Carotid endarterectomy with routine electroencephalography and selective shunting: Influence of contralateral internal carotid artery occlusion and utility in prevention of perioperative strokes

Objective: Carotid endarterectomy (CEA) is associated with a risk of cerebral ischemia during carotid clamping, particularly in the face of contralateral internal carotid artery (ICA) occlusion. We examined the results of CEA with continuous electroencephalography in patients without and with contralateral ICA occlusion. Design and Setting: We reviewed 564 primary CEAs with routine electroencephalography and general anesthesia performed between April 1, 1989, and March 31, 1999, in a community teaching medical center. Main outcome measures were perioperative stroke, temporary lateralizing neurologic deficit, and death. Shunts were placed primarily for significant electroencephalographic changes after carotid clamping but also selectively for contralateral ICA occlusion, prior stroke, or surgeon choice. CEA was performed for asymptomatic disease in 35% of cases. Results: Significant electroencephalographic changes occurred in 16% versus 39% (P < .001) and shunts were placed in 13% versus 55% (P < .001) of patients with patent (n = 507) versus occluded contralateral ICA (n = 57), respectively. The fraction of CEAs with significant electroencephalographic changes during clamping was stable, but shunt use declined slightly over time as our confidence in electroencephalography increased. Patches were placed more often (86% versus 65%; P = .002), but other operative details were similar when the contralateral ICA was occluded. Five early (30 days) strokes (0.9%) and eight early temporary postoperative neurologic events (1.4%) occurred, all ipsilateral to CEA and all after the patient left the operating room with none in patients with contralateral ICA occlusion. Two perioperative deaths occurred, one in a patient without and one in a patient with contralateral ICA occlusion. Neither of these deaths was related to ipsilateral stroke. No increase in stroke rate with decreased shunt use over time was seen. Conclusion: Routine use of electroencephalography was associated with apparent complete elimination of intraoperative strokes and less than 1% risk of perioperative strokes. These observations appear to be true even in the face of contralateral ICA occlusion. Electroencephalography is a sensitive detector of cerebral ischemia and a valuable tool for determination of need for shunting during CEA. Surgeons should consider routine use of electroencephalography and selective shunting for significant electroencephalographic changes with clamping.