Hostname: page-component-78c5997874-xbtfd Total loading time: 0 Render date: 2024-11-05T08:11:33.228Z Has data issue: false hasContentIssue false
  • English
  • Français

Comparison of Monitoring Techniques for Intraoperative Cerebral Ischemia

Published online by Cambridge University Press:  02 December 2014

David W. Rowed ,
David A. Houlden ,
Lee M. Burkholder  and
Amanda B. Taylor
David W. Rowed
Affiliation:
Department of Surgery, Division of Neurosurgery, Sunnybrook and Women's College Health, Sciences Centre, University of Toronto, Toronto, ON, Canada
David A. Houlden
Affiliation:
Department of Surgical Monitoring, Sunnybrook and Women's College Health, Sciences Centre, University of Toronto, Toronto, ON, Canada
Lee M. Burkholder
Affiliation:
Department of Surgical Monitoring, Sunnybrook and Women's College Health, Sciences Centre, University of Toronto, Toronto, ON, Canada
Amanda B. Taylor
Affiliation:
Department of Surgical Monitoring, Sunnybrook and Women's College Health, Sciences Centre, University of Toronto, Toronto, ON, Canada
Rights & Permissions [Opens in a new window]

Abstract

Core share and HTML view are not available for this content. However, as you have access to this content, a full PDF is available via the ‘Save PDF’ action button.
Objective:

To prospectively compare somatosensory evoked potentials, electroencephalography (EEG) and transcranial Doppler ultrasound (TCD) for detection of cerebral ischemia during carotid endarterectomy (CEA).

Methods:

Somatosensory evoked potentials and EEG recordings were attempted in 156 consecutive CEAs and TCD was also attempted in 91 of them. Recordings from all three modalities were obtained for at least 10 minutes before CEA, during CEAand for at least 15 minutes after CEA. Somatosensory evoked potentials peak-to-peak amplitude decrease of >50%, EEG amplitude decrease of >75%, and ipsilateral middle cerebral artery mean blood flow velocity (mean VMCAi) decrease >75% persisting for the entire period of internal carotid artery occlusion were individually considered to be diagnostic of cerebral ischemia. Clinical neurological examination was performed immediately prior to surgery and following recovery from general anaesthesia.

Results:

Somatosensory evoked potentials, EEG, and TCD were successfully obtained throughout the entire period of internal carotid artery occlusion in 99%, 95%, and 63% of patients respectively. Two patients (1.3%) suffered intraoperative cerebral infarction detected by clinical neurological examination and subsequent magnetic resonance imaging. Somatosensory evoked potentials accurately predicted intraoperative cerebral infarction in both instances without false negatives or false positives, EEG yielded one false negative result and no false positive results and VMCAi one true positive, four false positive and no false negative results. Transcranial Doppler ultrasound detection of emboli did not correlate with postoperative neurological deficits. Nevertheless the sensitivity and specificity of each test was not significantly different than the others because of the small number of disagreements between tests.

Conclusion:

A >50% decrease in the cortically generated P25 amplitude of the median somatosensory evoked potentials, which persisted during the entire period of internal carotid artery occlusion, appears to be the most reliable method of monitoring for intraoperative ischemia in our hands because it accurately detected both intraoperative strokes with no false positive or false negative results.

Type
Research Article
Information
Canadian Journal of Neurological Sciences , Volume 31 , Issue 3 , August 2004 , pp. 347 - 356
Copyright
Copyright © The Canadian Journal of Neurological 2004

