Cerebral perfusion and cerebral protection during carotid endarterectomy.

The relative safety of carotid endarterectomy depends upon surgical expertise combined with appropriate monitoring of cerebral perfusion and the ability to intervene either surgically or pharmacologically to match cerebral perfusion to cerebral oxygen requirement. Methods of monitoring adequacy of cerebral perfusion are reviewed and include regional cerebral blood flow measurements, electroencephalographic monitoring, carotid stump pressure measurements, jugular venous oxygen partial pressure, neurological assessment and plethysmographic techniques. When cerebral perfusion is inadequate, such procedures as insertion of a temporary bypass shunt and maintenance of normocarbia may improve cerebral perfusion. Anticoagulants along with pharmacologic intervention to either increase cerebral perfusion pressure or reduce cerebral oxygen requirement may be used to preserve cerebral function.