Intraoperative monitoring during carotid endarterectomy

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

The neurological complications of CEA

Mechanism Preventative methods Drawbacks of preventative methods

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

IOM during carotid endarterectomy

During CEA surgery, a cross clamp must be applied to the proximal and distal ends of the surgery to be incrised and repaired
20% carotid clamping results in a significant cerebral ischemia with an associated high probability of ischemic stroke

IOM during carotid endarterectomy

Inherent risks associated with shunting may be attributed to the following factors:
Intraoperative thrombosis formation Technical problems that limit the surgeons ability to expose and dissect the atheroma,especially the distal segment Shunt kinking or occlusion due to improper placement,resulting in ischemia Increased risk of cerebral embolization of atherosclerotic debris and air into the distal cerebral circulation Potential intimal damage resulting in postoperative thrombosis at the operative

IOM during carotid endarterectomy

the potential usefulness of IOM in CEA is threefold:
(1) immediately after induction and before any surgical maneuver to check whether head positioning is well tolerated (2) to decide whether a shunt should be installed and, in the affirmative, whether the shunt is well functioning (3) to decide whether BP is compatible with sufficient brain perfusion. In addition, IOM might provide useful information in order to decide for combined carotid and coronary bypass grafting (CABG) surgery.

EEG Technique in CEA

all authors have used symmetrical montages.
Channels that provide a frontoparietal & frontotemperal coverage correlative with the distribution of the blood supply of the superior and inferior M2 branch of the middle cerebral artery, respectively

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

EEG Technique in CEA(cont.)

UCLA(Nuwer,2008): F3-C3, C3-T3,T3-O1 and F4-C4, C4-T4, T4-O2

EEG Technique in CEA(cont.)

Filter: 0.3 and 70Hz (UCLA: 1 and 30Hz), notch filter ON Sensivity:3-5V/mm Compressing the EEG with a slow time base: 5-15mm/s( normal: 30mm/s)

EEG Technique in CEA(cont.)

At least 10minutes of preclamp baseline EEG be record while the patient is anasthesized to appreciate any clamp associated changes Adjusting gain until the fast activity pattern produces a deflection of about 1cm help detect the signs of ischemia An asymmetric EEG usually occurs with antecedent cerebral lesion Clamp related EEG changes usually occur within 1 minute

EEG Technique in CEA(cont.)

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 Technique in CEA

SEP: almost use both Median and Tibial SEP, but could use alone upper/lower limb SEP (Median SEP more than Tibial SEP)
SEP recordings should be obtained preoperatively if possible Certainly operative baselines should be obtains prior to Carotid cross clamping(CCC).

SEP Technique in CEA(cont.)

Display cortical, subcortical and peripheral waveforms if IOM machine enough channels. This allows more precise localization of ischemia and helps with troublshooting. An attemp should be made to reproduce the SEP waveforms every 30seconds during CCC to provide rapid feedback.

EEG vesus SEP Technique in CEA

EEG
monitors the spontaneous electrical activity of cortical neurons and is widely used to monitor cerebral perfusion during CEA and endovascular procedure

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.

EEG vesus SEP Technique in CEA

EEG
is limited by an inability to detect subcortical injury, a high false positive rate (lower specility, mainly due to sentivitive to anesthesia and drugs), and a diminished sentivity in patients who have a history of stroke

SEP
are particularly useful for patiens who have an normal EEG as a result of prior stroke

EEG vesus SEP Technique in CEA

EEG
Normal mean cerebral blood flow(CBF): 50ml/100g/min Mild hypotension: 2250ml/100g/min,doesnt induce neuronal perfusion. Mean CBF< 22ml/100g/min: EEG amplitude decrease, and/or EEG slowing become manifest Mean CBF 7-15ml/100g/min: suppresion of EEG activity Mean CBF 12-15ml/100g/min: neural damage begin to occur, making EEG a useful monitor for cortical ischemia

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

EEG vesus SEP Technique in CEA

EEG vesus SEP Technique in CEA

EEG vesus SEP Technique in CEA

EEG & SEP criteria for alam in CEA

Diagnosis EEG
Mild <50% decrease of fast activities (+) <50% increase of slow activities (+) >50% decrease of fast activities (+) >50% increase of slow activities (+)

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

EEG loss over all frequency bands Burst suppression

Criteria of mild, moderate, and severe EEG and SEP changes suggestive of impaired brain perfusion (Gurit et al.,1997; Smith and Prior, 2003)

Evidence supporting use of IOM in CEA

It is difficult whether IOM with EEG or SEP helps decrease the morbidity of CEA, as most surgeon shunt the carotid artery if neurophysiological changes are noted Florent et al(2004) Sensivity Specificity EEG SEP 0.27 0.52 0.87 0.98

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.

Proposed decision algorithms before the cross-clamping period.

Proposed decision algorithms during the cross-clamping period.

IOM during carotid endarterectomy

IOM modalities:
EEG SEP
Proved extremely sensitive to hemodynamic disturbances and macroembolism

Transcranial doppler(TCD): intraoperative detection of microembolism

IOM during carotid endarterectomy

IOM modalities:
EEG: EEG+SEP UCLA:
The vascular surgeons like EEG for CEA. The neurosurgeons like both EEG and SEP.
EEG covers a wider area and is more sensitive to changes. SEP is covers a more restricted region, and only changes when the ischemia is more severe. It is a choice as to what to do

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

16 channel IOM machine

Anterio-posterior longitudinal montage shoul be used Median and tibial SEPs

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

Thank you for your attention