping time was 21.8 min. Brain protection always consisted of: general anesthesia and heparinization, hyperoxygenation, light hypercapnia without shunting or monitoring. Two deaths and one hemiplegia (2.1%) were due to an incorrect indication or technical error. Three resolving neurological events were related to clamping intolerance (2.1%). What appears to be responsible, in case of stroke, is not so much clamping but technical errors. We also observed disturbances of higher functions in 25 patients (17.8%). A study using psychometric tests performed preoperatively and at a convenient time from the operation is proposed in order to demonstrate carotid clamping effects on higher functions.