Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Case Reports
. 2022 Aug 31;22(1):325.
doi: 10.1186/s12883-022-02835-7.

Perioperative stroke during carotid endarterectomy: benefits of multimodal neuromonitoring - a case report

D M Michels  1 , L C Van Dijk  2 , D L J Tavy  3
Affiliations
Case Reports

Perioperative stroke during carotid endarterectomy: benefits of multimodal neuromonitoring - a case report

D M Michels et al. BMC Neurol. .

Abstract

Background: Carotid endarterectomy is routinely performed after ischemic stroke due to carotid stenosis. Perioperative, cerebral blood flow and oxygenation can be monitored in different ways, but there is no clear evidence of a gold standard and a uniform guideline is lacking. Electroencephalography and near-infrared spectroscopy are among the most frequently used methods of neuromonitoring. Clinicians should be aware of their pitfalls and the added value of transcranial doppler.

Case presentation: We present the case of an 85-year old male with perioperative haemodynamic stroke during carotid endarterectomy. Ischemic stroke was caused by suddenly increased carotid stenosis resulting in major neurologic deficit. This was registered only by transcranial doppler, while surface electroencephalography and near-infrared spectroscopy failed to detect any significant change in cerebral perfusion, despite a large perfusion defect on computed tomography. Circulation was restored with endovascular treatment and neurologic deficit quickly resolved.

Conclusion: We strongly advocate the practice of multimodal neuromonitoring including transcranial doppler whenever possible to minimize the risk of persistent neurologic deficit due to perioperative stroke during carotid endarterectomy.

Keywords: Carotid endarterectomy; Case report; Electroencephalography; Monitoring; Near-infrared spectroscopy; Transcranial doppler.

PubMed Disclaimer

Conflict of interest statement

The authors report no competing interests.

Figures

Fig. 1
Fig. 1
Pre- and postoperative contrast enhanced computed tomography of left ICA stenosis (white arrow). A Pre-operative axial view, graded 60–70% using NASCET criteria. B Pre-operative sagittal view. C Postoperative near occlusion of the left ICA with postoperative subcutaneous emphysema, axial view. D Postoperative sagittal view
Fig. 2
Fig. 2
Perioperative transcranial doppler (TCD) signal of the left middle cerebral artery. A Before dissection, mean velocity 70 cm/s. B During dissection, mean velocity 13 cm/s (> 80% decrease compared to the start of procedure)
Fig. 3
Fig. 3
Postoperative computed tomography perfusion imaging showing a large perfusion defect of the entire anterior circulation of the left hemisphere consistent with hypoperfusion due to severe carotid artery stenosis. A Cerebral blood volume. B Cerebral blood flow. C Time to peak. D Mean transit time. Decreased cerebral blood flow with normal cerebral blood volume indicate a small infarct core and large penumbra, e.g. salvageable tissue
Fig. 4
Fig. 4
Carotid artery angioplasty and stenting. A Left internal carotid artery with near occlusion (white arrow). B Restored flow after carotid artery stenting. C Angiography post-stenting showing no occlusions of the distal middle cerebral artery territory
See this image and copyright information in PMC

References

    1. Ferguson GG, Eliaszim M, Barr HWK, et al. The north American symptomatic carotid endarterectomy trial surgical results in 1415 patients. Stroke. 1999;30(9):1751–1758. doi: 10.1161/01.STR.30.9.1751. - DOI - PubMed
    1. Chongruksut W, Vaniyapong T, Rerkasem K. Routine or selective carotid artery shunting for carotid endarterectomy (and different methods of monitoring in selective shunting). Cochrane Database Syst Rev. 2014;6. - PMC - PubMed
    1. Pennekamp CWA, Moll FL, de Borst GJ. The potential benefits and the role of cerebral monitoring in carotid endarterectomy. Curr Opin Anaesthesiol. 2011;24:693–697. doi: 10.1097/ACO.0b013e32834c7aa1. - DOI - PubMed
    1. Rothwell PM. Medical and surgical management of symptomatic carotid stenosis. Int J Stroke. 2006;1:140–149. doi: 10.1111/j.1747-4949.2006.00047.x. - DOI - PubMed
    1. Cina CS, Clase CM, Haynes BR. Refining the indications for carotid endarterectomy in patients with symptomatic carotid stenosis: a systematic review. J Vasc Surg. 1999;30:606–17. doi: 10.1016/S0741-5214(99)70100-X. - DOI - PubMed

Publication types

MeSH terms