thiopental and Carotid-Stenosis

The aim of this study is to establish the initial safety of triple neuroprotection (TNP) in an acute stroke setting in patients presenting outside the window for systemic tissue plasminogen activator (tPA).. Over 12,000 patients were referred to our vascular services with carotid artery disease, of whom 832 had carotid intervention with a stroke rate of 0.72%. Of these, 25 patients presented (3%), between March 2015 and 2019, with acute dense stroke. These patients had either failed tPA or passed the recommended timing for acute stroke intervention. Fifteen (60%) had hemi-neglect with evidence of acute infarct on magnetic resonance imaging of the brain and a Rankin score of 4 or 5. Ninety-six percent had an 80-99% stenosis on the symptomatic side. Mean ABCD3-I score was 11.35. All patients underwent emergency carotid endarterectomy (CEA) with therapeutically induced hypothermia (32-34°C), targeted hypertension (systolic blood pressure 180-200 mm Hg), and brain suppression with barbiturate.. There were no cases of myocardial infarction, death, cranial nerve injury, wound hematoma, or procedural bleeding. Mean hospital stay was 8.4 (±9.5) days. All cases had resolution of neurological symptoms, except 3 who had failed previous thrombolysis. Eighty percent had a postoperative Rankin score of 0 on discharge and 88% of patients were discharged home with 3 requiring rehabilitation.. Positive neurological outcomes and no serious adverse events were observed using TNP during emergency CEA in patients with acute brain injury. We recommend TNP for patients who are at an increased risk of stroke perioperatively, or who have already suffered from an acute stroke beyond the recommended window of 24 hr. Certainly, the positive outcomes are not likely reproducible outside of high-volume units and patients requiring this surgery should be transferred to experienced surgeons in appropriate tertiary referral centers.

Topics: Aged; Aged, 80 and over; Carotid Stenosis; Databases, Factual; Emergencies; Endarterectomy, Carotid; Female; Humans; Hypertension; Hypothermia, Induced; Infusions, Intravenous; Length of Stay; Male; Middle Aged; Neuroprotective Agents; Pilot Projects; Retrospective Studies; Risk Factors; Stroke; Thiopental; Time Factors; Time-to-Treatment; Treatment Outcome

We report a case of carotid endarterectomy and clipping of an ipsilateral internal carotid artery aneurysm in a patient with complete contralateral carotid stenosis. The patient developed an ischaemic electroencephalographic (EEG) tracing on temporary carotid clamping and bypass shunt was contraindicated. We used thiopentone titrated to EEG burst suppression for pharmacological cerebral protection during the subsequent prolonged carotid clamp necessary for carotid endarterectomy. We review the use of thiopentone for this purpose, in particular the evidence for efficacy, mechanism of action and optimal dosage and timing of administration.

Topics: Brain Ischemia; Carotid Artery, Internal; Carotid Stenosis; Constriction; Electroencephalography; Endarterectomy, Carotid; Female; Humans; Hypnotics and Sedatives; Intracranial Aneurysm; Intraoperative Complications; Middle Aged; Neuroprotective Agents; Thiopental

The aim of the present study was to investigate the role of potential clinical risk factors in the causation of peri-operative stroke associated with carotid endarterectomy. With the change in carotid endarterectomy practice from the use of a shunt to high-dose thiopental for cerebral protection (a previously undocumented method), it was essential to identify accurately the causes of all perioperative strokes.. A prospective audit was undertaken of 1000 carotid endarterectomies in which the causes and pathology of all peri-operative strokes were documented. The roles of advanced age, female gender, hypertension, previous stroke, contralateral carotid stenosis >70%, and contralateral carotid occlusion as potential causes of peri-operative stroke were defined. Results were statistically analysed using odds ratio and Fisher's exact test.. None of the potential risk factors was statistically significant for peri-operative stroke. Female gender was associated with a significant risk of peri-operative stroke due to operative site thrombosis. Complications at the endarterectomy site were the commonest cause of stroke.. Prospective audit is a useful tool for identifying causes of peri-operative stroke and indicating the need for modifications to surgical clinical management which might improve outcomes for carotid endarterectomy.

