Acta Neurochirurgica

, Volume 158, Issue 12, pp 2377–2383 | Cite as

Perioperative stroke after carotid endarterectomy: etiology and implications

  • Nicolas K. Khattar
  • Robert M. Friedlander
  • Rabih A. Chaer
  • Efthymios D. Avgerinos
  • Eric S. Kretz
  • Jeffrey R. Balzer
  • Donald J. Crammond
  • Miguel H. Habeych
  • Parthasarathy D. Thirumala
Clinical Article - Vascular

Abstract

Background

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.

Methods

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).

Results

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).

Conclusions

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.

Keywords

Perioperative stroke Carotid endarterectomy Etiology Length of stay 

References

  1. 1.
    Avgerinos ED, Chaer RA, Naddaf A, El-Shazly OM, Marone L, Makaroun MS (2016) Primary closure after carotid endarterectomy is not inferior to other closure techniques. J Vasc Surg 678–683Google Scholar
  2. 2.
    Balzer JR, Tomycz ND, Crammond DJ, Habeych M, Thirumala PD, Urgo L, Moossy JJ (2011) Localization of cervical and cervicomedullary stimulation leads for pain treatment using median nerve somatosensory evoked potential collision testing. J Neurosurg 114:200–205CrossRefPubMedGoogle Scholar
  3. 3.
    Barnett HJ, Taylor DW, Eliasziw M, Fox AJ, Ferguson GG, Haynes RB, Rankin RN, Clagett GP, Hachinski VC, Sackett DL, Thorpe KE, Meldrum HE, Spence JD (1998) Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med 339:1415–1425CrossRefPubMedGoogle Scholar
  4. 4.
    Bastian D, Tamburstuen MV, Lyngstadaas SP, Reikeras O (2008) Systemic and local cytokine kinetics after total hip replacement surgery. Eur Surg Res 41:334–340PubMedGoogle Scholar
  5. 5.
    Bradac O, Mohapl M, Kramar F, Netuka D, Ostry S, Charvat F, Lacman J, Benes V (2014) Carotid endarterectomy and carotid artery stenting: changing paradigm during 10 years in a high-volume centre. Acta Neurochir 156:1705–1712CrossRefPubMedGoogle Scholar
  6. 6.
    Cao P, De Rango P, Zannetti S (2002) Eversion vs conventional carotid endarterectomy: a systematic review. Eur J Vasc Endovasc Surg 23:195–201Google Scholar
  7. 7.
    Cao P, Giordano G, De Rango P, Zannetti S, Chiesa R, Coppi G, Palombo D, Peinetti F, Spartera C, Stancanelli V, Vecchiati E (2000) Eversion versus conventional carotid endarterectomy: late results of a prospective multicenter randomized trial. J Vasc Surg 31:19–30Google Scholar
  8. 8.
    Cao PG, de Rango P, Zannetti S, Giordano G, Ricci S, Celani MG (2001) Eversion versus conventional carotid endarterectomy for preventing stroke. Cochrane Database Syst Rev:CD001921Google Scholar
  9. 9.
    Capildeo R, Haberman S, Rose FC (1978) The definition and classification of stroke. A new approach. Q J Med 47:177–196PubMedGoogle Scholar
  10. 10.
    Carotid Stenting Trialists C, Bonati LH, Dobson J, Algra A, Branchereau A, Chatellier G, Fraedrich G, Mali WP, Zeumer H, Brown MM, Mas JL, Ringleb PA (2010) Short-term outcome after stenting versus endarterectomy for symptomatic carotid stenosis: a preplanned meta-analysis of individual patient data. Lancet 376:1062–1073CrossRefGoogle Scholar
  11. 11.
    DeGraba TJ (2006) How and when do we alter inflammatory mechanisms in stroke? Will it help? Semin Neurol 26:75–87CrossRefPubMedGoogle Scholar
  12. 12.
    Elkind MS (2010) Inflammatory mechanisms of stroke. Stroke; a J Cereb Circulat 41:S3–8CrossRefGoogle Scholar
  13. 13.
    Ferguson GG, Eliasziw M, Barr HW, Clagett GP, Barnes RW, Wallace MC, Taylor DW, Haynes RB, Finan JW, Hachinski VC, Barnett HJ (1999) The North American Symptomatic Carotid Endarterectomy Trial : surgical results in 1415 patients. Stroke; a J Cereb Circulat 30:1751–1758CrossRefGoogle Scholar
  14. 14.
    Halliday A, Harrison M, Hayter E, Kong X, Mansfield A, Marro J, Pan H, Peto R, Potter J, Rahimi K, Rau A, Robertson S, Streifler J, Thomas D, Asymptomatic Carotid Surgery Trial Collaborative G (2010) 10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1): a multicentre randomised trial. Lancet 376:1074–1084CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Halliday A, Mansfield A, Marro J, Peto C, Peto R, Potter J, Thomas D, Group MRCACSTC (2004) Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet 363:1491–1502CrossRefPubMedGoogle Scholar
  16. 16.
