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Acta Neurochirurgica

, Volume 155, Issue 11, pp 2085–2096 | Cite as

Stratification of intraoperative ischemic impact by somatosensory evoked potential monitoring, diffusion-weighted imaging and magnetic resonance angiography in carotid endarterectomy with routine shunt use

  • Tomohiro InoueEmail author
  • Kazuo Tsutsumi
  • Kazuhiro Ohwaki
  • Akira Tamura
  • Hideaki Ono
  • Isamu Saito
  • Nobuhito Saito
Clinical Article - Vascular

Abstract

Background

Routine shunting to minimize ischemia during carotid endarterectomy (CEA) is controversial. The aim of this study was to stratify the ischemic parameters associated with CEA and evaluate the effect of routine shunting in attempting to mitigate those ischemia.

Method

Data from 248 CEAs with routine shunting were retrospectively evaluated. Our assessment included somatosensory evoked potential (SSEP) amplitude reduction more than 50 % and longer than 5 min (SSEP<50%, >5 min), new postoperative diffusion-weighted imaging lesions (new DWI lesions), and severe stenosis as indicated by reduced ipsilateral middle cerebral artery (MCA) signal on preoperative magnetic resonance angiography (MRA asymmetry), as surrogates of hypoperfusion, microembli, and hemodynamic impairment, respectively.

Results

SSEP<50%, >5 min occurred in 15 % of CEAs during cross-clamping, and shunting reversed the SSEP changes. New DWI lesions were observed in 4.1 %. Pre-clamping the common and external carotid artery during dissection (pre-clamp method) decreased the rate of new DWI lesions compared to without pre-clamping (3.5 % vs. 7.5 %, P = 0.22). Occlusion time was significantly longer in the pre-clamp method than without pre-clamping (P < 0.0001). However, the incidence of SSEP<50%, >5 min was not increased with the pre-clamp method (p = 1.0) when using information regarding SSEP and collaterals to modify the speed of shunt manipulation. MRA asymmetry was identified in 39 CEAs (15.8 %) with correction of asymmetry postoperatively. MRA asymmetry correlated with symptomatic hyperperfusion (P = 0.0034). Only three CEAs had symptomatic hyperperfusion (1.2 %) with minimal symptoms. Ten CEAs sustained transient ischemia, symptomatic hyperperfusion, or 30-day-stroke (composite postoperative ischemic symptoms). Logistic regression analysis confirmed that SSEP<50%, >5 min (p = 0.009), new DWI lesions (p = 0.004) and MRA asymmetry (p = 0.042) were independent predictors of composite postoperative ischemic symptoms.

Conclusions

SSEP<50%, >5 min, new DWI lesions, and MRA asymmetry were able to stratify the ischemic impacts in CEA. Meticulous routine shunting could mitigate those appropriately.

Keywords

Carotid endarterectomy Cerebral ischemia Diffusion-weighted imaging Magnetic resonance angiography Shunt Somatosensory evoked potentials 

Abbreviations

CAG

Carotid angiography

CCA

Common carotid artery

CEA

Carotid endarterectomy

CT

Computed tomography

CTA

Computed tomographic angiography

DSA

Digital subtraction angiography

DWI

Diffusion-weighted imaging

ECA

External carotid artery

ICA

Internal carotid artery

MCA

Middle cerebral artery

MRA

Magnetic resonance angiography

MRI

Magnetic resonance imaging

SPECT

Single photon emission computed tomography

SSEP

Somatosensory evoked potentials

STA

Superficial temporal artery

TIA

Transient ischemic attack

T2WI

T2-weighted imaging

Notes

Acknowledgments

Conflicts of interest

None.

Supplementary material

Video 1

Video clip showing CEA with the pre-clamp method. (MPG 30988 kb)

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Copyright information

© Springer-Verlag Wien 2013

Authors and Affiliations

  • Tomohiro Inoue
    • 1
    Email author
  • Kazuo Tsutsumi
    • 2
  • Kazuhiro Ohwaki
    • 3
  • Akira Tamura
    • 1
  • Hideaki Ono
    • 4
  • Isamu Saito
    • 1
  • Nobuhito Saito
    • 4
  1. 1.Department of NeurosurgeryFuji Brain Institute and HospitalFujinomiya-shiJapan
  2. 2.Department of NeurosurgeryShowa General HospitalTokyoJapan
  3. 3.Department of Hygiene and Public HealthTeikyo University School of MedicineTokyoJapan
  4. 4.Department of NeurosurgeryUniversity of TokyoTokyoJapan

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