title: Somatosensory Evoked Potentials and Electroencephalography during Carotid Endarterectomy Predict Late Stroke but not Death.
abstract: BACKGROUND
  Late stroke and death rates are anticipated to be higher in patients undergoing carotid endarterectomy (CEA) compared with healthy counterparts. However, little is known regarding predictors other than the baseline comorbidities. We have recently shown that dual intraoperative somatosensory evoked potentials (SSEPs) and electroencephalography (EEG) monitoring improves the ability to predict perioperative strokes. We seek to determine if dual intraoperative monitoring (IOM) can further predict long-term strokes and death.
  
  
  METHODS
  Consecutive patients who underwent CEA under dual SSEP and EEG IOM between January 1, 2000 and December 31, 2010 were analyzed. Patients were divided in 2 groups, those with and those without IOM changes. IOM changes were classified as either occurring during carotid cross-clamp placement or at any time during the operation. End points were time to stroke and death. Log-rank tests and Cox regression analysis were used to identify predictors of postoperative stroke and death.
  
  
  RESULTS
  A total of 853 CEAs (mean age 70.6 ± 9.5 years, 58.7% male, 38.9% symptomatic) were performed during the study period with a mean clinical follow-up of 48 ± 38 months. One hundred seven patients (13.6%) had significant SSEP or EEG changes at the time of clamping, while considerably more patients (217, 25.4%) had SSEP and/or EEG changes recorded at any point during the procedure, including clamping. Baseline characteristics including rates of bilateral disease, statin use, and antiplatelet use were similar between groups. Female gender, symptomatic disease, and significant contralateral carotid stenosis were more frequent in the group with IOM changes. The overall stroke-free survival rate at 5 years was significantly higher in patients without IOM changes (94.7% vs. 88.2%, P < 0.05) and at 10 years (86.1% vs. 78.0%, P < 0.05). Despite differences in stroke-free survival, overall survival at 10 years was not different between groups (44.0% in patients with IOM changes vs. 42.8% in patients without, P = 0.7). Renal insufficiency (hazards ratio [HR] 2.13, P = 0.03), diabetes (HR 1.84, P = 005), and age > 80 at the time of operation (HR 3.24, P = 0.001) were significant predictors of late stroke, while statins were significantly protective (HR 0.55, P = 0.05). Controlling for these factors, IOM changes (HR 2.5, P = 0.004) were a strong predictor of long-term risk of stroke after CEA.
  
  
  CONCLUSIONS
  Intraoperative SSEP and/or EEG changes are predictive of late stroke but not death following CEA indicating a need for further elucidation and management of the underlying risk factors driving the elevated stroke risk in this subset of CEA patients.
authors: Department of Surgery, Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA. Electronic address: domenickna2@upmc.edu.
authors: Natalie
authors: N
authors: Domenick Sridharan
authors: Department of Surgery, Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
authors: Rabih A
authors: RA
authors: Chaer
authors: Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
authors: Partha D
authors: PD
authors: Thirumala
authors: Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
authors: Jeffrey
authors: J
authors: Balzer
authors: Department of Surgery, Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
authors: Becky
authors: B
authors: Long
authors: Department of Surgery, Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
authors: Edith
authors: E
authors: Tzeng
authors: Department of Surgery, Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
authors: Michel S
authors: MS
authors: Makaroun
authors: Department of Surgery, Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
authors: Efthymios D
authors: ED
authors: Avgerinos
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002340:Carotid Artery Diseases / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D018572:Disease-Free Survival; D004569:Electroencephalography; D016894:Endarterectomy, Carotid / Q000009:adverse effects* / Q000379:methods; D005073:Evoked Potentials, Somatosensory; D005260:Female; D006801:Humans; D064795:Intraoperative Neurophysiological Monitoring / Q000379:methods*; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D020521:Stroke / Q000175:diagnosis / Q000209:etiology* / Q000401:mortality; D013997:Time Factors; D016896:Treatment Outcome