    Hill MD, Brooks W, Mackey A, Clark WM, Meschia JF, Morrish WF, Mohr JP, Rhodes JD, Popma JJ, Lal BK, Longbottom ME, Voeks JH, Howard G, Brott TG, Investigators C (2012) Stroke after carotid stenting and endarterectomy in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). Circulation 126:3054–3061CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    International Carotid Stenting Study i, Ederle J, Dobson J, Featherstone RL, Bonati LH, van der Worp HB, de Borst GJ, Lo TH, Gaines P, Dorman PJ, Macdonald S, Lyrer PA, Hendriks JM, McCollum C, Nederkoorn PJ, Brown MM (2010) Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomised controlled trial. Lancet 375:985–997CrossRefGoogle Scholar
  18. 18.
    Jin R, Yang G, Li G (2010) Inflammatory mechanisms in ischemic stroke: role of inflammatory cells. J Leukoc Biol 87:779–789CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Limburg M, Wijdicks EF, Li H (1998) Ischemic stroke after surgical procedures: clinical features, neuroimaging, and risk factors. Neurology 50:895–901CrossRefPubMedGoogle Scholar
  20. 20.
    Mayberg MR, Wilson SE, Yatsu F, Weiss DG, Messina L, Hershey LA, Colling C, Eskridge J, Deykin D, Winn HR (1991) Carotid endarterectomy and prevention of cerebral ischemia in symptomatic carotid stenosis. Veterans Affairs Cooperative Studies Program 309 Trialist Group. JAMA 266:3289–3294CrossRefPubMedGoogle Scholar
  21. 21.
    Mehndiratta P, Chapman Smith S, Worrall BB (2015) Etiologic stroke subtypes: updated definition and efficient workup strategies. Curr Treat Options Cardiovasc Med 17:357CrossRefPubMedGoogle Scholar
  22. 22.
    Newgard CD, Fleischman R, Choo E, Ma OJ, Hedges JR, McConnell KJ (2010) Validation of length of hospital stay as a surrogate measure for injury severity and resource use among injury survivors. Acad Emerg Med 17:142–150CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    No A (1995) Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. JAMA 273:1421–1428Google Scholar
  24. 24.
    No A (1998) Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet 351:1379–1387CrossRefGoogle Scholar
  25. 25.
    Pappada G, Vergani F, Parolin M, Cesana C, Pirillo D, Pirovano M, Santoro P, Landi A, Ferrarese C (2010) Early acute hemispheric stroke after carotid endarterectomy. Pathogenesis and management. Acta Neurochir 152:579–587CrossRefPubMedGoogle Scholar
  26. 26.
    Rhee-Moore SJ, DeRubertis BG, Lam RC, Hynecek RL, Lee L, McKinsey JF, Morrissey NJ, Karwowski J, Mureebe L, Kent KC, Faries PL (2008) Periprocedural complication rates are equivalent between symptomatic and asymptomatic patients undergoing carotid angioplasty and stenting. Ann Vasc Surg 22:233–237CrossRefPubMedGoogle Scholar
  27. 27.
    Sacco RL, Kasner SE, Broderick JP, Caplan LR, Connors JJ, Culebras A, Elkind MS, George MG, Hamdan AD, Higashida RT, Hoh BL, Janis LS, Kase CS, Kleindorfer DO, Lee JM, Moseley ME, Peterson ED, Turan TN, Valderrama AL, Vinters HV, American Heart Association Stroke Council CoCS, Anesthesia, Council on Cardiovascular R, Intervention, Council on C, Stroke N, Council on E, Prevention, Council on Peripheral Vascular D, Council on Nutrition PA, Metabolism (2013) An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke; a J Cereb Circulat 44:2064–2089CrossRefGoogle Scholar
  28. 28.
    Szeder V, Torbey MT (2008) Prevention and treatment of perioperative stroke. Neurologist 14:30–36CrossRefPubMedGoogle Scholar
  29. 29.
    Zeller JA, Lenz A, Eschenfelder CC, Zunker P, Deuschl G (2005) Platelet–leukocyte interaction and platelet activation in acute stroke with and without preceding infection. Arterioscler Thromb Vasc Biol 25:1519–1523CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Wien 2016

Authors and Affiliations

  • Nicolas K. Khattar
    • 1
    • 2
  • Robert M. Friedlander
    • 1
  • Rabih A. Chaer
    • 3
  • Efthymios D. Avgerinos
    • 3
  • Eric S. Kretz
    • 1
  • Jeffrey R. Balzer
    • 1
  • Donald J. Crammond
    • 1
  • Miguel H. Habeych
    • 1
  • Parthasarathy D. Thirumala
    • 1
  1. 1.Department of Neurological SurgeryUniversity of Pittsburgh School of MedicinePittsburghUSA
  2. 2.Department of Neurological SurgeryUniversity of Louisville School of MedicineLouisvilleUSA
  3. 3.Department of Vascular SurgeryUniversity of Pittsburgh School of MedicinePittsburghUSA

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