References

1.Whitley, D, Cherry, KJ Jr.Predictive value of carotid artery stump pressures during carotid endarterectomy. Neurosurg Clin N Am 1996; 7: 723–732.Google Scholar
2.Blume, WT, Ferguson, GG, McNeill, DK.Significance of EEG changes at carotid endarterectomy. Stroke 1986; 17: 891–897.Google Scholar
3.Blume, WT, Sharbrough, FW.EEG Monitoring during Carotid Endarterectomy and Open Heart Surgery. In: Niedermeyer, E, Lopes Da Silva, F, (Eds). Electroencephalography: Basic Principles, Clinical Applications, and Related Fields. Baltimore: Williams and Wilkins, 1999: 797–808.Google Scholar
4.Chiappa, KH, Burke, SR, Young, RR.Results of electroencephalographic monitoring during 367 carotid endarterectomies. Use of a dedicated minicomputer. Stroke 1979; 10: 381–388.Google Scholar
5.Jansen, C, Vriens, EM, Eikelboom, BC, et al.Carotid endarterectomy with transcranial Doppler and electroencephalographic monitoring. A prospective study in 130 operations. Stroke 1993; 24: 665–669.Google Scholar
6.Sturzenegger, AM, Schaffler, L, Seiler, RW.Continuous intraoperative monitoring of middle cerebral artery blood flow velocity and electroencephalography during carotid endarterectomy. A comparison of methods to detect cerebral ischemia. Stroke 1997; 28: 1345–1350.Google Scholar
7.Tempelhoff, R, Modica, PA, Grubb, RL Jr, et al.Selective shunting during carotid endarterectomy based on two-channel computerized electroencephalographic/compressed spectral array analysis. Neurosurgery 1989; 24: 339–344.Google Scholar
8.Halsey, JH, McDowell, HA, Gelman, S.Transcranial Doppler and rCBF compared in carotid endarterectomy. Stroke 1986; 17: 1206–1208.Google Scholar
9.Rowed, DW, Vilaghy, MI.Intraoperative regional cerebral blood flow during carotid endarterectomy. Can J Neurol Sci 1981; 8: 235–241.Google Scholar
10.Guerit, JM, Witdoeckt, C, de Tourtchaninoff, M, et al.Somatosensory evoked potential monitoring in carotid surgery. I. Relationships between qualitative SEP alterations and intraoperative events. Electroencephalogr Clin Neurophysiol 1997; 104: 459–469.Google Scholar
11.Haupt, WF, Horsch, S.Evoked potential monitoring in carotid surgery: a review of 994 cases. Neurology 1992; 42: 835–838.CrossRefGoogle ScholarPubMed
12.Horsch, S, Ktenidis, K.Intraoperative use of somatosensory evoked potentials for brain monitoring during carotid surgery. Neurosurg Clin N Am 1996; 7: 693–702.Google Scholar
13.Lacroix, H, Beyens, G, Van Hemelrijck, J, et al.Is transcranial Doppler useful in the detection of internal carotid artery cross-clamp intolerance? Cardiovasc Surg 1999; 7: 203–207.Google Scholar
14.Naylor, AR, Hayes, PD, Allroggen, H, et al.Reducing the risk of carotid surgery: a 7-year audit of the role of monitoring and quality control assessment. J Vasc Surg 2000; 32: 750–759.Google Scholar
15.Smith, JL, Evans, DH, Gaunt, ME, et al.Experience with transcranial Doppler monitoring reduces the incidence of particulate embolization during carotid endarterectomy. Br J Surg 1998; 85: 56–59.CrossRefGoogle ScholarPubMed
16.Carlin, RE, McGraw, DJ, Calimlim, JR, Mascia, MF.The use of near-infrared cerebral oximetry in awake carotid endarterectomy. J Clin Anesth 1998; 10: 109–113.Google Scholar
17.Samra, SK, Dy, EA, Welch, K, et al.Evaluation of a cerebral oximeter as a monitor of cerebral ischemia during carotid endarterectomy. Anesthesiology 2000; 93: 964–970.CrossRefGoogle ScholarPubMed
18.Niinai, H, Nakagawa, I, Shima, T, et al.Continuous monitoring of jugular bulb venous oxygen saturation for evaluation of cerebral perfusion during carotid endarterectomy. Hiroshima J Med Sci 1998; 47: 133–137.Google Scholar
19.Thiel, A, Ritzka, M.Cerebral monitoring in carotid surgery. Results of a questionnaire in the Federal Republic of Germany. Anasthesiol Intensivmed Notfallmed Schmerzther 2001; 36: 693–697.CrossRefGoogle ScholarPubMed
20.Rowed, DW, Houlden, DA, Burkholder, LM.Comparative value of somatosensory evoked potentials (SSEP), electroencephalography (EEG), and transcranial Doppler (TCD) for detection of intraoperative cerebral ischemia. Can J Neurol Sci 2001; 28: S10.Google Scholar
21.Duffy, CM, Manninen, PH, Chan, A, Kearns, CF.Comparison of cerebral oximeter and evoked potential monitoring in carotid endarterectomy. Can J Anaesth 1997; 44: 1077–1081.Google Scholar
22.North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 1991; 325: 445–453.Google Scholar
23.Jasper, H.The ten-twenty electrode system of the International Federation. Electroencephalogr Clin Neurophysiol 1958; 10: 371–375.Google Scholar
24.Fiori, L, Parenti, G, Marconi, F.Combined transcranial Doppler and electrophysiologic monitoring for carotid endarterectomy. J Neurosurg Anesthesiol 1997; 9: 11–16.Google Scholar
25.Spielberger, L, Turndorf, H, Culliford, A, Imparato, A.Hand-held toy squeaker during carotid endarterectomy in the awake patient. Arch Surg 1979; 114: 103–104.Google Scholar
