Predictors Of Neurological Complications Research Articles

Neurological Screening in Elderly Liver Transplantation Candidates: A Single Center Experience.

Background: Cerebral small vessels disease (cSVD) is an age-related disorder and risk factor for stroke and cognitive/motor impairments. Neurological complications (NCs) are among the causes of adverse outcomes in older liver transplant recipients. This study sought to determine whether cSVD predicts acute NCs in over 65-year-old liver transplant patients. Methods: Data were collected, from a retrospective medical chart review, of 22 deceased donor liver transplant recipients aged 65 years or older with a pre-operative brain magnetic resonance imaging (MRI). We used the Fazekas score (0–3) as a quantitative measurement of the vascular lesion load seen in the MRI. We analyzed all post-operative acute NCs occurring during the hospital stay and any other non-NC. Results: cSVD was recognized in all patients. Neurological complications (NCs) occurred in 18.1% of patients with toxic-metabolic encephalopathy the most frequent diagnosis (13.64%). More severe cSVD was associated with seizures (p = 0.0362), longer hospital stay (p 0.0299), and disability (p 0.0134). In our elderly cohort, hepatic encephalopathy (HE) (p 0.0287) and ascites (p 0.0270) were predictors of NCs after liver transplantation. Ascites and/or variceal bleeding and severity of liver disease were associated with adverse post-operative outcomes. The small sample size limited the statistical analysis power. Conclusions: We present the preliminary data of a single-center retrospective study aimed at understanding the cSVD role on NCs and non-NCs after a liver transplantation in elderly patients. This would encourage a more appropriate multicenter prospective study that will definitely confirm if a neurological screening in old age liver transplant candidates is appropriate.

Predictors of neurological complications in postcardiac surgery: a retrospective study

Predictors of neurological complications in postcardiac surgery: a retrospective study

234. Neurologic complications after adult spinal deformity surgery

<h3>BACKGROUND CONTEXT</h3> Adult spinal deformity (ASD) surgery can entail extensive correction for rigid deformities with an associated risk for neurologic complications. Existing reports of neurologic complications after ASD surgery often utilize multicenter databases with considerable heterogeneity. The rate of recovery at long-term follow-up has been less widely examined. We sought to describe the incidence of neurologic complications and rate of resolution. <h3>PURPOSE</h3> To assess the rate of complete resolution of neurologic complications after ASD surgery. <h3>STUDY DESIGN/SETTING</h3> Retrospective review of prospectively collected database. <h3>PATIENT SAMPLE</h3> This study included 949 patients (Age: 45 ± 24 y; mFI: .41 ± .67; Levels fused: 10 ± 4) underwent ASD surgery. <h3>OUTCOME MEASURES</h3> Outcomes evaluated at a mean of 48.9 months of follow-up were the rate of neurologic complications and resolution of neurologic injury. <h3>METHODS</h3> Neurologic complications were identified and characterized in a cohort of patients undergoing ASD surgery. The rate of resolution of neurologic injury was assessed until long-term follow-up. Strength grading was assessed at each postoperative visit until final follow-up. Patient and surgical risk factors were assessed for their relationship with incurrence of a neurologic complication. <h3>RESULTS</h3> The neurologic complication rate was 18.9% (179/949). Of the 179 neurologic complications, 150 (83.8%) were new onset postoperative radiculopathies with pain or sensory deficit, 21 (11.7%) were radiculopathies with motor deficit, 7 (3.9%) were spinal cord injuries, and 1 (0.6%) was cauda equina syndrome. At final follow-up, 97/179 patients (54.2%) had either complete resolution (n=53, 29.6%) or partial resolution (n=44, 24.6%) of the neurologic injury, and 82 patients had no resolution (45.8%). Of those who had a postoperative motor deficit, mean strength grading at final follow-up was 4.14 ± 1.46. Of the 179 patients, 30 (16.8%) required revision surgery. Age >70, current smoking, revision surgery, higher BMI (28.6 vs 24.3 mg/k2, p<0.0001), higher preoperative SVA (103.8 mm vs 71.4 mm, p<0.0001) and greater correction of SVA (34.4 mm vs 17.8 mm, p=0.004) were associated with neurologic complications. Two attending spine surgeons were present for 18.9% of cases with no effect on rate of neurologic complications. BMI (OR:1.04, p=0.029), revision surgery (OR:2.5, p<0.0001), and PSO (OR:2.2, 0.007) were predictors of neurologic complications. <h3>CONCLUSIONS</h3> We report an overall neurologic complication rate of 18.9% after ASD surgery with a 29.6% rate of complete resolution and 24.6% rate of partial resolution. Of total patients, 11.7% had an associated motor deficit with mean strength grade of 4.14 at final follow-up. Higher BMI and history of revision surgery were predictors of neurologic complications. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Abstract 17484: Prevalence, Prognosis and Predictors of Neurological Complications After Heart Transplantation

