Green R M, Messick W J, Ricotta J J, Charlton M H, Satran R, McBride M M, DeWeese J A
Ann Surg. 1985 Jun;201(6):785-92. doi: 10.1097/00000658-198506000-00017.
A 5-year experience with 562 carotid endarterectomies, using electroencephalogram (EEG) monitoring and selective shunting, was reviewed. EEG changes occurred in 102 patients (18%). The frequency of EEG changes, as related to cerebral vascular symptoms, was as follows: transient ischemic attacks, seven per cent (19/259); completed strokes, 37% (36/98); vertebral basilar insufficiency, 24% (32/135); asymptomatic, 21% (15/71). Patients with contralateral carotid occlusion exhibited EEG changes in 37% (28/76) of operations. Fifteen patients suffered perioperative strokes (2.6%). Nine of the 15 were associated with a technical problem of either thrombosis of the internal carotid artery (five) or emboli (four). Technical problems were more common when shunts were used (five per cent) than when they were not (0.9%). Patients who suffered strokes prior to surgery were more at risk to develop a perioperative stroke (three per cent) than those not suffering prior strokes (0.3%). The EEG did not change in three patients who had lacunar infarcts prior to surgery and who awoke with a worsened deficit. Our series does not clearly establish the advantages of EEG monitoring, which is expensive (+375/patient) and may not detect ischemia in all areas of the brain. However, the use of shunts may introduce a risk of stroke due to technical error that is equal or greater than the risk of stroke due to hemodynamic ischemia. Since the need for protection is unpredictable by angiographic or clinical criteria, the benefit of EEG monitoring may be in reducing the incidence of shunting in those patients whose tracing remains normal after clamping. The decision to shunt, however, when there is electrical dysfunction after carotid clamping should be based not only on the EEG but also on the clinical signs and computed tomography (CT) scan. Our data does not show a net benefit in selective shunting unless the patient has sustained a stroke prior to surgery.
回顾了562例颈动脉内膜切除术的5年经验，术中使用了脑电图（EEG）监测和选择性分流。102例患者（18%）出现了脑电图变化。与脑血管症状相关的脑电图变化频率如下：短暂性脑缺血发作，7%（19/259）；完全性卒中，37%（36/98）；椎基底动脉供血不足，24%（32/135）；无症状，21%（15/71）。对侧颈动脉闭塞的患者在37%（28/76）的手术中出现脑电图变化。15例患者发生围手术期卒中（2.6%）。15例中有9例与技术问题有关，即颈内动脉血栓形成（5例）或栓子（4例）。使用分流时技术问题比不使用时更常见（5%）（不使用时为0.9%）。术前发生过卒中的患者发生围手术期卒中的风险（3%）高于未发生过术前卒中的患者（0.3%）。3例术前有腔隙性梗死且醒来后神经功能缺损加重的患者脑电图未发生变化。我们的系列研究并未明确证实脑电图监测的优势，该监测费用昂贵（每位患者+375美元），且可能无法检测到脑所有区域的缺血情况。然而，使用分流可能因技术失误而带来卒中风险，这种风险等于或大于血流动力学缺血导致的卒中风险。由于通过血管造影或临床标准无法预测是否需要保护，脑电图监测的益处可能在于减少那些夹闭后脑电图追踪仍正常的患者的分流发生率。然而，当颈动脉夹闭后出现电功能障碍时，是否进行分流的决定不仅应基于脑电图，还应基于临床体征和计算机断层扫描（CT）。除非患者术前已发生卒中，否则我们的数据并未显示选择性分流有净益处。
