Somatosensory Evoked Potential and Transcranial Doppler Monitoring to Guide Shunting in Carotid Endarterectomy

Abstract

Objective Clamping of the internal carotid artery (ICA) during carotid endarterectomy (CEA) is a critical step. In our neurosurgical department, CEAs are performed with transcranial Doppler (TCD) and somatosensory evoked potential (SEP) monitoring with a 50% flow velocity/amplitude decrement warning criteria for shunting. The aim of our study was to evaluate our protocol with immediate neurologic deficits after surgery for the primary end point.

Methods This is a single-center retrospective cohort study of symptomatic and asymptomatic ICA stenosis patients from January 2012 to June 2015. Only those cases in which CEA was performed with both modalities (TCD and SEP) were included. The Mann-Whitney U test was applied to evaluate TCD and SEP ratios based on immediate postoperative neurologic deficits.

Results A total of 144 patients were included, 120 (83.3%) with symptomatic ICA stenosis. The primary end point was met by six patients (4.2%); all of them were patients with a symptomatic ICA stenosis. The stroke and death rate was 1.4%. Ratios of SEP amplitudes demonstrated significant differences between patients with and without an immediate postoperative neurologic deficit at the time of ICA clamping (p = 0.005), ICA clamping at 10 minutes (p = 0.044), and ICA reperfusion (p = 0.005). Ratios of TCD flow velocity showed no significant difference at all critical steps.

Conclusion In this retrospective series of simultaneous TCD and SEP monitoring during CEA surgery of predominantly symptomatic ICA stenosis patients, the stroke and death rate was 1.4%. SEP seemed to be superior to TCD in predicting the need for an intraoperative shunt and for predicting temporary postoperative deficits. Further prospective studies are needed.

Keywords

carotid endarterectomy - intraoperative neurophysiologic monitoring - somatosensory evoked potential - shunt - transcranial Doppler sonography - warning criteria

Ethical Approval

This study was approved by the local ethics committee.

Informed Consent

All patients signed the necessary consent forms.

^* Both authors contributed equally to this work and share the first authorship.

