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J Neurol Surg A Cent Eur Neurosurg 2021; 82(04): 299-307
DOI: 10.1055/s-0039-1698441
Original Article

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

Kathleen Seidel   *
1   Department of Neurosurgery, Inselspital, Bern University Hospital, Bern, Switzerland
,
Johannes Jeschko‡   *
1   Department of Neurosurgery, Inselspital, Bern University Hospital, Bern, Switzerland
,
Philippe Schucht
1   Department of Neurosurgery, Inselspital, Bern University Hospital, Bern, Switzerland
,
David Bervini
1   Department of Neurosurgery, Inselspital, Bern University Hospital, Bern, Switzerland
,
Christian Fung
1   Department of Neurosurgery, Inselspital, Bern University Hospital, Bern, Switzerland
2   Department of Neurosurgery, University of Freiburg, Freiburg, Germany
,
Vladimir Krejci
3   Department of Anesthesiology, Inselspital, Bern University Hospital, Bern, Switzerland
,
Werner Z'Graggen
1   Department of Neurosurgery, Inselspital, Bern University Hospital, Bern, Switzerland
4   Department of Neurology, Inselspital, Bern University Hospital, Bern, Switzerland
,
Urs Fischer
4   Department of Neurology, Inselspital, Bern University Hospital, Bern, Switzerland
,
Marcel Arnold
4   Department of Neurology, Inselspital, Bern University Hospital, Bern, Switzerland
,
Johannes Goldberg
1   Department of Neurosurgery, Inselspital, Bern University Hospital, Bern, Switzerland
,
Andreas Raabe
1   Department of Neurosurgery, Inselspital, Bern University Hospital, Bern, Switzerland
,
Juergen Beck
1   Department of Neurosurgery, Inselspital, Bern University Hospital, Bern, Switzerland
2   Department of Neurosurgery, University of Freiburg, Freiburg, Germany
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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.




Publication History

Received: 27 February 2019

Accepted: 23 April 2019

Article published online:
14 January 2020

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