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Online ISSN 1827-1847
Varroni A., Gizzi E., Totaro R. *, Mangiacotti B., Carlucci M. D., Ventura M., Spartera C.
From the Department and School of Specialisation in Vascular Surgery (Head: Prof. C. Spartera) * Neurological Clinic Department of Internal Medicine and Public Health
University of L’Aquila, Italy
Background. Several techniques have been proposed for intraoperative cerebral monitoring in carotid endarterectomy to identify the patients who do not tolerate carotid clamping and require cerebral protection. The aim of this study is to evaluate intracranial collateral circulation, correlate the neurological status (gold standard) with stump pressure measurement, EEG monitoring and TCD values, and determine the critical levels of cross-clamping tolerance for selecting those patients who need a shunt.
Methods. In the last two years we performed 109 carotid endarterectomies under locoregional anaesthesia (84 males, 25 females; mean age: 66.4±9.4). Transcranial Doppler (TCP) monitoring was used combined with electroencephalography (EEG), LRA and stump pressure measurement for the prevention of cerebral ischaemia.
Results. The percentage of residual mean middle cerebral artery velocity (mMCAv) during carotid artery compression was significantly correlated with mMCAv at carotid clamping. Cross-clamping TCD values were significantly lower in patients with intraoperative neurological deficits (37.2±16 vs 13.27±8 cm/sec; p<0.0001). Cross-clamping values were also lower in patients with EEG abnormalities (36.39±16 vs 20.23±14 cm/sec; p<0.001). Five minutes after clamping time mMCAv increased significantly (36.3±14.6 cm/sec vs 34.7±14.7 cm/sec; p<0.001). According to neurological status, a shunt was inserted in 12 cases. TCD showed a reduction of 70% in mMCAv at cross- clamping in 10 cases. In this series the sensitivity and specificity of EEG monitoring was 75% and 96.8%, respectively. TCD monitoring shows a sensitivity and specificity of 83.3% and 96.9% respectively, while stump pressure showed a sensitivity of 81.8% and a specificity of 87.4%.
Conclusions. EEG and TCD monitoring are complementary techniques. Patients with mMCAv reductions of ≥70% at cross- clamping require a shunt. In our opinion, the versatility of TCD suggests a more extensive application in the field of carotid surgery.
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