Introduction: Heart transplantation (HT) is the gold-standard treatment for end-stage heart failure. In spite of its benefits, this therapy still involves complications. Among them, neurological complications may impact significantly patient’s morbidity and mortality. The aim of this study is to identify the prevalence, prognosis and predictors of neurological complications after HT. Methods: Data from all patients who underwent orthotopic HT between 2007 and 2017 in a single center were collected and analyzed. Neurological complications were defined as seizures, ischemic and hemorrhagic stroke. Univariate and multivariate analysis were performed to identify significant predictors and ROC curves were generated to determine cutoff values that could influence the presence of neurological complications. Results: We assessed 132 patients from 15-76 years of age, mean age of 51.8 (73.5% men), who were mainly in INTERMACS profile 3 (78.8%). Cardiomyopathy etiologies included Chagas disease (26.7%), ischemic cardiomyopathy (26.7%), idiopathic dilated (24.4%) and other etiologies (22.2%). Neurological events before transplant were present in 16.7%. Neurological complications after HT occurred in 17.4% of patients (8.7% ischemic stroke, 60.9% hemorrhagic stroke and 30.4% seizures), mainly in the first 10 postoperative days (71.4%) and were not related to a higher mortality risk (p=0.159). In the multivariate analysis, pre-transplant adrenaline use (p-value=0.044; 95% CI of 1.07-179.25, OR 13.84) and the difference between mean systolic blood pressure before HT and on the 3rd postoperative day (p-value=0.011; 95% CI of 1.38-11.56, OR 3.99) were independent predictors of neurological complications. A cutoff value higher than 32 mmHg (between mean systolic blood pressure before HT and on the 3rd postoperative day) increased the risk of neurological complications (64.3% sensitivity, 63% specificity; AUROC 0.652). Conclusion: In this single center study, prevalence of neurological complications was high, however had no impact on prognosis. Pre-transplant adrenaline use and systolic blood pressure elevation in the 3rd postoperative day in comparison to the pre-transplant period were predictors of neurological complications.

Are modified Fisher Scale and bleeding pattern helpful predictors of neurological complications in non-aneurysmal subarachnoid hemorrhage?

Non-aneurysmal subarachnoid hemorrhage (NA-SAH) is a clinical-radiological entity with a different prognosis than aneurysmal SAH (A-SAH). The purpose of this study is to assess the predictive value of the modified Fisher Scale (mFS) for neurological complications in patients with this diagnosis. We recruited patients admitted at our hospital services between 2009 and 2017 who were diagnosed with spontaneous SAH, with either perimesencephalic (PM-SAH) or diffuse pattern (D-SAH), an initial negative angio-CT, and at least one digital subtraction angiography of brain vessels discarding underlying brain aneurysms or other vascular malformations. The retrospective observational study included 116 patients. The mean age was 54.4, and the sample included predominantly male subjects (62.9%). Hunt and Hess (HH) scores on admission ranged from 3 to 5 in 18.1% of patients. The prevalence of hydrocephalus requiring ventricular drainage was 18.1%. The prevalence of symptomatic vasospasm was 4.3%. A modified Rankin Scale (mRS) 0-2 at discharge was found in 95.6%. In a multivariate logistic regression for the presence of neurological complications including age, sex, admission HH 3-5 compared with < 3, mFS 4 compared with mFS < 4, D-SAH compared with PM-SAH, and mRS score at discharge of 0-2 compared with > 2, the only significant predictors were mFS 4 compared with mFS < 4 (OR 4.47 (95% CI 1.21, 16.66) p value = 0.03) and D-SAH compared with PM-SAH (OR 7.10 (95% CI 1.24, 40.8) p value = 0.03). In patients with NA-SAH, a mFS score of 4 and/or a D-SAH bleeding pattern in non-contrast cranial CT on admission predicted the development of relevant neurological complications.

