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



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.


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).


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).


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.


Perioperative stroke Carotid endarterectomy Etiology Length of stay 


Compliance with ethical standards


No funding was received for this research.

Conflict of interest

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. For this type of study formal consent is not required.


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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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