Frawley J E, Hicks R G, Gray L J, Niesche J W
Department of Vascular and Transplantation Surgery and Clinical Neurophysiology, Prince Henry Hospital, Sydney, Australia.
J Vasc Surg. 1996 Mar;23(3):421-7. doi: 10.1016/s0741-5214(96)80006-1.
The purpose of this study was to assess the adequacy of thiopental protection against ischemic cerebral damage in patients undergoing carotid endarterectomy for symptomatic stenosis greater than 70% in association with contralateral stenosis greater than 70% or contralateral occlusion.
All patients (n=259) with severe bilateral carotid disease who underwent carotid endarterectomy for symptomatic stenosis greater than 70% were extracted from the database of an ongoing prospective carotid surgery study. Large-dose thiopental sodium without shunting was used for cerebral protection during endarterectomy. Asymmetric electroencephalogram changes during the operation, carotid occlusion time, stroke onset, and neuropathologic outcomes were analyzed.
Three contralateral strokes occurred in the series, producing a cerebral morbidity/mortality rate of 1.2% (major 0.4%, minor 0.8%). Transient morbidity was 1.9% made of two reversible ischemic neurologic deficits and three transient ischemic attacks. New asymmetric electroencephalography changes were seen in 49 (19% patients, one of whom had transient deficit. Average occlusion time was 35 minutes. All strokes occurred within 24 hours of the procedure. Patients with previous stroke and and systemic hypertension seemed at greatest risk, and the contralateral hemisphere was the area at greatest risk. All transient deficits were ipsilateral and related to technical complications rather failed protection.
Thiopental cerebral protection eliminates strokes caused by complications of shunting, prevents ischemic stroke during carotid occlusion for periods up to 67 minutes (average 35 minutes), allows meticulous management of the operative site, may modify or minimize clinical neurologic deficit, and in our experience has rendered intraluminal shunting obsolete.
本研究旨在评估硫喷妥钠对有症状性狭窄大于70%且伴有对侧狭窄大于70%或对侧闭塞的患者行颈动脉内膜切除术时预防缺血性脑损伤的充分性。
从一项正在进行的前瞻性颈动脉手术研究数据库中提取所有因有症状性狭窄大于70%而接受颈动脉内膜切除术的严重双侧颈动脉疾病患者（n = 259）。在动脉内膜切除术中使用大剂量硫喷妥钠且不进行分流以保护大脑。分析手术期间的不对称脑电图变化、颈动脉闭塞时间、卒中发作情况及神经病理学结果。
该系列中发生了3例对侧卒中，脑发病率/死亡率为1.2%（严重0.4%，轻微0.8%）。短暂性发病率为1.9%，由2例可逆性缺血性神经功能缺损和3次短暂性脑缺血发作组成。49例（19%）患者出现新的不对称脑电图变化，其中1例有短暂性缺损。平均闭塞时间为35分钟。所有卒中均发生在手术后24小时内。既往有卒中史和全身性高血压的患者似乎风险最大，对侧半球是风险最大的区域。所有短暂性缺损均为同侧，且与技术并发症而非保护失败有关。
硫喷妥钠脑保护可消除分流并发症引起的卒中，在颈动脉闭塞长达67分钟（平均35分钟）期间预防缺血性卒中，允许对手术部位进行精细处理，可能改变或最小化临床神经功能缺损，并且根据我们的经验已使腔内分流过时。
