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Perioperative stroke after carotid endarterectomy: etiology and implications

  • Clinical Article - Vascular
  • Published:
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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.

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References

  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 678–683

  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 114:200–205

    Article  PubMed  Google Scholar 

  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 339:1415–1425

    Article  CAS  PubMed  Google Scholar 

  4. Bastian D, Tamburstuen MV, Lyngstadaas SP, Reikeras O (2008) Systemic and local cytokine kinetics after total hip replacement surgery. Eur Surg Res 41:334–340

    CAS  PubMed  Google Scholar 

  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 156:1705–1712

    Article  CAS  PubMed  Google Scholar 

  6. Cao P, De Rango P, Zannetti S (2002) Eversion vs conventional carotid endarterectomy: a systematic review. Eur J Vasc Endovasc Surg 23:195–201

  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 31:19–30

  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:CD001921

  9. Capildeo R, Haberman S, Rose FC (1978) The definition and classification of stroke. A new approach. Q J Med 47:177–196

    CAS  PubMed  Google Scholar 

  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 376:1062–1073

    Article  Google Scholar 

  11. DeGraba TJ (2006) How and when do we alter inflammatory mechanisms in stroke? Will it help? Semin Neurol 26:75–87

    Article  PubMed  Google Scholar 

  12. Elkind MS (2010) Inflammatory mechanisms of stroke. Stroke; a J Cereb Circulat 41:S3–8

    Article  CAS  Google Scholar 

  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 30:1751–1758

    Article  CAS  Google Scholar 

  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 376:1074–1084

    Article  PubMed  PubMed Central  Google Scholar 

  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 363:1491–1502

    Article  CAS  PubMed  Google Scholar 

  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 126:3054–3061

    Article  PubMed  PubMed Central  Google Scholar 

  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 375:985–997

    Article  Google Scholar 

  18. Jin R, Yang G, Li G (2010) Inflammatory mechanisms in ischemic stroke: role of inflammatory cells. J Leukoc Biol 87:779–789

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. Limburg M, Wijdicks EF, Li H (1998) Ischemic stroke after surgical procedures: clinical features, neuroimaging, and risk factors. Neurology 50:895–901

    Article  CAS  PubMed  Google Scholar 

  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 266:3289–3294

    Article  CAS  PubMed  Google Scholar 

  21. Mehndiratta P, Chapman Smith S, Worrall BB (2015) Etiologic stroke subtypes: updated definition and efficient workup strategies. Curr Treat Options Cardiovasc Med 17:357

    Article  PubMed  Google Scholar 

  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 17:142–150

    Article  PubMed  PubMed Central  Google Scholar 

  23. No A (1995) Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. JAMA 273:1421–1428

  24. No A (1998) Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet 351:1379–1387

    Article  Google Scholar 

  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 152:579–587

    Article  PubMed  Google Scholar 

  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 22:233–237

    Article  PubMed  Google Scholar 

  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 44:2064–2089

    Article  Google Scholar 

  28. Szeder V, Torbey MT (2008) Prevention and treatment of perioperative stroke. Neurologist 14:30–36

    Article  PubMed  Google Scholar 

  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 25:1519–1523

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Neurological Surgery, University of Pittsburgh School of Medicine, UPMC Presbyterian Hospital Suite B-400, 200 Lothrop Street, Pittsburgh, PA, 15213, USA

    Nicolas K. Khattar, Robert M. Friedlander, Eric S. Kretz, Jeffrey R. Balzer, Donald J. Crammond, Miguel H. Habeych & Parthasarathy D. Thirumala

  2. Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, KY, USA

    Nicolas K. Khattar

  3. Department of Vascular Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA

    Rabih A. Chaer & Efthymios D. Avgerinos

Authors
  1. Nicolas K. Khattar
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  2. Robert M. Friedlander
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  3. Rabih A. Chaer
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  4. Efthymios D. Avgerinos
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  9. Parthasarathy D. Thirumala
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Correspondence to Parthasarathy D. Thirumala.

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Funding

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.

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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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Comments

I have been over and over this manuscript. The basic message seems to be that indwelling shunts placed during CEA are dangerous. This has not been my experience, and I disagree with this, but I do accept that these authors’ data show it in their experience.

I was taught to practice universal shunting for CEA. I soon abandoned this practice and switched to selective monitoring-dependent shunting when it became clear that universal shunting placed many patients at embolic risk who did not need shunt flow during surgery. This was the work of Halsey et. al. (1), not cited by these authors. What is also clear, from Halsey, above, and others like Gary Ferguson (2), is that there are clearly patients who need a shunt and have bad outcomes from cross-clamp ischemia if one is not used. So I do not personally agree with the proponents of a “never-shunt” strategy.

Regarding the current paper, the perioperative stroke rate is higher in shunted cases with eversion endarterectomy for reasons that I cannot discern, since I do not practice this technique. Stroke rate is also higher in this series in left-sided cases. There is no doubt in my mind that for right-handed surgeons a left CEA is more difficult to do, but with experience we learn to deal with this, and in my personal experience there is no difference at all.

So what can we take away? These authors report their retrospective data from a highly mixed patient series with different surgeons and different techniques. There are inherent compromises with this approach. I respect what they have done, but as for me, one surgeon with one constant technique, shunts are useful and lifesaving devices when called for, and we place them without hesitation when the monitoring changes (3). To their credit, they conclude that the need for shunting is a biomarker of cerebral hypoperfusion. While this seems intuitive, this is also the problem that a properly placed shunt, quickly inserted within a minute or less, and with audible confirmation of shunt flow (Doppler) is intended to, and in our experience effective at, solving. It is imperative that the monitoring returns at least partially to baseline after shunt placement. If it does not, the surgeon needs to audibly ascertain shunt flow, or else remove and replace it.

Similarly, in my own experience we approach left CEA with more caution, but the results are identical for us, and we do not hesitate to recommend surgery on the left when the clinical criteria are aligned.

Christopher M. Loftus

IL, USA

1. Halsey JH(1992) Risks and benefits of shunting in carotid endarterectomy. Stroke 23: 1583–1587.

2. Ferguson GG (1984) Protection of the brain during carotid endarterectomy. IV. Shunt almost never. Int Anesthesiol Clin. 22(3):147–52.

3. Loftus CM(2006) Carotid Artery Surgery: Principles and Technique. 2nd edition. New York, Informa Publishing

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Khattar, N.K., Friedlander, R.M., Chaer, R.A. et al. Perioperative stroke after carotid endarterectomy: etiology and implications. Acta Neurochir 158, 2377–2383 (2016). https://doi.org/10.1007/s00701-016-2966-2

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