Limitations of median nerve somatosensory evoked potential monitoring during carotid endarterectomy

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OBJECTIVE

Hypoperfusion during carotid artery cross-clamping (CC) for carotid endarterectomy (CEA) may result in the major complication of perioperative stroke. Median nerve somatosensory evoked potential (MNSSEP) monitoring, which is an established method for the prediction of cerebral ischemia, has low sensitivity in detecting such hypoperfusion. In this study the authors sought to explore the limitations of MNSSEP monitoring compared to tibial nerve somatosensory evoked potential (TNSSEP) monitoring for the detection of CC-related hypoperfusion.

METHODS

The authors retrospectively analyzed data from patients who underwent unilateral CEA with routine shunt use. All patients underwent preoperative magnetic resonance angiography and were monitored for intraoperative cerebral ischemia by using MNSSEP, TNSSEP, and carotid stump pressure during CC. First, the frequency of MNSSEP and TNSSEP changes during CC were analyzed. Subsequently, variables related to stump pressure were determined by using linear analysis and those related to each of the somatosensory evoked potential (SSEP) changes were determined by using logistic regression analysis.

RESULTS

A total of 94 patients (mean age 74 years) were included in the study. TNSSEP identified a greater number of SSEP changes during CC than MNSSEP (20.2% vs 11.7%; p < 0.05). Linear regression analysis demonstrated that hypoplasia of the contralateral proximal segment of the anterior cerebral artery (A1 hypoplasia) (p < 0.01) and hypoplasia of the ipsilateral precommunicating segment of the posterior cerebral artery (P1 hypoplasia) (p = 0.02) independently and negatively correlated with stump pressure. Both contralateral A1 hypoplasia (OR 26.25, 95% CI 4.52–152.51) and ipsilateral P1 hypoplasia (OR 8.75, 95% CI 1.83–41.94) were independently related to the TNSSEP changes. However, only ipsilateral P1 hypoplasia (OR 8.76, 95% CI 1.61–47.67) was independently related to MNSSEP changes.

CONCLUSIONS

TNSSEP monitoring appears to be superior to MNSSEP in detecting CC-related hypoperfusion. Correlation with stump pressure and SSEP changes indicates that TNSSEP, and not MNSSEP monitoring, is a reliable indicator of cerebral ischemia in the territory of the anterior cerebral artery.

ABBREVIATIONS ACA = anterior cerebral artery; ACoA = anterior communicating artery; CC = carotid artery cross-clamping; CEA = carotid endarterectomy; MNSSEP = median nerve somatosensory evoked potential; MRA = magnetic resonance angiography; PCoA = posterior communicating artery; SSEP = somatosensory evoked potential; TIA = transient ischemic attack; TNSSEP = tibial nerve somatosensory evoked potential.

Article Information

Correspondence Sumito Okuyama: Southern Tohoku General Hospital, Iwanuma, Japan. okuyama.sumito@gmail.com.

INCLUDE WHEN CITING Published online September 7, 2018; DOI: 10.3171/2018.4.JNS171784.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Venn diagram illustrating the distributions of the patients who showed changes with either MNSSEP or TNSSEP monitoring or with both methods. *Significantly different from zero (p < 0.05).

  • View in gallery

    Forest plot demonstrating the association of SSEP changes and clinical variables.

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