(Stroke. 2000;31:1817.)
© 2000 American Heart Association, Inc.
Original Contributions |
Association of Intraoperative Transcranial Doppler Monitoring Variables With Stroke From Carotid Endarterectomy
From St. Antonius Hospital (R.G.A.A., K.G.M.M., F.L.M., F.E.E.V.), Nieuwegein; Slingeland Hospital (C.J.W.v.d.V.), Doetinchem; Julius Center for General Practice and Patient Oriented Research (A.A.); and the Department of Neurology (A.A.), University Medical Center Utrecht, Utrecht, the Netherlands; and Spencer Technologies (M.P.S.), Seattle, Wash.
Correspondence to R.G.A. Ackerstaff, MD, St. Antonius Hospital, Nieuwegein, Postbus 2500, 3430 EM Nieuwegein, Utrecht, The Netherlands. E-mail knf{at}antonius.net
Background and Purpose—The outcomes of carotid endarterectomy (CEA) are, in addition to patient baseline characteristics, highly dependent on the safety of the surgical procedure. During the successive stages of the operation, transcranial Doppler (TCD) monitoring of the middle cerebral artery (MCA) was used to assess the association of cerebral microembolism and hemodynamic changes with stroke and stroke-related death.
Methods—By use of data pooled from 2 hospitals in the United States and the Netherlands, including 1058 patients who underwent CEA, the association of various TCD emboli and velocity variables with operative stroke and stroke-related death was evaluated by univariable and multivariable logistic regression analyses in combination with receiver operating characteristic (ROC) curve analyses. The impact of basic patient characteristics, such as age, sex, preoperative cerebral symptoms, and ipsilateral and contralateral internal carotid artery stenosis, on the prediction of operative stroke was also evaluated.
Results—We observed 31 patients with ischemic and 8
patients with hemorrhagic operative strokes. Four of these patients
died. Emboli during dissection (odds ratio [OR] 1.5, 95% CI 0.8 to
2.9) and wound closure (OR 2.3, 95% CI 1.2 to 4.4) as well as 
90%
decrease of MCA peak systolic velocity at cross-clamping (OR
3.3, 95% CI 1.3 to 8.5) and 100% increase of the pulsatility index
of the Doppler signal at clamp release (OR 7.1, 95% CI 1.4 to
35.7) were independently associated with stroke. The ROC area of this
model was 0.69. Of the patient characteristics, only preoperative
cerebral ischemia (OR 1.9, 95% CI 1.0 to 3.7) and 70%
ipsilateral internal carotid artery stenosis (OR 0.5, 95% CI
0.2 to 0.9) were associated with stroke. Adding these patient
characteristics to the model, the area under the ROC curve increased to
0.73.
Conclusions—In CEA, TCD-detected microemboli during dissection
and wound closure, 90% MCA velocity decrease at cross-clamping, and
100% pulsatility index increase at clamp release are associated with
operative stroke. In combination with the presence of preoperative
cerebral symptoms and 70% ipsilateral internal carotid artery
stenosis, these 4 TCD monitoring variables reasonably
discriminate between patients with and without operative stroke. This
supports the use of TCD as a potential intraoperative monitoring
modality to alter the surgical technique by enhancing a decrease of the
risk of stroke during or immediately after the operation.
Key Words: carotid endarterectomy • monitoring, intraoperative • stroke • surgery • ultrasonography, Doppler, transcranial
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