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Original communication

Efficacy of near-infrared spectroscopy cerebral oximetry on detection of critical cerebral perfusion during carotid endarterectomy under regional anesthesia

Published Online:June 08, 2020https://doi.org/10.1024/0301-1526/a000879

Abstract

Summary:Background: Patients undergoing carotid endarterectomy (CEA) may suffer from cerebral hypoperfusion during the carotid cross-clamping. Near-infrared spectroscopy cerebral oximetry (NIRS) is a non-invasive method of regional cerebral oxygen saturation measurement reflecting changes in cerebral blood flow during CEA. The main goal of the study was to evaluate the accuracy of the NIRS in detecting cerebral hypoperfusion during CEA under regional anesthesia (RA) and compare it with awake neurological testing. Patients and methods: A prospective observational study of 28 patients that underwent CEA in RA and manifested neurologic deficits, and 28 consecutive controls from a tertiary and referral center, was performed. All patients were monitored with NIRS cerebral oximetry and awake testing as the control technique. Subsequently, operating characteristic curve and Cohen’s kappa coefficient were determined to evaluate the reliability of the monitoring test. Results: NIRS presented a sensitivity of 27.3% and a specificity of 89.3% in comparison to awake testing. Receiver operating characteristic (ROC) curve analysis demonstrated that a decrease of at least 20% in cerebral oxygen saturation is the best threshold to infer cerebral hypoperfusion. However, the respective area under the curve (AUROC) was 0.606 (95% CI: 0.456–0.756, P = 0.178) with a calculated Cohen’s kappa of 0.179, P = 0.093. Regarding 30-days outcomes, only awake testing has shown significant associations with stroke and postoperative complications (P = 0.043 and P = 0.05), which were higher in patients with post-clamping neurologic deficits. Conclusions: NIRS demonstrated a reduced discriminative capacity for critical cerebral hypoperfusion, and does not seem to add substantial clinical benefits to the awake test.

References

  • 1 Naylor AR, Ricco JB, de Borst GJ, Debus S, de Haro J, Halliday A, et al. Editorʼs choice – Management of atherosclerotic carotid and vertebral artery disease: 2017 clinical practice guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2018;55(1):3–81. First citation in articleCrossref Medline, Google Scholar

  • 2 Sharpe RY, Dennis MJ, Nasim A, McCarthy MJ, Sayers RD, London NJ, et al. Dual antiplatelet therapy prior to carotid endarterectomy reduces post-operative embolisation and thromboembolic events: Post-operative transcranial Doppler monitoring is now unnecessary. Eur J Vasc Endovasc Surg. 2010;40(2):162–7. First citation in articleCrossref Medline, Google Scholar

  • 3 Li J, Shalabi A, Ji F, Meng L. Monitoring cerebral ischemia during carotid endarterectomy and stenting. J Biomed Res. 2017;31(1):11–16. First citation in articleGoogle Scholar

  • 4 Wolf O, Heider P, Heinz M, Poppert H, Sander D, Greil O, et al. Microembolic signals detected by transcranial Doppler sonography during carotid endarterectomy and correlation with serial diffusion-weighted imaging. Stroke. 2004;35(11):e373–5. First citation in articleCrossref Medline, Google Scholar

  • 5 Wang Y, Li L, Wang T, Zhao L, Feng H, Wang Q, et al. The efficacy of near-infrared spectroscopy monitoring in carotid endarterectomy: A prospective, single-center, observational study. Cell Transplant. 2019;28(2):170–5. First citation in articleCrossref Medline, Google Scholar

  • 6 Lewis SC, Warlow CP, Bodenham AR, Colam B, Rothwell PM, Torgerson D, et al. General anaesthesia versus local anaesthesia for carotid surgery (GALA): A multicentre, randomised controlled trial. Lancet. 2008;372(9656):2132–42. First citation in articleCrossref Medline, Google Scholar

  • 7 Ali AM, Green D, Zayed H, Halawa M, El-Sakka K, Rashid HI. Cerebral monitoring in patients undergoing carotid endarterectomy using a triple assessment technique. Interact Cardiovasc Thorac Surg. 2011;12(3):454–7. First citation in articleCrossref Medline, Google Scholar

