Intraoperative Blood Pressure Lability Carries a Higher Risk of Headache after Carotid Endarterectomy.

Abstract

OBJECTIVES\nCerebral hyper-perfusion (CH) is a rare but potentially devastating complication following carotid endarterectomies (CEA). Its symptoms range from new-onset unilateral headache (HA) to intracranial hemorrhage (ICH). Risk factors of CH in the literature to date have not yet yielded a consensus. This study examines intraoperative and postoperative blood pressure variation as a potential risk factor for HA.\n\n\nMETHODS\nA single center retrospective review at a tertiary care center from January 2010 to November 2019 was performed. Inclusion criteria were all patients undergoing carotid endarterectomy for symptomatic or asymptomatic carotid disease. Patients with incomplete charts were excluded. Primary endpoints were new-onset unilateral HA or post-operative ICH. Data on intraoperative and post-operative mean arterial blood pressure (MAP), systolic blood pressure (SBP), the mode of endarterectomy, shunt placement, and contralateral carotid status were collected.\n\n\nRESULTS\n735 patients met inclusion criteria: 430 patients underwent modified eversion CEA (59%) vs 305 patients for patch angioplasty (42%). The incidence of HA was 19% (N= 142) in our total cohort. Of the 19% with HA, 1.5% (N=11) demonstrated no relief with analgesics and strict blood pressure control; non-contrast head computed tomography scans were subsequently performed. One patient (0.1%) had an ipsilateral ICH. Univariate analysis demonstrated that greater intra-operative MAP peak had the highest risk for HA (OR 1.014, 95% CI:1.007,1.022 p=0.0002) followed by intra-operative MAP variability (OR 1.011, 95% CI:1.005,1.018 p=<0.0008) and lastly peak intra-operative SBP (OR 1.01, 95% CI:1.004, 1.015 p=0.0011). An unpaired Student s t-test identified change in intra-operative MAP (p<0.005), change in SBP (p<0.005) as well as peak SBP (p<0.001) were significantly associated with HA. Interestingly, there was no significant difference between post-operative MAP variability and HA (p=0.1). Mode of endarterectomy showed no statistically significant difference in risk for developing HA (OR 1.165, 95% CI 0.801, 1.694; p=0.42).\n\n\nCONCLUSIONS\nGreater intra-operative variability in blood pressures are significantly associated with higher risk of HA. Adhering to stricter intra-operative blood pressure parameters and limiting blood pressure variability may be beneficial at reducing the incidence of CH and its complications.