26.Spencer, MP, Thomas, GI, Moehring, MA.Relation between middle cerebral artery blood flow velocity and stump pressure during carotid endarterectomy. Stroke 1992; 23: 1439–1445.Google Scholar
27.Lennard, N, Smith, J, Dumville, J, et al.Prevention of postoperative thrombotic stroke after carotid endarterectomy: the role of transcranial Doppler ultrasound. J Vasc Surg 1997; 26: 579–584.Google Scholar
28.Thiel, A, Russ, W, Zeiler, D, et al.Transcranial Doppler sonography and somatosensory evoked potential monitoring in carotid surgery. Eur J Vasc Surg 1990; 4: 597–602.Google Scholar
29.Dinkel, M, Langer, H, Loerler, H, et al.Neuromonitoring in carotid surgery: possibilities and limits of transcranial Doppler ultrasound. Vasa 1994; 23: 337–344.Google Scholar
30.Aackerstaff, RG, Moons, KG, van de Vlasakker, CJ, et al.Association of intraoperative transcranial doppler monitoring variables with stroke from carotid endarterectomy. Stroke 2000; 31: 1817–1823.Google Scholar
31.Heyer, EJ, Winfree, CJ, Mack, WJ, Connolly, ES Jr.Transcranial Doppler monitoring during carotid endarterectomy: a technical case report. J Neurosurg Anesthesiol 2000; 12: 233–239.CrossRefGoogle ScholarPubMed
32.Halsey, JH, McDowell, HA, Gelmon, S, Morawetz, RB.Blood velocity in the middle cerebral artery and regional cerebral blood flow during carotid endarterectomy. Stroke 1989; 20: 53–58.Google Scholar
33.Jansen, C, Moll, FL, Vermeulen, FE, et al.Continuous transcranial Doppler ultrasonography and electroencephalography during carotid endarterectomy: a multimodal monitoring system to detect intraoperative ischemia. Ann Vasc Surg 1993; 7: 95–101.Google Scholar
34.Tegos, TJ, Sabetai, MM, Nicolaides, AN, et al.Correlates of embolic events detected by means of transcranial Doppler in patients with carotid atheroma. J Vasc Surg 2001; 33: 131–138.CrossRefGoogle ScholarPubMed
35.Dunne, VG, Besser, M, Ma, WJ.Transcranial Doppler in carotid endarterectomy. J Clin Neurosci 2001; 8: 140–145.Google Scholar
36.Arnold, M, Sturzenegger, M, Schaffler, L, Seiler, RW.Continuous intraoperative monitoring of middle cerebral artery blood flow velocities and electroencephalography during carotid endarterectomy. A comparison of the two methods to detect cerebral ischemia. Stroke 1997; 28: 1345–1350.Google Scholar
37.Steiger, HJ, Schaffler, L, Boll, J, Liechti, S.Results of microsurgical carotid endarterectomy. A prospective study with transcranial Doppler and EEG monitoring, and elective shunting. Acta Neurochir (Wien ) 1989; 100: 31–38.Google Scholar
38.Lam, AM, Manninen, PH, Ferguson, GG, Nantau, W.Monitoring electrophysiologic function during carotid endarterectomy: a comparison of somatosensory evoked potentials and conventional electroencephalogram. Anesthesiology 1991; 75: 15–21.Google Scholar
39.Manninen, PH, Tan, TK, Sarjeant, RM.Somatosensory evoked potential monitoring during carotid endarterectomy in patients with a stroke. Anesth Analg 2001; 93: 39–44.Google Scholar
40.Aackerstaff, RG, Jansen, C, Moll, FL.Carotid Endarterectomy and Intraoperative Emboli Detection: Correlation of Clinical, Transcranial Doppler, and Magnetic Resonance Findings. Echocardiography 1996; 13: 543–550.Google Scholar
41.Bass, A, Krupski, WC, Schneider, PA, et al.Intraoperative transcranial Doppler: limitations of the method. J Vasc Surg 1989; 10: 549–553.CrossRefGoogle ScholarPubMed
42.Gaunt, ME.Transcranial Doppler: preventing stroke during carotid endarterectomy. Ann R Coll Surg Engl 1998; 80: 377–387.Google Scholar
43.Jorgensen, LG.Transcranial Doppler ultrasound for cerebral perfusion. Acta Physiol Scand Suppl 1995; 625: 1–44.Google Scholar
44.de Boorst, GJ, Moll, FL, van de Pavoordt, HDWM.Stroke from carotid endarterectomy: when and how to reduce perioperative rate? Eur J Vasc Endovasc Surg 2001; 21: 484–489.Google Scholar
45.Haupt, WF, Erasmi-Korber, H, Lanfermann, H.Intraoperative recording of parietal SEP can miss hemodynamic infarction during carotid endarterectomy: a case study. Electroencephalogr Clin Neurophysiol 1994; 92: 86–88.Google ScholarPubMed
46.Linstedt, U, Maier, C, Petry, A.Intraoperative monitoring with somatosensory evoked potentials in carotid artery surgery--less reliable in patients with preoperative neurologic deficiency? Acta Anaesthesiol Scand 1998; 42: 13–16.Google Scholar
47.Sundt, TM Jr, Sharbrough, FW, Anderson, RE, Michenfelder, JD.Cerebral blood flow measurements and electroencephalograms during carotid endarterectomy. J Neurosurg 1974; 41: 310–320.Google Scholar
48.Fava, E, Bortolani, E, Ducati, A, Schieppati, M.Role of SEP in identifying patients requiring temporary shunt during carotid endarterectomy. Electroencephalogr Clin Neurophysiol 1992; 84: 426–432.Google Scholar
49.Schneider, PA, Ringelstein, EB, Rossman, ME, et al.Importance of cerebral collateral pathways during carotid endarterectomy. Stroke 1988; 19: 1328–1334.Google Scholar