title: Carotid endarterectomy without shunt: the role of cerebral metabolic protection.
abstract: BACKGROUND
  The optimal method to protect the brain from hemodynamic ischemia during carotid endarterectomy (CEA) remains controversial. This study reports our experience with induced arterial hypertension and selective etomidate cerebral protection in a cohort of patients who underwent CEA without shunting and continuous electroencephalography (EEG) monitoring.
  
  
  METHODS
  We reviewed retrospectively 102 consecutive CEAs performed in 102 patients with routine EEG monitoring and general anesthesia between March 1998 and October 2002. There were 65 (66%) symptomatic and 37 (34%) asymptomatic individuals. A protocol of induced arterial hypertension against EEG ischemic changes during carotid artery cross clamping was followed. Only patients with EEG changes refractory to induced hypertension went into etomidate-induced burst suppression.
  
  
  RESULTS
  EEG changes were classified as mild, moderate and severe. Twenty patients (19.6%) developed asymmetric EEG changes, of which the great majority were mild and moderate (75%, p< 0.05). Seven patients with moderate (n=3) and severe (n=4) EEG changes needed etomidate cerebral protection. There were no mortalities and only one stroke (0.98%) is reported in the series. The morbidity rate was 6.8% and included transient cranial nerve palsies (n=5) and wound hematoma (n=1).
  
  
  CONCLUSIONS
  Carotid endarterectomy can be safely performed with EEG monitoring and selective induced arterial hypertension and etomidate cerebral protection. Our results suggest that this method may be a good alternative for shunting and its inherent risks.
authors.affiliation: Department of Neurosurgery, Tulane University School of Medicine, New Orleans, Louisiana, USA. mmelgar@tulane.edu
authors.forename: Miguel A
authors.initials: MA
authors.lastname: Melgar
authors.forename: Nitin
authors.initials: N
authors.lastname: Mariwalla
authors.forename: Hassan
authors.initials: H
authors.lastname: Madhusudan
authors.forename: Martin
authors.initials: M
authors.lastname: Weinand
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D018686:Anesthetics, Intravenous / Q000008:administration & dosage / Q000627:therapeutic use*; D000925:Anticoagulants / Q000627:therapeutic use; D001794:Blood Pressure; D016893:Carotid Stenosis / Q000150:complications / Q000000981:diagnostic imaging / Q000601:surgery*; D015331:Cohort Studies; D003250:Constriction; D004562:Electrocardiography; D004569:Electroencephalography; D016894:Endarterectomy, Carotid / Q000379:methods*; D005045:Etomidate / Q000008:administration & dosage / Q000627:therapeutic use*; D005260:Female; D005500:Follow-Up Studies; D006439:Hemodynamics; D006493:Heparin / Q000627:therapeutic use; D006801:Humans; D020766:Intracranial Embolism / Q000209:etiology / Q000517:prevention & control*; D007432:Intraoperative Period; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative; D017202:Myocardial Ischemia / Q000150:complications; D018696:Neuroprotective Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome; D014463:Ultrasonography
chemical_list: D018686:Anesthetics, Intravenous; D000925:Anticoagulants; D018696:Neuroprotective Agents; D006493:Heparin; D005045:Etomidate