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Arterial Blood Pressure Management During Carotid Endarterectomy and Early Cognitive Dysfunction

Heyer, Eric J. MD, PhD*,‡; Mergeche, Joanna L. BA*; Anastasian, Zirka H. MD*; Kim, Minjae MD*; Mallon, Kaitlin A. BA*; Connolly, E. Sander MD‡,§

doi: 10.1227/NEU.0000000000000256
Research-Human-Clinical Studies

BACKGROUND: A common practice during cross-clamp of carotid endarterectomy (CEA) is to manage mean arterial pressure (MAP) above baseline to optimize the collateral cerebral blood flow and reduce the risk of ischemic stroke.

OBJECTIVE: To determine whether MAP management ≥20% above baseline during cross-clamp is associated with lower risk of early cognitive dysfunction, a subtler form of neurological injury than stroke.

METHODS: One hundred eighty-three patients undergoing CEA were enrolled in this ad hoc study. All patients had radial arterial catheters placed before the induction of general anesthesia. MAP was managed at the discretion of the anesthesiologist. All patients were evaluated with a battery of neuropsychometric tests preoperatively and 24 hours postoperatively.

RESULTS: Overall, 28.4% of CEA patients exhibited early cognitive dysfunction (eCD). Significantly fewer patients with MAP ≥20% above baseline during cross-clamp exhibited eCD than those managed <20% above (11.6% vs 38.6%, P < .001). In a multivariate logistic regression model, MAP ≥20% above baseline during the cross-clamp period was associated with significantly lower risk of eCD (odds ratio [OR], 0.18 [0.07-0.40], P < .001), whereas diabetes mellitus (OR, 2.73 [1.14-6.61], P = .03) and each additional year of education (OR, 1.19 [1.06-1.34], P = .003) were associated with significantly higher risk of eCD.

CONCLUSION: The observations of this study suggest that MAP management ≥20% above baseline during cross-clamp of the carotid artery may be associated with lower risk of eCD after CEA. More prospective work is necessary to determine whether MAP ≥20% above baseline during cross-clamp can improve the safety of this commonly performed procedure.

ABBREVIATIONS: CABG, coronary artery bypass graft

CEA, carotid endarterectomy

eCD, early cognitive dysfunction

EEG, electroencephalography

MAP, mean arterial pressure

MI, myocardial infarction

OR, odds ratio

PVD, peripheral vascular disease

SD, standard deviation

*Department of Anesthesiology, Columbia University, New York, New York;

Department of Neurology, Columbia University, New York, New York;

§Department of Neurological Surgery, Columbia University, New York, New York

Correspondence: Eric J. Heyer, MD, PhD, Department of Anesthesiology, Columbia University, 630 W 168th St, P&S Box 46, New York, NY 10032. E-mail:

Received August 27, 2013

Accepted November 14, 2013

Copyright © by the Congress of Neurological Surgeons