Department of Neurosurgery, Penn State Health, 500 University Drive, Hershey, PA 17033, USA.
Department of Neurosurgery, Penn State Health, 500 University Drive, Hershey, PA 17033, USA.
Clin Neurol Neurosurg. 2021 Dec;211:107032. doi: 10.1016/j.clineuro.2021.107032. Epub 2021 Nov 13.
Carotid endarterectomy (CEA) is a safe and effective operation in the management of carotid stenosis. Intraoperative neurophysiologic monitoring (IONM) changes during carotid clamping has been well studied, but there is scant evidence detailing IONM changes during carotid exposure.
We analyzed our experience with IONM changes during CEA exposure to determine whether multimodal IONM changes during exposure predict outcomes and how best to manage this challenging clinical scenario.
We reviewed all CEAs performed at our medical center between January 2015 and June 2020 and identified patients with multimodal IONM changes during exposure of the carotid artery. Our primary outcomes were perioperative stroke and functional outcomes. Functional outcomes were measured by modified Rankin scale (mRS), with good functional outcome defined at mRS scores 0-3. We also reviewed our intraoperative IONM change management strategies.
Five patients (4 males, 1 female) with an average age of 67 ± 12 years had intraoperative IONM changes during carotid exposure. Among these, three patients were discharged with good functional outcome, and four patients had a good functional outcome at last follow-up. Two patients had perioperative stroke, half of which resulted in significant disability. One patient was transferred to the neuroendovascular suite intraoperatively for evaluation for thromboembolism followed by angioplasty and stenting with distal protection.
Intraoperative IONM changes during carotid exposure predict outcomes in CEA. We propose that transition to the neuroendovascular suite following significant IONM changes during carotid exposure may be a useful strategy for management of this challenging clinical scenario. This approach provides the opportunity to evaluate and treat thromboembolism and still complete carotid revascularization when appropriate. This algorithm may be particularly useful in the era of dual trained vascular neurosurgeons.
颈动脉内膜切除术（CEA）是治疗颈动脉狭窄的安全有效的手术。术中神经生理监测（IONM）在颈动脉夹闭期间的变化已经得到了充分的研究，但很少有证据详细描述颈动脉暴露期间 IONM 的变化。
我们分析了我们在 CEA 暴露期间进行 IONM 变化的经验，以确定暴露期间多模态 IONM 变化是否可以预测结果，以及如何最好地管理这种具有挑战性的临床情况。
我们回顾了我们医疗中心在 2015 年 1 月至 2020 年 6 月期间进行的所有 CEA，并确定了在暴露颈动脉期间出现多模态 IONM 变化的患者。我们的主要结果是围手术期中风和功能结果。功能结果通过改良 Rankin 量表（mRS）测量，mRS 评分 0-3 定义为良好的功能结果。我们还回顾了我们术中 IONM 变化管理策略。
5 名患者（4 名男性，1 名女性），平均年龄 67±12 岁，在颈动脉暴露期间出现术中 IONM 变化。其中，3 名患者出院时功能良好，4 名患者在最后一次随访时功能良好。2 名患者发生围手术期中风，其中一半导致严重残疾。1 名患者术中因血栓栓塞被转移到神经血管套房，随后进行血管成形术和支架置入术并进行远端保护。
颈动脉暴露期间的术中 IONM 变化可预测 CEA 的结果。我们提出，在颈动脉暴露期间出现显著 IONM 变化后，过渡到神经血管套房可能是管理这种具有挑战性临床情况的有用策略。这种方法为评估和治疗血栓栓塞提供了机会，并且在适当的情况下仍可以完成颈动脉血运重建。在双训练血管神经外科医生的时代，这种算法可能特别有用。
