Download PDF
J Neurol Surg A Cent Eur Neurosurg 2016; 77(04): 291-296
DOI: 10.1055/s-0036-1580596
Original Article
Georg Thieme Verlag KG Stuttgart · New York

The Relationship between Carotid Stump Pressure and Changes in Motor-Evoked Potentials in Carotid Endarterectomy Patients

Masaaki Hokari
1   Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
2   Department of Neurosurgery, Kushiro Rousai Hospital, Kushiro, Japan
,
Yasuhiro Ito
1   Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
,
Kazuyoshi Yamazaki
2   Department of Neurosurgery, Kushiro Rousai Hospital, Kushiro, Japan
,
Yasuhiro Chiba
2   Department of Neurosurgery, Kushiro Rousai Hospital, Kushiro, Japan
,
Masanori Isobe
2   Department of Neurosurgery, Kushiro Rousai Hospital, Kushiro, Japan
,
Toyohiko Isu
2   Department of Neurosurgery, Kushiro Rousai Hospital, Kushiro, Japan
› Author Affiliations
Further Information

Publication History

03 February 2015

30 November 2015

Publication Date:
11 March 2016 (online)

Also available at
    Permissions and Reprints

Abstract

Background The threshold of ischemic tolerance has not been completely identified in human clinical studies. Distal carotid artery pressure can be easily measured through the internal shunt tube during carotid endarterectomy (CEA). To confirm the critical threshold of intracranial arterial pressure and its maximum duration, we investigated the distal internal carotid artery (ICA) pressure and motor-evoked potential (MEP) changes during ICA clamping.

Material and Methods Between September 2012 and March 2014, 9 patients (10 sides) with carotid stenosis (70–99%) were surgically treated at our hospital. All CEAs were performed under general anesthesia, and we routinely used a carotid shunt with the intraoperative MEP monitors. When the MEP amplitude decreased to < 50% of the control during carotid clamping, the MEP amplitude was defined as significantly reduced.

Results The MEP amplitude significantly decreased in 2 of the 10 procedures (20%) during ICA clamping. The mean distal ICA pressure varied widely, ranging from 13 to 48 mm Hg. In seven cases with a mean distal ICA pressure > 20 mm Hg, there were no significant changes in the MEP during ICA clamping. However, there were three cases with a mean distal ICA pressure < 20 mm Hg, and the MEP amplitude significantly decreased in two of those three patients from 4 to 5 minutes after clamping.

Conclusions The present study provides considerable information about a higher incidence of MEP amplitude deterioration in CEA patients with a mean distal ICA pressure < 20 mm Hg during ICA clamping.

