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Dr.Tuan Tu Quoc Le
(presented at Tuen Mun Hospital, Hong Kong 2008)
Background
CEA is a surgical procedure designed to prevent ischemic stroke by removing an atheromatous lesion at the carotid bifurcation & restoring the patency of the carotid vessels to an almost normal level But: Stroke is the most feared complication of carotid artery surgery, stroke rate ranges from 2% to 7.5% (Sila,1998).
CEA is recommended in patients with:
5069% symptomatic stenosis provided that the rate of stroke/ death is < 6%, 6099% asymptomatic stenosis provided that the risk is < 3% (Chaturvedi et al., 2005 ).
Carotid endarterectomy
Intraoperative
Embolism Hemodynamic Myocardiac infarction Careful manipulation Shunt avoidance Shunt Blood presure Blood presure Angioplasty Avoid ischemia Treat HTA Duration of surgery Risk of brain hypoperfusion Risk of embolism Risk of myocardial infarct Risk of brain hypoperfusion Duration of surgery
Postoperative
Carotid restenosis Brain hemorrhage
Intra- and postoperative factors determining CEA morbidity and mortality, the ways to prevent those, and drawbacks of preventative methods
4/8 channel IOM machine: F3-C3,F7-T3/T3-T5 and F4-T4,F8T4/T4-T6 or C3-P3,F7-T3/T3-T5 and C4-P4,F8-T4/T4-T6 16 channel IOM machine: F3-C3,C3-P3,F7-T3/T3-T5 and F4T4,C4-P4,F8-T4/T4-T6 UCLA(Nuwer,2008): F3-C3, C3-T3,T3-O1 and F4-C4, C4T4, T4-O2
The effect of clamping of the right internal carotid artery (ICA). Eight EEG channels are shown and transcranial Doppler envelope for the ipsilateral middle cerebral artery
SEP
improve the ability to detect deep brain and brainstem ischemia. Ischemic damage to cortical or subcortical neurons produces a characteristic, detecable pattern: a decrease in signal amplitude & concomitant increase in signal latency.
SEP
are particularly useful for patiens who have an normal EEG as a result of prior stroke
SEP
Mean CBF 16-20ml/100g/min: cortical waveform s amplitude decrease<50% Mean CBF <14ml/100g/min: cortical waveforms amplitude decrease >50%, 5% latency prolongatiion Mean CBF 12-15ml/100g/min: Cortical waveform s dissappear, subcortical waveform s amplitude decrease But CBF values resulting in a loss of spontaneous neuronal activities is extremely variable(6-22ml/100g/min). This large variability can be explained by the differences among individual neurons in energy metabolism and local feature of blood supply
SEPs
Desynchronization or disappearance of the frontal N30 and/or parietal P45 Desynchronization or disappearance of the parietal P27 (early warning) or P27 and P24 (urgent warning) Disappearance of all activities following N20 Desynchronization or disappearance of N20
Moderate
Severe
Criteria of mild, moderate, and severe EEG and SEP changes suggestive of impaired brain perfusion (Gurit et al.,1997; Smith and Prior, 2003)
This analysis suggests that there is no clear superiority of one technique over the other. Multimodallity monitoring may be more effetive than any single modality alone.
Technical considerations
There are many patients-related conditions that may effect IOM.
Prior stroke , demyelinating disease may result in slowing of EEG frequencies at baselinekeep in mind in interpreting focal slowing after CCC The presence of peripheral neuropathy, neuromuscular disorder,myelopathy, cerebral palsy: may effect SEPs
Technical considerations
Procedure
8 channel IOM machine:
At least 4 EEG channels are used SEP: C3,Cz,C4,CSp5
Communication between IOM,surgery and anesthesia teams is critical for optimal monitoring
Conclusion
IOMduring CEA can provide the surgeon with critical information that may modify surgical procedure. A complementary working environment between IOM,suregy,anesthesia team will ensure the best monitoring