Incidence and Predictors of Neurological Complications Following Thoracic Endovascular Aneurysm Repair in the Global Registry for Endovascular Aortic Treatment

The aim of this study was to investigate the incidence and predictors of early and mid term neurological complications following thoracic endovascular repair (TEVAR) in the Global Registry for Endovascular Aortic Treatment (GREAT). The GREAT is a prospective observational multicentre registry on Gore aortic endografts that was initiated in 2010. Only isolated thoracic aortic pathologies were included (aortic arch and descending thoracic aneurysms, type B dissections, penetrating ulcers, intramural haematomas, pseudoaneurysms, and transections). Thoraco-abdominal aneurysms and concomitant abdominal aneurysms were excluded. Neurological complications were classified as cerebrovascular accidents (CVA) and spinal cord injuries (SCI). Clinical, procedural, and technical data were evaluated for their association with early (30 day) and mid term CVAs and SCIs. In total, 833 patients were included: 28 with arch aneurysms (3.4%), 329 with descending thoracic aneurysms (39.5%), 273 with type B dissections (32.8%), and 203 (24.4%) with other thoracic pathologies. Altogether, 593 (71.2%) were elective procedures and 240 (28.8%) were urgent. Aortic coverage >20 cm was performed in 42.1% (n = 351); proximal landing zone 0-1-2 was adopted in 267 patients (32.1%) and of these 98 (36.7%) underwent left subclavian artery (LSA) revascularisation. There were 13 early CVAs (1.5%) and the four year freedom from CVA rate was 96.3%. On multivariable analysis, aortic arch aneurysm was the only independent predictor of early CVA (odds ratio 16.7, p = .001). LSA coverage (hazard ratio [HR] 3.31, p = .005) and hypercholesterolaemia (HR 2.96, p = .024) were independent predictors of mid term ischaemic CVAs. There were 15 (1.8%) early SCIs, and the four year freedom from SCI rate was 97.8%. No independent predictors of early SCI were identified, but length of coverage was an independent predictor of SCI at four years (HR 1.24; p = .044). In this real world registry, the overall rate of neurological complication after TEVAR for isolated thoracic aortic pathologies was low. Aortic arch aneurysms were associated with increased peri-operative CVA risk. Length of coverage was an independent predictor of mid term SCIs, as LSA coverage was associated with late CVAs.

Predictors of Neurological Complications After Transthoracic Endovascular Aneurysm Repair: More Questions than Answers

Predictors of Neurological Complications After Transthoracic Endovascular Aneurysm Repair: More Questions than Answers

Incidence and Predictors of Neurological Complications Following Thoracic Endovascular Aneurysm Repair in the Global Registry for Endovascular Aortic Treatment

