Cerebral Perfusion and Cerebral Protection during Carotid Endarterectomy

McMeniman, W. J.; Kam, P. C. A.

doi:10.1177/0310057x8301100308

Cited by 7 publications

(4 citation statements)

References 61 publications

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“…In the only randomized controlled human trial to date, Nussmeier et al showed a decrease in neuropsychiatric impairment in patients who had EEG burst suppression induced by thiopentone prior to warm cardiopulmonary bypass for cardiac surgery 10 . Two large prospective series have reported good results using thiopentone titrated to burst suppression in place of bypass shunting for CEA 11,12 . Frawley et al reported a stroke rate of 1.7% in 621 patients treated this way 12 and later in the same series a stroke rate of 1.2% in 259 patients with associated contralateral carotid stenosis 13 .…”

Section: Discussionmentioning

confidence: 99%

Cerebral Protection with Thiopentone during Combined Carotid Endarterectomy and Clipping of Intracranial Aneurysm

McConkey

Kien

2002

Anaesth Intensive Care

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We report a case of carotid endarterectomy and clipping of an ipsilateral internal carotid artery aneurysm in a patient with complete contralateral carotid stenosis. The patient developed an ischaemic electroencephalographic (EEG) tracing on temporary carotid clamping and bypass shunt was contraindicated. We used thiopentone titrated to EEG burst suppression for pharmacological cerebral protection during the subsequent prolonged carotid clamp necessary for carotid endarterectomy. We review the use of thiopentone for this purpose, in particular the evidence for efficacy, mechanism of action and optimal dosage and timing of administration.

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Section: Discussionmentioning

confidence: 99%

Cerebral Protection with Thiopentone during Combined Carotid Endarterectomy and Clipping of Intracranial Aneurysm

McConkey

Kien

2002

Anaesth Intensive Care

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“…Failure to restore cortical EEG to precross-clamp status with hypertensive therapy would prompt the initiation of pharmacological burst-suppression for neuroprotection while avoiding intraluminal shunting altogether. 48 Evidence supporting this approach is mostly based on large case series. [49][50][51][52][53][54] To date, there has been no prospective randomized study to compare the efficacy of pharmacological burst-suppression in preventing perioperative stroke to routine shunting and/or selective shunting in the setting of CEA, although these case series have www.anesthesia-analgesia.org…”

Section: Cerebral Protection In Carotid Surgerymentioning

confidence: 99%

Electroencephalographic Burst-Suppression, Perioperative Neuroprotection, Postoperative Cognitive Function, and Mortality: A Focused Narrative Review of the Literature

Ma¹,

Bebawy

2021

Anesthesia &Amp; Analgesia

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Burst-suppression is an electroencephalographic pattern that results from a diverse array of pathophysiological causes and/or metabolic neuronal suppression secondary to the administration of anesthetic medications. The purpose of this review is to provide an overview of the physiological mechanisms that underlie the burst-suppression pattern and to present in a comprehensive way the available evidence both supporting and in opposition to the clinical use of this electroencephalographic pattern as a therapeutic measure in various perioperative settings. (Anesth Analg 2022;135:79-90) GLOSSARY ACNS = American Clinical Neurophysiology Society; ADAPT-2 = Anesthetic Depth and Postoperative Delirium Trial-2; ATP = adenosine triphosphate; [ATP] I = intracellular ATP concentration; BIS = bispectral index; BSR = burst-suppression ratio; CBF = cerebral blood flow; CEA = carotid endarterectomy; CI = confidence interval; CMRO2 = cerebral metabolic rate of oxygen consumption; CPB = cardiopulmonary bypass; CV = cardiovascular; EEG = electroencephalogram; ENGAGES = Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes; ET = end-tidal; GABA = gamma-aminobutyric acid; GOS = Glasgow Outcome Scale; HR = hazard ratio; IAR = intraoperative aneurysm rupture; ICP = intracranial pressure; ICU = intensive care unit; K ATP = ATPgated potassium channels; MAC = minimum alveolar concentration; MAP = mean arterial pressure; OR = odds ratio; PACU = postanesthetic care unit; PD = postoperative delirium; pEEG = processed EEG; POD = postoperative day; RCT = randomized controlled trial; TC = temporary clip Basic, Clinical and Systems Neuroscience

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“…They have displayed beneficial cerebral effects while performing CEA without adverse cardiovascular outcomes (63,64). They reduce oxygen demand throughout relative tissue ischemia induced by arterial clamping (65,66). Thiopentone has also been demonstrated to provide cerebral protection during CEA and intracranial aneurysm clipping (67).…”

Section: Barbiturate Infusionmentioning

confidence: 99%

A pilot protocol and review of triple neuroprotection with targeted hypothermia, controlled induced hypertension, and barbiturate infusion during emergency carotid endarterectomy for acute stroke after failed tPA or beyond 24-hour window of opportunity

Sultan¹,

Acharya²,

Barrett³

et al. 2020

Ann Transl Med

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An alternative to tissue plasminogen activator (tPA) failure has been a daunting challenge in ischemic stroke management. As tPA is time-dependent, delays can occur in definitive treatment while passively waiting to observe a clinical response to intravenous thrombolysis. Until today, uncertainty exists in the management strategy of wake-up stroke patients or those presenting beyond the therapeutic tPA window.Clinical dilemmas in these situations can prolong the transitional period of inertia, resulting in an adverse neurological outcome. We propose and review an innovative approach called triple neuro-protection (TNP), which encompasses three technical domains-targeted hypothermia, systemic induced hypertension, and barbiturates infusion, to protect the brain during carotid endarterectomy after failed tPA and/or beyond the 24-hour therapeutic mechanical thrombectomy window. This proposal assimilates discussion on the clinical evidence of the individual domains of TNP with our own clinical experience with TNP. Our first TNP was successfully employed in a 55-year-old man in 2015 while performing emergency carotid endarterectomy after he was referred to us 72 hours post tPA failure. The patient had a successful clinical outcome despite being in therapeutic inertia with 90-99% ipsilateral carotid stenosis and contralateral occlusion on presentation. In the last five years, we have safely used TNP in 25 selected cases with favourable clinical outcomes.

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Cerebral Perfusion and Cerebral Protection during Carotid Endarterectomy

Cited by 7 publications

References 61 publications

Cerebral Protection with Thiopentone during Combined Carotid Endarterectomy and Clipping of Intracranial Aneurysm

Cerebral Protection with Thiopentone during Combined Carotid Endarterectomy and Clipping of Intracranial Aneurysm

Electroencephalographic Burst-Suppression, Perioperative Neuroprotection, Postoperative Cognitive Function, and Mortality: A Focused Narrative Review of the Literature

A pilot protocol and review of triple neuroprotection with targeted hypothermia, controlled induced hypertension, and barbiturate infusion during emergency carotid endarterectomy for acute stroke after failed tPA or beyond 24-hour window of opportunity

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