Results of microsurgical carotid endarterectomy. A prospective study with transcranial Doppler and EEG monitoring, and elective shunting.

100 consecutive carotid endarterectomies in a total of 93 patients were performed using the operative microscope. Cerebral perfusion and activity were monitored with simultaneous transcranial Doppler (TCD) and EEG. Thiopentone for cerebral protection was given prior to carotid clamping in 11 cases when an insufficient collateral circulation was suspected on the basis of the pre-operative TCD or angiography and if temporary intraluminal shunting was to be avoided because of a high bifurcation, long stenosis or associated carotid artery kinking. A temporary intraluminal shunt was inserted electively if the mean middle cerebral artery flow velocity fell after cross-clamping below 30-40%. Direct closure of the arteriotomy was preferred over a patch graft, which was performed only in cases with concomitant stricture of the arterial wall. No peri-operative strokes occurred in the present series. Two patients died due to medical complications in the post-operative period. During the mean follow-up of 15 months, 1 patient suffered a lethal stroke ipsilateral to the treated carotid artery and another patient had a minor contralateral stroke. Two patients died of unrelated causes during follow-up. Two patients suffered a single reversible neurologic deficit corresponding to the treated carotid territory. Four other patients had a single contralateral hemispheric or retinal reversible ischaemic attack during follow-up.