The aim of this study was to investigate the incidence and predictors of early and mid term neurological complications following thoracic endovascular repair (TEVAR) in the Global Registry for Endovascular Aortic Treatment (GREAT). The GREAT is a prospective observational multicentre registry on Gore aortic endografts that was initiated in 2010. Only isolated thoracic aortic pathologies were included (aortic arch and descending thoracic aneurysms, type B dissections, penetrating ulcers, intramural haematomas, pseudoaneurysms, and transections). Thoraco-abdominal aneurysms and concomitant abdominal aneurysms were excluded. Neurological complications were classified as cerebrovascular accidents (CVA) and spinal cord injuries (SCI). Clinical, procedural, and technical data were evaluated for their association with early (30 day) and mid term CVAs and SCIs. In total, 833 patients were included: 28 with arch aneurysms (3.4%), 329 with descending thoracic aneurysms (39.5%), 273 with type B dissections (32.8%), and 203 (24.4%) with other thoracic pathologies. Altogether, 593 (71.2%) were elective procedures and 240 (28.8%) were urgent. Aortic coverage >20cm was performed in 42.1% (n=351); proximal landing zone 0-1-2 was adopted in 267 patients (32.1%) and of these 98 (36.7%) underwent left subclavian artery (LSA) revascularisation. There were 13 early CVAs (1.5%) and the four year freedom from CVA rate was 96.3%. On multivariable analysis, aortic arch aneurysm was the only independent predictor of early CVA (odds ratio 16.7, p=.001). LSA coverage (hazard ratio [HR] 3.31, p=.005) and hypercholesterolaemia (HR 2.96, p=.024) were independent predictors of mid term ischaemic CVAs. There were 15 (1.8%) early SCIs, and the four year freedom from SCI rate was 97.8%. No independent predictors of early SCI were identified, but length of coverage was an independent predictor of SCI at four years (HR 1.24; p=.044). In this real world registry, the overall rate of neurological complication after TEVAR for isolated thoracic aortic pathologies was low. Aortic arch aneurysms were associated with increased peri-operative CVA risk. Length of coverage was an independent predictor of mid term SCIs, as LSA coverage was associated with late CVAs.

Use of adductor pollicis muscle thickness in hospitalized or ambulatory patients: a systematic review.

ABSTRACTObjective: to analyze the use of the Adductor Pollicis Muscle Thickness (APMT) as an anthropometric parameter and prognostic indicator in hospitalized or ambulatory patients. Method: systematic review carried out the Web of Science, SCOPUS and Lilacs databases. Results: Twenty-three studies were performed on critical, surgical, oncological, nephropathic and hepatopathic patients, collecting data on bibliographic reference, study site, objectives, number of patients, age group, methodology, main results and conclusion. APMT proved to be a good anthropometric parameter for evaluation of nutritional status in critical patients without edema, and surgical, oncological and nephropathic patients, but presented poor performance for diagnosis of malnutrition in hepatopathic patients. It was a good prognostic indicator for mortality in critical, nephropathic and oncological patients, and also a good predictor of hospitalization in nephropathic patients. There was an association with neurological complications in Hepatic Encephalopathy (HE) in the case of hepatophatic patients, but it was not a predictor of postoperative complications in surgical patients. Conclusion: APTM was considered a good anthropometric parameter in most clinical conditions, except in patients with liver disease and a good prognostic indicator for mortality in critical, oncological and nephropathic patients, and a predictor of neurological complications in HE. Further prognostic investigation, standardization of cutoff points and evaluation of sensitivity and specificity are required.

Predictors of neurological complications during surgical treatment of the ascending aorta and aortic arch chronic dissection

To evaluate the prognostic significance of oxygen supply to the brain in the risk of neurological complications in the early post operative period of surgical treatment of the ascending aorta and aortic arch. The level of oxygenation (rSO2) in the right and left hemispheres was measured in 68 patients with ascending aorta and aortic arch chronic dissection. Before and in the nearest period after surgery, the patients underwent a clinical/instrumental neurological study. The incidence of ischemic stroke in the early post operative period was 5.9%, cognitive impairment was recorded in 22% of patients. Among the parameters of oxygen supply to the brain, the dynamics of rSO2 during circulatory arrest had a significant impact on the post operative neurological status. The risk of cognitive impairment, besides the association with the oxygen status of the brain, increased with the age of patients and comorbid pathology. The decrease in rSO2 by ≥30% during surgical treatment of ascending aorta and aortic arch dissection increases the risk of ischemic stroke and cognitive impairment in the early post operative period.

