Comparison of simultaneous electroencephalographic and mental status monitoring during carotid endarterectomy with regional anesthesia.

PURPOSE: This study examines the accuracy of intraoperative electroencephalographic (EEG) monitoring for the detection of cerebral ischemia by comparing EEG with simultaneous mental status evaluation (MSE) during carotid endarterectomy in awake patients. METHODS: Between 1994 and 1997, 208 consecutive carotid endarterectomies were prospectively evaluated for cerebral function during surgery with simultaneous MSE and EEG monitoring. Regional anesthesia (RA), which consisted of superficial cervical block, was chosen preferentially in 75% of the cases, with general anesthesia (GA) reserved for the patients who did not fulfill the criteria for RA. When available, 8-channel EEG monitoring was performed (59% with RA and 55% with GA). RESULTS: The EEG was a reliable predictor in comparison with MSE in most but not all cases of cerebral ischemia. Significant neurologic changes were noted using MSE in 4 of 89 patients (4.5%) that were not detected using EEG (false negative results). Conversely, 6 of 89 cases (6.7%) showed unilateral slowing without associated changes in MSE (false positive results). For the awake patients, 21 of 150 cases (14%) showed MSE changes that required a shunt. By contrast, 9 of 32 GA cases (28%) showed EEG changes that would have led to shunting (P = NS). In the RA group, there were no strokes versus 3 of 58 cases (5.2%) with strokes in the GA group. Two of 150 cases (0.1%) had transient ischemic attacks in the RA group. There was 1 myocardial infarction in the GA group; no deaths occurred in this series. CONCLUSION: EEG monitoring yielded a significant number of false positive (6.7%) and false negative (4.5%) results in the detection of neurologic deficits when compared with MSE in the awake patients. In this series, the preferential use of RA resulted in less shunt use and was possibly associated with a lower stroke rate.

Streptococcal toxic shock syndrome from a puncture wound to the foot.

Puncture wounds to the foot are a common occurrence. If treated properly, the majority will be resolved without major complications. Toxic shock syndrome and streptococcal toxic shock-like syndrome are devastating complications of some staphylococcal and streptococcal infections. This paper discusses the similarities and differences between the two toxic states, reviews the pathophysiology, and presents a case report of near-fatal streptococcal toxic shock-like syndrome secondary to a puncture wound of the foot.

Vasculogenic impotence: role of the pelvic steal test.

A new dynamic pelvic flow test is described that measures differential right and left corporeal artery blood pressure changes with exercise. Previous penile blood flow measurements have been made at rest. It is well known that exercise may unmask vascular pathological conditions not apparent at rest. Furthermore, cases have been reported that document potency at rest and impotence following exercise. As a result exercise was used to stress the pelvic vasculature in 97 patients chosen from vascular and urology clinics. A decrease of 0.15 or more in penile-brachial index with exercise was found to be statistically abnormal. A total of 23 patients (27 per cent) fulfilled the criteria for positive pelvic steal testing. In this group there were high incidences of smoking (52 per cent), hypertension (52 per cent) and diabetes (30 per cent). Although 70 per cent of these patients had at least occasional morning erections 78 per cent complained of loss of erection with exercise. The pelvic steal test detected vascular pathological conditions in 17 patients (20 per cent) previously missed by resting penile-brachial index measurements. Nocturnal penile tumescence studies in these patients demonstrated poor quality erections and correlated with the intermediate penile-brachial index values. Angiographic data performed in 5 of 23 patients corroborated the pathophysiology of a pelvic steal condition in each case. The pelvic steal test is simple to perform and markedly improves the sensitivity and yield of penile blood pressure measurements. The test appears to have better results in patients with suspected vasculogenic impotence and intermediate resting penile-brachial index values.

Lower gastrointestinal bleeding. Diagnostic approach and management conclusions.

The management of patients with lower gastrointestinal bleeding requires a systematic approach based on defined diagnostic and therapeutic methods. Although in 80 percent of patients bleeding will stop spontaneously, 25 percent will have rebleeding and 50 percent of those with rebleeding will bleed again. Angiography documents specific bleeding sites but raises questions related to the incidence, site and frequency of bleeding, as well as the necessity of demonstrating extravasation. We reviewed 49 arteriograms performed for lower gastrointestinal bleeding. We conclude from our findings that angiography identifies a presumptive cause of bleeding in 49 percent of patients; angiography identified the site of bleeding in 86 percent of the patients with active bleeding, thus allowing segmental colectomy. We believe that documentation of angiodysplasia in a patient with lower gastrointestinal bleeding is presumptive evidence for the site of bleeding. Angiography is useful and worthwhile in the work-up of patients with lower gastrointestinal bleeding in an attempt to plan localized, definitive resection, and this may lead to a lower mortality rate.

The multidisciplinary approach to vasculogenic impotence.

The proper assessment of erectile dysfunction can be objectively accomplished only by examining the vascular, hormonal, neurologic, and psychologic components. The vascular surgeon today requires the ability to participate in multidisciplinary approach to diagnosis and needs an understanding of pelvic hemodynamics to design aortoiliac reconstructions that optimize pelvic blood flow. We perform a history and physical examination carefully designed to evaluate erectile ability and detail vascular involvement. Outpatient serum samples are obtained for hormonal analysis. In the noninvasive vascular laboratory, we measure the penile blood pressure using a 2.5 cm cuff and a 10 MHz Doppler probe. We feel strongly that measuring the right and left cavernosal artery pressures directly and determining the penile/brachial index (PBI) most accurately reflects penile flow. A PBI less than 0.6 is diagnostic of vasculogenic impotence, and a PBI greater than 0.75 is normal. We perform our pelvic steal test by exercising the thigh and buttock muscle groups, and comparing the PBI before and after exercise. A decrease of 0.1 or more represents a positive steal test. Measurement of nocturnal penile tumescence is valuable in cases where history, physical examination, and noninvasive vascular laboratory evaluations do not correspond. A neurologic evaluation may include cystometrography or sacral latency testing when indicated. Psychological screening is performed in all patients. We screened 54 vascular clinic patients and found 81% to be symptomatic of erectile dysfunction. In this group, 79% had a PBI less than 0.75, and 38% had a positive pelvic steal test. Illustrative cases are presented herein and the implications in aortoiliac surgery are discussed.