Topics: Age Factors; Aged; Anesthetics, Intravenous; Carotid Stenosis; Endarterectomy, Carotid; Female; Humans; Hypertension; Male; Medical Audit; Postoperative Period; Prospective Studies; Risk Factors; Sex Factors; Stroke; Thiopental

The results of carotid endarterectomy can be improved by reducing the perioperative embolic and hemodynamic risks. Electrophysiologic monitoring, although reliable, cannot provide full information. In this study, we report on the combined use of transcranial Doppler (TCD) and electrophysiologic monitoring in 153 patients undergoing 166 carotid endarterectomy procedures. TCD monitoring confirmed the low incidence of intolerance to cross-clamp (1.8%), showing a good correlation with electrophysiologic monitoring. In addition, it frequently showed embolic signals immediately after clamp release, but never during carotid dissection or in the final operative phases. Furthermore, TCD allowed the detection of hyperperfusional flow patterns in four cases, making immediate and aggressive control of arterial pressure possible.

Topics: Aged; Aged, 80 and over; Anesthesia, General; Carotid Stenosis; Cerebrovascular Disorders; Electroencephalography; Endarterectomy, Carotid; Female; Follow-Up Studies; Hemodynamics; Humans; Incidence; Intraoperative Complications; Isoflurane; Male; Middle Aged; Monitoring, Intraoperative; Nitrous Oxide; Postoperative Complications; Succinylcholine; Thiopental; Ultrasonography, Doppler, Transcranial

The purpose of this study was to validate the commonly accepted indicators of risk of ischemic stroke that indicate the necessity for cerebral protection during carotid endarterectomy (CEA), and to examine the efficacy of high-dose thiopentone sodium (thiopental) as a cerebral protection method in patients who are at high risk of intraoperative ischemic stroke.. In a prospective study of 37 CEAs performed for symptomatic stenosis > 70%, functional and clinical indicators of risk of ischemic stroke during carotid cross-clamping were identified. Functional indicators of risk were the development of ischemic electro-encephalogram (EEG) changes and stump pressure < 25 mm Hg. Clinical indicators of risk were previous ischemic hemispheric stroke and severe bilateral disease. These indicators were correlated in all patients, some of whom had two or three coexisting indicators of risk. The EEG and stump pressure were monitored continuously during carotid occlusion in all operations. Carotid occlusion times were recorded. Intraluminal shunting was eliminated in favor of high-dose thiopental cerebral protection in all patients. Neurologic outcome was deemed to measure the efficacy of thiopental protection in patients who are identified to be at risk and, hence, in need of cerebral protection. The validity of the indicators used to identify risk of ischemic stroke during CEA was assessed.. The absolute stroke risk was found to be 29.7% for the whole group (37 patients) and 57.9% in 19 patients who had commonly accepted indications for protective shunting. The correlation of ischemic EEG changes with stump pressure < 25 mm Hg was only 27.3%, whereas the expected correlation based on well-documented reports in the literature was 100%. The lack of correlation may have been related to the prevention of ischemic EEG changes by thiopental. There were no neurologic deficits in the series.. The absence of neurologic deficit in the study indicated that thiopental protection was effective in preventing ischemic stroke in high-risk patients and safely replaced intraluminal shunting.