  • 8 Murkin JM, Arango M. Near-infrared spectroscopy as an index of brain and tissue oxygenation. Br J Anaesth. 2009;103(Suppl 1):i3–13. First citation in articleCrossref Medline, Google Scholar

  • 9 Ritter JC, Green D, Slim H, Tiwari A, Brown J, Rashid H. The role of cerebral oximetry in combination with awake testing in patients undergoing carotid endarterectomy under local anaesthesia. Eur J Vasc Endovasc Surg. 2011;41(5):599–605. First citation in articleCrossref Medline, Google Scholar

  • 10 Texakalidis P, Giannopoulos S, Kokkinidis DG, Jabbour P, Reavey-Cantwell J. Rangel-Castilla L. Outcome of carotid artery endarterectomy in statin users versus statin-naive patients: A systematic review and meta-analysis. World Neurosurg. 2018;116:444––50e1. First citation in articleCrossref Medline, Google Scholar

  • 11 Kilickap G, Ergun E, Basbay E, Kosar P, Kosar U. Carotid stenosis evaluation by 64-slice CTA: Comparison of NASCET, ECST and CC grading methods. Int J Cardiovasc Imaging. 2012;28(5):1257–66. First citation in articleCrossref Medline, Google Scholar

  • 12 von Reutern GM, Goertler MW, Bornstein NM, Del Sette M, Evans DH, Hetzel A, et al. Grading carotid stenosis using ultrasonic methods. Stroke. 2012;43(3):916–21. First citation in articleCrossref Medline, Google Scholar

  • 13 Rozeman AD, Hund H, Westein M, Wermer MJH, Lycklama ANGJ, Boiten J, et al. Duplex ultrasonography for the detection of vertebral artery stenosis: A comparison with CT angiography. Brain Behav. 2017;7(8):e00750. First citation in articleCrossref Medline, Google Scholar

  • 14 von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: Guidelines for reporting observational studies. Int J Surg. 2014;12(12):1495–9. First citation in articleCrossref Medline, Google Scholar

  • 15 Timaran CH, McKinsey JF, Schneider PA, Littooy F. Reporting standards for carotid interventions from the Society for Vascular Surgery. J Vasc Surg. 2011;53(6):1679–95. First citation in articleCrossref Medline, Google Scholar

  • 16 Stoneham MD, Stamou D, Mason J. Regional anaesthesia for carotid endarterectomy. Br J Anaesth. 2015;114(3):372–83. First citation in articleCrossref Medline, Google Scholar

  • 17 Pereira-Macedo J, Rocha-Neves JP, Dias-Neto MF, Andrade JPV. Prognostic effect of troponin elevation in patients undergoing carotid endarterectomy with regional anesthesia – A prospective study. Int J Surg. 2019;71:66–71. First citation in articleCrossref Medline, Google Scholar

  • 18 Kondov S, Beyersdorf F, Schöllhorn J, Benk C, Rylski B, Czerny M, et al. Outcome of near-infrared spectroscopy-guided selective shunting during carotid endarterectomy in General Anesthesia. Ann Vasc Surg. 2019;61:170–7. First citation in articleCrossref Medline, Google Scholar

  • 19 Vieira-Andrade JD, Rocha-Neves JP, Macedo JP, Dias-Neto MF. Onset of neurological deficit during carotid clamping with carotid endarterectomy under regional anesthesia is not a predictor of carotid restenosis. Ann Vasc Surg. 2019;61:193–202. First citation in articleCrossref Medline, Google Scholar

  • 20 Pennekamp CW, Bots ML, Kappelle LJ, Moll FL, de Borst GJ. The value of near-infrared spectroscopy measured cerebral oximetry during carotid endarterectomy in perioperative stroke prevention. A review. Eur J Vasc Endovasc Surg. 2009;38(5):539–45. First citation in articleCrossref Medline, Google Scholar

  • 21 Pini R, Faggioli G, Vacirca A, Dieng M, Goretti M, Gallitto E, et al.. The benefit of deferred carotid revascularization in patients with moderate-severe disabling cerebral ischemic stroke. J Vasc Surg. 2020;S0741–5214(20):30597–8. First citation in articleGoogle Scholar

