Guidelines do not include cerebral oximetry among monitoring for carotid endarterectomy (CEA). The purpose of this study was to evaluate the reliability of near-infrared spectroscopy (NIRS) in the detection of clamping ischemia and in the prevention of clamping-related neurologic deficits using, as a cutoff for shunting, a 20% regional cerebral oxygen saturation (rSO2) decrease if persistent more than 4 minutes, otherwise a 25% rSO2 decrease. Bilateral rSO2 was monitored continuously in patients undergoing CEA under general anesthesia (GA). Data was recorded after clamping, declamping, during shunting and lowest values achieved. Preoperative neurologic, CT-scan, and vascular lesions were recorded.
We reviewed 473 cases: 305 males (64.5%) mean age 73.3 ± 7.3. Three patients presented transient ischemic deficits at awakening, no perioperative stroke or death; 41 (8.7%) required shunting: 30 based on the initial rSO2 value and 11 due to a decrease during surgery. Using the ROC curve analysis we found, for a >25% reduction from baseline value, a sensitivity of 100% and a specificity of 90.6%. Reliability, PPV, and NPV were 95.38%, 9%, and 100%, respectively. In conclusion, this study indicates the potential reliability of NIRS monitoring during CEA under GA, using a cutoff of 25% or a cutoff of 20% for prolonged hypoperfusion.
the endovascular approach reduced the number of patients unsuitable for revascularization, however, some patients cannot be treated by angioplasty or open surgery; moreover, some are unfit for surgery, and others have persistent distal ischemia and pain with a functioning revascularization. In these cases SCS (alone or associated with prostanoids) can be indicated on the basis of the more recent evidences. A trial period with external stimulator, associated with a microcirculatory evaluation, is currently utilized to select patients that can derive benefit from this treatment, reducing costs.
The aim of this study was to investigate changes in cognitive function following carotid endarterectomy (CEA). In 74 asymptomatic CEA patients cognitive function, depression, laterality and severity of stenosis, cerebral Computer Tomography results, and ischemic heart diseases were measured preoperatively. The sample included 31 patients with dementia and 43 patients without any symptom of dementia. Cognitive function was measured again at 3 months postoperatively using a brief standardised test. After controlling for cognitive function and depression at baseline, cognitive function improved significantly at 3 months after CEA in both patients with and without dementia. CEA may offer more than reduced stroke risk to patients, independent of cognitive function.
Results of the 39 studies considered suggest that, although few studies show cognitive deterioration, most of them show stability with a tendency to improve both in cognitive functions and in other psychological areas. Further research is needed to clarify when it would be appropriate the use of CEA, the characteristics of eligible patients, and psychological as well as physical expected outcomes.
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