Importance of cerebral angiography and intraoperative neuromonitoring in carotid endarterectomy

It is an increasingly common practice to indicate a carotid endarterectomy procedure based on the information provided by non-invasive tests like Duplex ultrasound, MR angiography or CT angiography, thereby obviating the performance of a conventional cerebral angiography. We present a case of symptomatic left carotid artery 80% stenosis in which cerebral angiography showed absence of the right Al segment and bilateral anterior cerebral artery territories that filled only from a left injection. Just 90 seconds after carotid artery clamping at the neck, brain oximetry and somatosensory evoked potentials significantly dropped, that recovered after immediate clamp removal. Endarterectomy was dismissed and a carotid stent was successfully placed. This case highlights the importance of knowing the dynamics of cerebral blood circulation distal to the stenosis. If endarterectomy had been attempted, unawareness of the information provided by the cerebral angiography would have likely result in severe bi-hemispheric ischemia. (C) 2020 Sociedad Espanola de Neurocirugia. Published by Elsevier Espana, S.L.U. All rights reserved.