Publikationsverlauf

Eingereicht: 27. Februar 2019

Angenommen: 23. April 2019

Artikel online veröffentlicht:
14. Januar 2020

• References

• 1 Chongruksut W, Vaniyapong T, Rerkasem K. Routine or selective carotid artery shunting for carotid endarterectomy (and different methods of monitoring in selective shunting). Cochrane Database Syst Rev 2014; (06) CD000190
• 2 Ott DA, Cooley DA, Chapa L, Coelho A. Carotid endarterectomy without temporary intraluminal shunt. Study of 309 consecutive operations. Ann Surg 1980; 191 (06) 708-714
• 3 Green RM, Messick WJ, Ricotta JJ. et al. Benefits, shortcomings, and costs of EEG monitoring. Ann Surg 1985; 201 (06) 785-792
• 4 Salvian AJ, Taylor DC, Hsiang YN. et al. Selective shunting with EEG monitoring is safer than routine shunting for carotid endarterectomy. Cardiovasc Surg 1997; 5 (05) 481-485
• 5 Malcharek MJ, Herbst V, Bartz GJ. et al. Multimodal evoked potential monitoring in asleep patients versus neurological evaluation in awake patients during carotid endarterectomy: a single-centre retrospective trial of 651 patients. Minerva Anestesiol 2015; 81 (10) 1070-1078
• 6 Isley MR, Edmonds Jr HL, Stecker M. ; American Society of Neurophysiological Monitoring. Guidelines for intraoperative neuromonitoring using raw (analog or digital waveforms) and quantitative electroencephalography: a position statement by the American Society of Neurophysiological Monitoring. J Clin Monit Comput 2009; 23 (06) 369-390
• 7 Edmonds Jr HL, Isley MR, Sloan TB, Alexandrov AV, Razumovsky AY. American Society of Neurophysiologic Monitoring and American Society of Neuroimaging joint guidelines for transcranial Doppler ultrasonic monitoring. J Neuroimaging 2011; 21 (02) 177-183
• 8 Nwachuku EL, Balzer JR, Yabes JG, Habeych ME, Crammond DJ, Thirumala PD. Diagnostic value of somatosensory evoked potential changes during carotid endarterectomy: a systematic review and meta-analysis. JAMA Neurol 2015; 72 (01) 73-80
• 9 Abbott AL, Paraskevas KI, Kakkos SK. et al. Systematic review of guidelines for the management of asymptomatic and symptomatic carotid stenosis. Stroke 2015; 46 (11) 3288-3301
• 10 De Rango P, Brown MM, Chaturvedi S. et al. Summary of evidence on early carotid intervention for recently symptomatic stenosis based on meta-analysis of current risks. Stroke 2015; 46 (12) 3423-3436
• 11 Reinert M, Mono ML, Kuhlen D. et al. Restenosis after microsurgical non-patch carotid endarterectomy in 586 patients. Acta Neurochir (Wien) 2012; 154 (03) 423-431 ; discussion 431
• 12 Macdonald DB, Al Zayed Z, Al Saddigi A. Four-limb muscle motor evoked potential and optimized somatosensory evoked potential monitoring with decussation assessment: results in 206 thoracolumbar spine surgeries. Eur Spine J 2007; 16 (Suppl. 02) S171-S187
• 13 MacDonald DB, Dong C, Quatrale R. et al. Recommendations of the International Society of Intraoperative Neurophysiology for intraoperative somatosensory evoked potentials. Clin Neurophysiol 2019; 130 (01) 161-179
• 14 Malcharek MJ, Kulpok A, Deletis V. et al. Intraoperative multimodal evoked potential monitoring during carotid endarterectomy: a retrospective study of 264 patients. Anesth Analg 2015; 120 (06) 1352-1360
• 15 Malcharek MJ, Ulkatan S, Marinò V. et al. Intraoperative monitoring of carotid endarterectomy by transcranial motor evoked potential: a multicenter study of 600 patients. Clin Neurophysiol 2013; 124 (05) 1025-1030
• 16 Imparato AM, Ramirez A, Riles T, Mintzer R. Cerebral protection in carotid surgery. Arch Surg 1982; 117 (08) 1073-1078
• 17 Riles TS, Imparato AM, Jacobowitz GR. et al. The cause of perioperative stroke after carotid endarterectomy. J Vasc Surg 1994; 19 (02) 206-214 ; discussion 215–216
• 18 Sundt Jr TM, Ebersold MJ, Sharbrough FW, Piepgras DG, Marsh WR, Messick Jr JM. The risk-benefit ratio of intraoperative shunting during carotid endarterectomy. Relevancy to operative and postoperative results and complications. Ann Surg 1986; 203 (02) 196-204
• 19 Schwartz ML, Panetta TF, Kaplan BJ. et al. Somatosensory evoked potential monitoring during carotid surgery. Cardiovasc Surg 1996; 4 (01) 77-80
• 20 Inoue T, Ohwaki K, Tamura A, Tsutsumi K, Saito I, Saito N. Subclinical ischemia verified by somatosensory evoked potential amplitude reduction during carotid endarterectomy: negative effects on cognitive performance. J Neurosurg 2013; 118 (05) 1023-1029
• 21 Mazul-Sunko B, Hromatko I, Tadinac M. et al. Subclinical neurocognitive dysfunction after carotid endarterectomy-the impact of shunting. J Neurosurg Anesthesiol 2010; 22 (03) 195-201
• 22 Haupt WF, Horsch S. Evoked potential monitoring in carotid surgery: a review of 994 cases. Neurology 1992; 42 (04) 835-838
• 23 Raabe A, Seidel K. Prevention of ischemic complications during aneurysm surgery. J Neurosurg Sci 2016; 60 (01) 95-103
• 24 Florence G, Guerit JM, Gueguen B. Electroencephalography (EEG) and somatosensory evoked potentials (SEP) to prevent cerebral ischaemia in the operating room. Neurophysiol Clin 2004; 34 (01) 17-32
• 25 Astrup J, Symon L, Branston NM, Lassen NA. Cortical evoked potential and extracellular K+ and H+ at critical levels of brain ischemia. Stroke 1977; 8 (01) 51-57
• 26 Powers WJ. Cerebral hemodynamics in ischemic cerebrovascular disease. Ann Neurol 1991; 29 (03) 231-240
• 27 Panerai RB, Moody M, Eames PJ, Potter JF. Dynamic cerebral autoregulation during brain activation paradigms. Am J Physiol Heart Circ Physiol 2005; 289 (03) H1202-H1208
• 28 Pennekamp CW, van Laar PJ, Hendrikse J. et al. Incompleteness of the circle of Willis is related to EEG-based shunting during carotid endarterectomy. Eur J Vasc Endovasc Surg 2013; 46 (06) 631-637