Serum S100 protein could predict altered consciousness in glyphosate or glufosinate poisoning patients

Background: Central nervous system (CNS) complications such as seizures and reduced consciousness are important in glufosinate and may occur in severe glyphosate poisoning. The aim of this study was to assess the possible role of serum S100B protein as a biochemical marker of CNS complications associated with glyphosate or glufosinate poisoning.Methods: The study enrolled 40 patients (23 glyphosate poisoning and 17 glufosinate poisoning). Altered consciousness and seizure were observed during hospitalization. S100B level was measured with fully automated modular analytic E170 system using electrochemoluminometric immunoassay.Results: Among 40 patients, neurologic features were observed in 12 patients with a median time to onset of 21.5 (IQR 8.25–24.75) h. Serum S100B concentrations measured on admission were higher in the group with neurologic features than in the group without neurologic features [0.148 μg/L (IQR 0.128–0.248) vs. 0.072 μg/L (IQR 0.047–0.084), p < .001]. Univariate analysis of measured patient raw parameters using a ROC curve showed that S100B was a significant predictor of neurologic features in glyphosate and glufosinate poisoning. The area under the ROC curve was 0.894 (95% confidential interval 0.791–0.998). When S100B was set at 0.0965, its sensitivity and specificity for predicting neurologic features in glyphosate and glufosinate poisoning were 92% and 82%, respectively.Conclusions: In our pilot study, S100B was a significant predictor of neurologic complications in patients with glyphosate and glufosinate poisoning. Large prospective cohorts are needed to confirm this finding.

Initial Serum Ammonia as a Predictor of Neurologic Complications in Patients with Acute Glufosinate Poisoning.

PurposeGlufosinate poisoning can cause neurologic complications that may be difficult to treat due to delayed manifestation. Studies assessing possible predictors of complications are lacking. Although serum ammonia level is a potential predictor of severe neurotoxicity, it has only been assessed via case reports. Therefore, we investigated factors that predict neurologic complications in acute glufosinate-poisoned patients.Materials and MethodsWe conducted a retrospective review of 45 consecutive glufosinate-poisoning cases that were diagnosed in the emergency department (ED) of Wonju Severance Christian Hospital between May 2007 and July 2014. Patients with a Glasgow Coma Scale (GCS) score of <8, seizure, and/or amnesia were defined to a neurologic complication group.ResultsThe neurologic complication group (29 patients, 64.4%) comprised patients with GCS<8 (27 patients, 60.0%), seizure (23 patients, 51.1%), and amnesia (5 patients, 11.1%). Non-neurologic complications included respiratory failure (14 patients, 31.1%), intubation and ventilator care (23 patients, 51.1%), shock (2 patients, 4.4%), pneumonia (16 patients, 35.6%), acute kidney injury (10 patients, 22.2%), and death (4 patients, 8.9%). Complications of GCS<8, seizure, respiratory failure, and intubation and ventilator care appeared during latent periods within 11 hrs, 34 hrs, 14 hrs, and 48 hrs, respectively. Initial serum ammonia was a predictor of neurologic complications [odds ratio 1.039, 95% confidence interval (1.001-1.078), p=0.046 and area under the curve 0.742].ConclusionNeurologic complications developed in 64.4% of patients with acute glufosinate poisoning. The most common complication was GCS<8. Initial serum ammonia level, which can be readily assessed in the ED, was a predictor of neurologic complications.

Relationship between neurological complications, cerebrovascular and cerebral perfusion following off-pump coronary artery bypass grafting