Keywords

motor-evoked potential - carotid endarterectomy - stump pressure
 

  • References

  • 1 Collaborators NASCET; North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 1991; 325 (7) 445-453
    CrossrefPubMedSearch in Google Scholar
  • 2 Group ECSTC. MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70-99%) or with mild (0-29%) carotid stenosis. European Carotid Surgery Trialists' Collaborative Group. Lancet 1991; 337 (8752) 1235-1243
    CrossrefPubMedSearch in Google Scholar
  • 3 Sheffet AJ, Roubin G, Howard G , et al. Design of the Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST). Int J Stroke 2010; 5 (1) 40-46
    PubMedSearch in Google Scholar
  • 4 Yadav JS, Wholey MH, Kuntz RE , et al; Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy Investigators. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med 2004; 351 (15) 1493-1501
    CrossrefPubMedSearch in Google Scholar
  • 5 Gaunt M, Naylor AR, Lennard N, Smith JL, Bell PR. Transcranial Doppler detected cerebral microembolism following carotid endarterectomy. Brain 1998; 121 (Pt 2) 389-390
    CrossrefPubMedSearch in Google Scholar
  • 6 Riles TS, Imparato AM, Jacobowitz GR , et al. The cause of perioperative stroke after carotid endarterectomy. J Vasc Surg 1994; 19 (2) 206-214 ; discussion 215–216
    CrossrefPubMedSearch in Google Scholar
  • 7 Hossmann KA. Viability thresholds and the penumbra of focal ischemia. Ann Neurol 1994; 36 (4) 557-565
    CrossrefPubMedSearch in Google Scholar
  • 8 Jones TH, Morawetz RB, Crowell RM , et al. Thresholds of focal cerebral ischemia in awake monkeys. J Neurosurg 1981; 54 (6) 773-782
    CrossrefPubMedSearch in Google Scholar
  • 9 Yoshimoto T, Shirasaka T, Yoshizumi T, Fujimoto S, Kaneko S, Kashiwaba T. Evaluation of carotid distal pressure for prevention of hyperperfusion after carotid endarterectomy. Surg Neurol 2005; 63 (6) 554-557 ; discussion 557–558
    CrossrefPubMedSearch in Google Scholar
  • 10 Deletis V, Camargo AB. Transcranial electrical motor evoked potential monitoring for brain tumor resection. Neurosurgery 2001; 49 (6) 1488-1489
    CrossrefPubMedSearch in Google Scholar
  • 11 Neuloh G, Pechstein U, Cedzich C, Schramm J. Motor evoked potential monitoring with supratentorial surgery. Neurosurgery 2004; 54 (5) 1061-1070 ; discussion 1070–1072
    CrossrefPubMedSearch in Google Scholar
  • 12 Uchino H, Nakamura T, Kuroda S, Houkin K, Murata J, Saito H. Intraoperative dual monitoring during carotid endarterectomy using motor evoked potentials and near-infrared spectroscopy. World Neurosurg 2012; 78 (6) 651-657
    CrossrefPubMedSearch in Google Scholar
  • 13 Neuloh G, Schramm J. Monitoring of motor evoked potentials compared with somatosensory evoked potentials and microvascular Doppler ultrasonography in cerebral aneurysm surgery. J Neurosurg 2004; 100 (3) 389-399
    CrossrefPubMedSearch in Google Scholar
  • 14 Horiuchi K, Suzuki K, Sasaki T , et al. Intraoperative monitoring of blood flow insufficiency during surgery of middle cerebral artery aneurysms. J Neurosurg 2005; 103 (2) 275-283
    CrossrefPubMedSearch in Google Scholar
  • 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 (5) 1025-1030
    CrossrefPubMedSearch in Google Scholar
  • 16 Iwasaki M, Kuroda S, Nakayama N , et al. Clinical characteristics and outcomes in carotid endarterectomy for internal carotid artery stenosis in a Japanese population: 10-year microsurgical experience. J Stroke Cerebrovasc Dis 2011; 20 (1) 55-61
    CrossrefPubMedSearch in Google Scholar
  • 17 Hans SS, Jareunpoon O. Prospective evaluation of electroencephalography, carotid artery stump pressure, and neurologic changes during 314 consecutive carotid endarterectomies performed in awake patients. J Vasc Surg 2007; 45 (3) 511-515
    CrossrefPubMedSearch in Google Scholar
  • 18 Calligaro KD, Dougherty MJ. Correlation of carotid artery stump pressure and neurologic changes during 474 carotid endarterectomies performed in awake patients. J Vasc Surg 2005; 42 (4) 684-689
    CrossrefPubMedSearch in Google Scholar
  • 19 Kim GE, Cho YP, Lim SM. The anatomy of the circle of Willis as a predictive factor for intra-operative cerebral ischemia (shunt need) during carotid endarterectomy. Neurol Res 2002; 24 (3) 237-240
    CrossrefPubMedSearch in Google Scholar
  • 20 lshikawa T, Kamiyama H, Kobayashi N, Tanikawa R, Takizawa K, Kazumata K. Experience from “double-insurance bypass.” Surgical results and additional techniques to achieve complex aneurysm surgery in a safer manner. Surg Neurol 2005; 63 (5) 485-490 ; discussion 490
    CrossrefPubMedSearch in Google Scholar
  • 21 Kazumata K, Kamiyama H, Ishikawa T, Nakamura T, Terasaka S, Houkin K. Impact of cervical internal carotid clamping and radial artery graft bypass on cortical arterial perfusion pressure during craniotomy. Neurosurg Rev 2014; 37 (3) 493-499 ; discussion 499–500
    CrossrefPubMedSearch in Google Scholar
  • 22 Czosnyka M, Pickard JD. Monitoring and interpretation of intracranial pressure. J Neurol Neurosurg Psychiatry 2004; 75 (6) 813-821
    CrossrefPubMedSearch in Google Scholar
  • 23 Steiner LA, Andrews PJ. Monitoring the injured brain: ICP and CBF. Br J Anaesth 2006; 97 (1) 26-38
    CrossrefPubMedSearch in Google Scholar
  • 24 Tomura N, Omachi K, Takahashi S , et al. Comparison of technetium Tc 99m hexamethylpropyleneamine oxime single-photon emission tomograph with stump pressure during the balloon occlusion test of the internal carotid artery. AJNR Am J Neuroradiol 2005; 26 (8) 1937-1942
    PubMedSearch in Google Scholar
  • 25 Zhong J, Ding M, Mao Q, Wang B, Fu H. Evaluating brain tolerability to carotid artery occlusion. Neurol Res 2003; 25 (1) 99-103
    CrossrefPubMedSearch in Google Scholar
  • 26 Sugawara Y, Kikuchi T, Ueda T , et al. Usefulness of brain SPECT to evaluate brain tolerance and hemodynamic changes during temporary balloon occlusion test and after permanent carotid occlusion. J Nucl Med 2002; 43 (12) 1616-1623
    PubMedSearch in Google Scholar
  • 27 Hyogo T, Takeda R, Nakagawara J , et al. Measurement of middle cerebral artery perfusion pressure in patients with middle cerebral artery occlusion in the acute phase. Hokkaidonousikkannkennkyushoishi 1998; 8: 39-44
    PubMedSearch in Google Scholar
  • 28 Shima T, Okada Y, Matsumura S, Yamada TTH. Physiologic study in cerebrovascular occlusive disease during bypass surgery. In: Spetzler RF, Selman WR, Carter LP, Martin NA, eds. Cerebral Revascularization for Stroke. New York, NY: Thieme-Stratton; 1985: 197-201
    Search in Google Scholar
  • 29 Katsoulas G, Tsolakis I, Argyriou AA, Polychronopoulos P, Argentou M, Chroni E. Effects of carotid endarterectomy on motor evoked potentials elicited by transcranial magnetic stimulation. J Neurol 2005; 252 (9) 1050-1054
    CrossrefPubMedSearch in Google Scholar
  • 30 Bell BA, Symon L, Branston NM. CBF and time thresholds for the formation of ischemic cerebral edema, and effect of reperfusion in baboons. J Neurosurg 1985; 62 (1) 31-41
    CrossrefPubMedSearch in Google Scholar
  • 31 Hunter GC, Sieffert G, Malone JM, Moore WS. The accuracy of carotid back pressure as an index for shunt requirements. A reappraisal. Stroke 1982; 13 (3) 319-326
    CrossrefPubMedSearch in Google Scholar