  • 22 Stilo F, Spinelli F, Martelli E, Pipito N, Barilla D, De Caridi G, et al. The sensibility and specificity of cerebral oximetry, measured by INVOS-4100, in patients undergoing carotid endarterectomy compared with awake testing. Minerva Anestesiol. 2012;78(10):1126–35. First citation in articleMedline, Google Scholar

  • 23 Kardassis D, Schonander M, Sjostrom L, Karason K. Carotid artery remodelling in relation to body fat distribution, inflammation and sustained weight loss in obesity. J Intern Med. 2014;275(5):534–43. First citation in articleCrossref Medline, Google Scholar

  • 24 Kamenskaya OV, Loginova IY, Lomivorotov VV. Brain oxygen supply parameters in the risk assessment of cerebral complications during carotid endarterectomy. J Cardiothorac Vasc Anesth. 2017;31(3):944–9. First citation in articleCrossref Medline, Google Scholar

  • 25 Mille T, Tachimiri ME, Klersy C, Ticozzelli G, Bellinzona G, Blangetti I, et al. Near infrared spectroscopy monitoring during carotid endarterectomy: Which threshold value is critical? Eur J Vasc Endovasc Surg. 2004;27(6):646–50. First citation in articleCrossref Medline, Google Scholar

  • 26 Gough MJ. Comments regarding “the role of cerebral oximetry in combination with awake testing in patients undergoing carotid endarterectomy under local anaesthesia”. Eur J Vasc Endovasc Surg. 2011;41(5):606. First citation in articleCrossref Medline, Google Scholar

  • 27 Jonsson M, Lindstrom D, Wanhainen A, Djavani Gidlund K, Gillgren P. Near infrared spectroscopy as a predictor for shunt requirement during carotid endarterectomy. Eur J Vasc Endovasc Surg. 2017;53(6):783–91. First citation in articleCrossref Medline, Google Scholar

  • 28 Moritz S, Kasprzak P, Arlt M, Taeger K, Metz C. Accuracy of cerebral monitoring in detecting cerebral ischemia during carotid endarterectomy: A comparison of transcranial Doppler sonography, near-infrared spectroscopy, stump pressure, and somatosensory evoked potentials. Anesthesiology. 2007;107(4):563–9. First citation in articleCrossref Medline, Google Scholar

  • 29 Pedrini L, Magnoni F, Sensi L, Pisano E, Ballestrazzi MS, Cirelli MR, et al. Is near-infrared spectroscopy a reliable method to evaluate clamping ischemia during carotid surgery? Stroke Res Treat. 2012;2012:156975. First citation in articleMedline, Google Scholar

  • 30 Tosh W, Patteril M, Cerebral oximetry. BJA Education. 2016;16(12):417–21. First citation in articleCrossref, Google Scholar

  • 31 McCleary AJ, Maritati G, Gough MJ. Carotid endarterectomy; local or general anaesthesia? Eur J Vasc Endovasc Surg. 2001;22(1):1–12. First citation in articleCrossref Medline, Google Scholar

  • 32 Uhrig L, Dehaene S, Jarraya B. Cerebral mechanisms of general anesthesia. Ann Fr Anesth Reanim. 2014;33(2):72–82. First citation in articleCrossref Medline, Google Scholar

  • 33 Mergeche JL, Bruce SS, Sander Connolly E, Heyer EJ. Reduced middle cerebral artery velocity during cross-clamp predicts cognitive dysfunction after carotid endarterectomy. J Clin Neurosci. 2014;21(3):406–11. First citation in articleCrossref Medline, Google Scholar

  • 34 Choi BM, Park SK, Shin S, Cho YP, Kwon TW, Choi YJ, et al. Neurologic derangement and regional cerebral oxygen desaturation associated with patency of the circle of Willis during carotid endarterectomy. J Cardiothorac Vasc Anesth. 2015;29(5):1200–5. First citation in articleCrossref Medline, Google Scholar

  • 35 Kawamata T, Okada Y, Kawashima A, Yoneyama T, Yamaguchi K, Ono Y, et al. Postcarotid endarterectomy cerebral hyperperfusion can be prevented by minimizing intraoperative cerebral ischemia and strict postoperative blood pressure control under continuous sedation. Neurosurgery. 2009;64(3):447–53. First citation in articleCrossref Medline, Google Scholar