Objective:To investigate risk factors for neurological complications after off-pump coronary artery bypass grafting (OPCABG).Methods:We reviewed the cases of 813 patients who underwent OPCABG between August 2010 and September 2013.Data from preoperative 320 dynamic volume computed tomography (CT), CT angiography (CTA), CTA perfusion, and cerebrovascular function examinations were assessed. Neural function was assessed before and 7 days after operation, and patients were assigned to either the neurological complications or non-neurological complications group.Results:Neurological complications were observed in 23.4% (190/813) of patients; cerebral infarction in 1.1% (9/813); hypoxic ischemic encephalopathy in 2.3% (19/813); delirium in 1.5% (12/813); postoperative cognitive dysfunction in 12.9% (105/813); and anxiety/depression in 8.2% (67/813). Patients in the neurological complications group were older, were more likely to have a previous history of cerebrovascular disease and diabetes, had more severe extra-cranial carotid artery stenosis, had more severe stenosis on CTA, and had more perfusion abnormalities compared to patients in the non-neurological- complications group (P < 0.05). Logistic regression analysis identified the following independent risk factors for neurological complications: male gender (odds ratio [OR], 1.816; 95% confidence interval [CI], 1.017–3.244; P = 0.044); cerebrovascular disease history (OR, 1.837; 95% CI, 1.075–3.141; P = 0.026); and perfusion abnormalities (OR, 3.224; 95% CI, 2.073–5.013; P = 0.000). Occipital lobe cerebral blood flow (CBF); differences in temporal lobe, occipital lobe, and basal ganglial time to peak (TTP); and the difference in occipital lobe and basal ganglial mean transit time (MTT) were significantly higher in the neurological complications group (P < 0.05). For the TTP difference, the area under the receiver operating characteristic (ROC) curve was 0.606.Discussion:Neurological complications were observed in 23.4% of patients following OPCABG. Male gender, cerebrovascular disease history, and perfusion abnormalities were independent risk factors for neurological complications. Temporal lobe TTP on CTA perfusion was the best predictor of neurological complications.

Carotid artery stenting in elderly patients: Importance of case selection

This study was conducted to determine if carotid stenting (CS) could be safely performed in the elderly. Age has been shown to be a predictor of neurological complications during CS. We postulated that CS could be safely performed in elderly patients if certain anatomical and clinical markers such as excessive vascular tortuosity, heavy concentric calcification of the lesion, and decreased cerebral reserve were avoided. From July 2003 to October 2007, 142 patients aged > or =50% or asymptomatic stenosis > or =70%. All patients underwent carotid and cerebral angiography to determine anatomic suitability and stent risk. Demographic and outcome data were entered into a database; other data were obtained retrospectively. Independent neurology evaluation was performed before and at 24 hr after the procedure. The mean age was 83.2 years, 62% were male, 25.5% were symptomatic, 8.5% had postcarotid endarterectomy restenosis, and 6.0% had contralateral internal carotid artery occlusion. There were no intracranial hemorrhages or periprocedural myocardial infarctions. One patient had amaurosis fugax. There were two minor and three major strokes in-hospital (3.3%). All patients had 30-day follow-up. One of the major strokes expired. Thus the overall 30-day stroke or death rate was 3.3% and major stroke or death rate was 2.0%. The 30-day stroke or death rate was 5.1% for symptomatic patients and 2.6% for asymptomatic patients. CS can be performed safely in anatomically suitable elderly patients with low adverse event rates. CS should remain a revascularization option in appropriately selected elderly patients.

Early neurological complications after coronary artery bypass grafting and valve surgery in octogenarians☆

