Perioperative stroke after carotid endarterectomy: etiology and implications.
Carotid endarterectomy (CEA) is the procedure of choice for reducing the risk of stroke in both symptomatic and asymptomatic carotid artery stenoses. Stroke is associated with significant morbidity and mortality peri-operatively (2-3 %). Our primary aim is to evaluate the etiology of these strokes after CEA and their impact on morbidity by comparing the length of stay in the hospital.



A total of 584 patients with documented neurological status evaluations who underwent CEAs were included in the study. Neurophysiological monitoring data was obtained during CEA for carotid stenosis included eight-channel electroencephalography (EEG) and upper extremity somatosensory evoked potentials (SSEPs).



Twenty-one (3.595 %) patients had strokes in the perioperative period and they were more likely to have left-sided surgery (p = 0.008), intraoperative monitoring (IOM) changes (p < 0.001), an intraoperative shunt placed (p = 0.0002) or a hospital stay longer than 5 days (p = 0.0042). Unilateral anterior circulation ischemic stroke were the most common in our series. In a logistic regression model, left-sided surgery was shown to be 4.78 times more likely to be associated with perioperative stroke (1.50-15.27; p = 0.008) while intraoperative shunts were 11.85 times more likely to have strokes (3.97-35.34; p < 0.0001). Patients with stenosis greater than 70 % were 6.67 times less likely to have a stroke (0.04-0.59; p = 0.007).



Ischemic anterior circulation strokes are the most common type of post-operative neurological changes in patients undergoing CEA. Intraoperative shunt placement was a strong predictor of perioperative strokes. Since shunts are only placed following intraoperative monitoring changes, SSEPs and EEG can therefore function as a biomarker of cerebral hypo-perfusion.
Department of Neurological Surgery, University of Pittsburgh School of Medicine, UPMC Presbyterian Hospital Suite B-400, 200 Lothrop Street, Pittsburgh, PA, 15213, USA.|Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, KY, USA.
Nicolas K
NK
Khattar
Department of Neurological Surgery, University of Pittsburgh School of Medicine, UPMC Presbyterian Hospital Suite B-400, 200 Lothrop Street, Pittsburgh, PA, 15213, USA.
Robert M
RM
Friedlander
Department of Vascular Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
Rabih A
RA
Chaer
Department of Vascular Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
Efthymios D
ED
Avgerinos
Department of Neurological Surgery, University of Pittsburgh School of Medicine, UPMC Presbyterian Hospital Suite B-400, 200 Lothrop Street, Pittsburgh, PA, 15213, USA.
Eric S
ES
Kretz
Department of Neurological Surgery, University of Pittsburgh School of Medicine, UPMC Presbyterian Hospital Suite B-400, 200 Lothrop Street, Pittsburgh, PA, 15213, USA.
Jeffrey R
JR
Balzer
Department of Neurological Surgery, University of Pittsburgh School of Medicine, UPMC Presbyterian Hospital Suite B-400, 200 Lothrop Street, Pittsburgh, PA, 15213, USA.
Donald J
DJ
Crammond
Department of Neurological Surgery, University of Pittsburgh School of Medicine, UPMC Presbyterian Hospital Suite B-400, 200 Lothrop Street, Pittsburgh, PA, 15213, USA.
Miguel H
MH
Habeych
Department of Neurological Surgery, University of Pittsburgh School of Medicine, UPMC Presbyterian Hospital Suite B-400, 200 Lothrop Street, Pittsburgh, PA, 15213, USA. thirumalapd@upmc.edu.
Parthasarathy D
PD
Thirumala
D000368:Aged; D016893:Carotid Stenosis / Q000601:surgery*; D004569:Electroencephalography; D016894:Endarterectomy, Carotid / Q000009:adverse effects*; D005073:Evoked Potentials, Somatosensory; D005260:Female; D006801:Humans; D064795:Intraoperative Neurophysiological Monitoring; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology* / Q000517:prevention & control; D020521:Stroke / Q000209:etiology* / Q000517:prevention & control
Carotid endarterectomy; Etiology; Length of stay; Perioperative stroke