Topics: Aged; Aged, 80 and over; Blood Pressure; Brain Ischemia; Carotid Arteries; Carotid Stenosis; Cerebrovascular Circulation; Cerebrovascular Disorders; Constriction; Electroencephalography; Endarterectomy, Carotid; Female; Hemodynamics; Humans; Intraoperative Complications; Male; Middle Aged; Monitoring, Intraoperative; Neurologic Examination; Neuroprotective Agents; Prospective Studies; Reproducibility of Results; Risk Assessment; Risk Factors; Thiopental; Time Factors; Treatment Outcome

Intraoperative monitoring of brain function may influence the outcome of carotid endarterectomy (CEA).. We performed transcranial Doppler (TCD) monitoring of middle cerebral artery blood flow velocities (VMCAs) and eight-channel electroencephalographic (EEG) recording simultaneously in 82 patients undergoing CEA. Thiopental narcosis limited EEG interpretation in 11 patients, thus allowing direct comparison of both methods in 71 patients.. There was a significant correlation between VMCA decrease and the frequency of EEG changes after carotid clamping (P < .001). Eight patients (11%) showed a VMCA decrease exceeding 60%, accompanied by EEG changes in 7 patients. Altogether, 16 patients (22%) showed severe or moderate EEG changes. Stenosis or occlusion of the contralateral carotid artery led to an increase of abnormal findings with both monitoring methods, which was, however, significant only for TCD (P < .05). Four patients (4.8%) suffered intraoperative transient ischemic attacks. In 3 of these patients, there were no abnormal findings with either of the methods. The events were thus unpredictable and probably of embolic origin. The fourth patient showed VMCA decrease to 0 and severe EEG changes. Nine patients had severe or moderate EEG changes without significant VMCA decrease and without complications. EEG monitoring alone in these would have led to unnecessary use of a shunt with the increased risk of embolism.. EEG and TCD monitoring are complementary techniques. Their results showed a good overall correlation but with marked differences in the individual patient. TCD monitoring alone was sensitive enough to prevent ischemic intraoperative complications. EEG findings are of limited value when barbiturates are used.

Topics: Aged; Aged, 80 and over; Blood Flow Velocity; Brain Ischemia; Carotid Stenosis; Cerebral Arteries; Cerebrovascular Circulation; Cerebrovascular Disorders; Electroencephalography; Endarterectomy, Carotid; Female; Humans; Hypnotics and Sedatives; Ischemic Attack, Transient; Male; Middle Aged; Monitoring, Intraoperative; Postoperative Complications; Predictive Value of Tests; Retrospective Studies; Thiopental; Treatment Outcome; Ultrasonography, Doppler, Transcranial

This study reports our experience with thiopental sodium (Pentothal) cerebral protection, without intraluminal shunting, during carotid endarterectomy. Only those complications that occurred during surgery or within 30 days of operation have been addressed.. A prospective, unselected, consecutive series of 621 carotid endarterectomies was done during a 7-year period, with electroencephalography-monitored, high-dose Pentothal for cerebral protection.. Five ischemic strokes (0.8%), completion of two strokes-in-evolution (0.3%) and four strokes caused by cerebral hemorrhage (0.6%) occurred in 11 patients in the perioperative (30-day) period, for a combined cerebral morbidity-mortality rate of 1.7%. Four reversible ischemic neurologic deficits (0.6%) and two transient ischemic attacks (0.3%) in six patients produced a transient deficit rate of 0.9%. Symptomatic coronary artery disease coexisted in 37% of the patients but resulted in only five acute myocardial infarctions (0.7%), one of which was fatal (0.1%). Other perioperative complications in 10 patients (1.5%) were associated with the operative procedure. There were no complications directly attributable to the high-dose Pentothal. Prospective data collection has allowed definition of the disease and cause of all cerebral complications.. The complications in this series have been related to surgical and clinical management problems rather than failure of cerebral protection. Cerebral protection with high-dose Pentothal under electroencephalographic control has been effective and complication free.

Topics: Aged; Brain Ischemia; Carotid Stenosis; Electroencephalography; Endarterectomy, Carotid; Female; Humans; Intraoperative Care; Intraoperative Complications; Male; Monitoring, Intraoperative; Morbidity; Postoperative Complications; Prospective Studies; Thiopental