To determine the incidence and risk factors for neurological events complicating cardiac surgery, and the implications for operative outcome in octogenarians. Of 6791 who underwent primary on-pump CABG and/or valve surgery from 1998 through 2006, 383 were aged > or =80 years. Neurological complications, classified as reversible or permanent, were investigated by head CT scan in patients who did not recover soon after an event. There were more females (47% vs 26%, p<0.0001) among octogenarians (n=383, median age 82 years) than among younger patients (n=6408, median age 66 years). Controlled heart failure, NYHA class III/IV and chronic obstructive pulmonary disease were more prevalent in octogenarians while preoperative myocardial infarction was predominant in younger patients. Octogenarians were at higher operative risk (median EuroScore 6 vs 2, p<0.0001). Operative procedures differed between octogenarians and younger patients (p<0.0001); respective frequencies were 45% vs 77% for CABG, 26% vs 10% for AVR, and 23% vs 6% for AVR+CABG. Mortality was higher for octogenarians (8.9% vs 2.1, p<0.0001). Early neurological complications observed in 3.9% of the entire study population were mostly reversible (3.2%). Age > or =80 years (odds ratio [OR] 2.82, 95% confidence interval [CI] 1.89-4.21, p<0.0001), prior cerebrovascular disease (OR 2.23, 95% CI 1.56-3.18, p<0.0001), AVR+CABG (OR 2.92, 95% CI 1.60-5.33, p<0.0001) and MVR+CABG (OR 4.77, 95% CI 2.10-10.85, p<0.0001) were predictive of neurological complications. More octogenarians experienced neurological events (p<0.0001): overall 12.8% vs 3.4%, reversible 11.5% vs 2.8%, permanent 1.3% vs 0.6%. Among octogenarians, neurological complication was associated with elevated operative mortality (18% vs 8% for those without neurological complication, p=0.03), and prolonged ventilation, intensive care stay and hospitalisation. Predictors of neurological complications in octogenarians were blood and/or blood product transfusion (OR 3.60, 95% CI 1.56-8.32, p=0.003) and NYHA class III/IV (OR 7.6, 95% CI 1.47-39.70, p=0.02). Octogenarians undergoing on-pump CABG and/or valve repair/replacement are at higher risk of neurological dysfunction, from which the majority recover fully. The adverse implications for operative mortality and morbidity, however, are profound. Blood product transfusion which has a powerful correlation with neurological complication should be reduced by rigorous haemostasis with parsimonious use of sealants when appropriate.

Hypotensive endovascular test occlusion of the carotid artery in head and neck cancer

To evaluate the reliability of balloon test occlusion with hypotensive challenge (BTO and HC) as a predictor of neurological complications before internal carotid artery (ICA) sacrifice in patients with advanced head and neck cancer, the authors retrospectively reviewed the medical records of patients presenting to their institutions between 1992 and 1997 in whom this preoperative assessment was performed. Eleven patents who were candidates for extended comprehensive neck dissection (ECND) and potential ICA sacrifice were included in the study. Eight patients tolerated the test and underwent endovascular occlusion or surgical ligation of the ICA before ECND (four patients), preservation of the ICA at the time of surgery (three patients), or palliative therapy (one patient). Of three patients in whom BTO and HC failed, one patient received palliative treatment only; the other two underwent ECND with preservation of the ICA. In the group of patients who passed the test and underwent ICA occlusion or ligation before ECND, fatal thromboembolic stroke occurred within 24 hours of permanent balloon occlusion in one patient, resulting in a combined neurological morbidity/mortality rate of 25% in this subset of patients and an overall complication rate of 9% in this series. The authors found that BTO and HC offers a simple and reliable method of preoperative risk assessment when ICA resection is planned for regional control of disease in advanced head and neck cancer. This management option, however, is associated with a potential for neurological complication that must be weighed against the natural course of the disease and the risks and benefits of other treatment modalities.

Contralateral stenosis and stump pressures: Parameters to identify the high risk patient undergoing carotid endarterectomy under local anaesthesia

Carotid endarterectomy (CEA) under local anaesthesia (LA) enables the assessment of the two parameters of stump pressure and contralateral stenosis as predictors of neurological complications both intra- and postoperatively. Over a 7 year period, 175 carotid endarterectomies were performed under LA and of these, stump pressure measurements and angiographic findings were recorded on 99 patients. There were no deaths, two patients (2.0%) suffered a perioperative stroke (CVA) and one (1.0%) a transient ischaemic attack (TIA). An additional eight patients "obtunded" while the internal carotid artery was clamped, with complete resolution upon revascularisation in all but one patient who recovered fully within 24 h. Patients with contralateral occlusion or > or = 80% stenosis were more likely to develop complications (6/25 vs. 5/74 p < 0.03) and stump pressures were significantly lower in patients suffering an event (34.36 +/- 23.15 vs. 55.57 +/- 27.58, p < 0.02). By combining contralateral stenosis (> or = 80%) and stump pressure (< or = 35 mmHg), a "high risk" group of 42 patients in whom eight of the 11 events occurred, were identified. Contralateral stenosis and low stump pressures can be used in combination to identify high risk patients likely to develop neurological complications during or following CEA.