Prospective evaluation of electroencephalography, carotid artery stump pressure, and neurologic changes during 314 consecutive carotid endarterectomies performed in awake patients.
OBJECTIVE
This study attempted to correlate neurologic changes in awake patients undergoing carotid endarterectomy (CEA) under cervical block anesthesia (CBA) with electroencephalography (EEG) and measurement of carotid artery stump pressure (SP).


METHODS
Continuous EEG and SP monitoring was measured prospectively in 314 consecutive patients undergoing CEA between April 1, 2003, and July 30, 2006, under CBA. Indications for CEA were asymptomatic 70% to 99% internal carotid artery stenosis in 242 (77.1%), transient ischemic attacks (including transient monocular blindness) in 45 (14.3%), and prior stroke in 27 (8.6%). Mean common carotid artery pressure before clamping, mean SP after carotid clamping, and intraarterial pressure were continuously monitored in all patients. An indwelling shunt was placed when neurologic events (contralateral motor weakness, aphasia, loss of consciousness, or seizures) occurred, regardless of SP or EEG changes.


RESULTS
Shunt placement was necessary because of neurologic changes in 10% (32/314) of all CEAs performed under CBA. Only 3 patients (1.4%) of 216 required shunt placement if SP was 50 mm Hg or more, vs 29 (29.6%) of 98 if SP was less than 50 mm Hg (P < .00001; sensitivity, 29.8%; specificity, 98.6%). In patients with SP of 40 mm Hg or more, 7 (2.6%) of 270 required shunt placement, vs 25 (56.8%) of 44 if SP was less than 40 mm Hg (P < .00001; sensitivity, 56.8%; specificity, 97.4%). Ischemic EEG changes were observed in 19 (59.4%) of 32 patients (false-negative rate, 40.6%) requiring shunt placement under CBA. Three patients had false-positive EEG results and did not require shunt placement (false-positive rate, 1.0%). The perioperative stroke/death rate was 4 (1.2%) in 314. All strokes occurred after surgery and were unrelated to cerebral ischemia or lack of shunt placement.


CONCLUSIONS
Ten percent of patients required a shunt placement during CEA under CBA. Shunt placement was necessary in 56.8% of patients with SP less than 40 mm Hg. EEG identified cerebral ischemia in only 59.4% of patients needing shunt placement, with a false-positive rate of 1.0% and a false-negative rate of 40.6%. Both SP and EEG as a guide to shunt placement have poor sensitivity. Intraoperative monitoring of the awake patients under regional anesthesia (CBA) is the most sensitive and specific method to identify patients requiring shunt placement.
Hans
Sachinder Singh
SS
Department of Surgery, St John Macomb Hospital, Warren, MI 48093, USA. SSHans@Comcast.com
Jareunpoon
Olan
O
D000368:Aged; D000369:Aged, 80 and over; D001794:Blood Pressure; D001795:Blood Pressure Determination; D002545:Brain Ischemia / Q000175:diagnosis* / Q000209:etiology / Q000503:physiopathology; D002339:Carotid Arteries / Q000503:physiopathology* / Q000601:surgery; D002560:Cerebrovascular Circulation; D002572:Cervical Plexus; D004569:Electroencephalography; D016894:Endarterectomy, Carotid / Q000009:adverse effects* / Q000379:methods; D005188:False Negative Reactions; D005189:False Positive Reactions; D005260:Female; D006801:Humans; D008297:Male; D008824:Michigan; D008875:Middle Aged; D016343:Monitoring, Intraoperative / Q000379:methods*; D009407:Nerve Block; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012680:Sensitivity and Specificity; D016896:Treatment Outcome