Neuroprotection During Carotid Endarterectomy

Abstract

The goal of neuroprotection during carotid endarterectomy is a reduction in the frequency and severity of perioperative stroke. This includes cerebral ischemic events secondary to hypoperfusion during cross clamping, emboli, or both. However, rational use of protective techniques requires that patients at risk first be identified. This process begins with a thorough preoperative assessment, including neurological status and angiographic findings. lntraoperative monitoring is the next step in the identification. This can include the awake patient, electroencephalogram, transcranial Doppler, stump pressure or combinations of these. Unfortunately, evidence is lacking to demonstrate that any of these modalities is superior to another or to no monitoring at all. Finally, when a patient is at risk, a protective technique needs to be chosen. The use of surgical shunt placement has received mixed acceptance from surgeons performing these procedures. Barbiturate coma and anticoagulation may offer benefit but come with inherent risks as well. Maintenance of a high mean arterial pressure with vasopressors and fluids may also help improve collateral flow.