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Awake CEA Neurological Testing — FRCA Final MCQ

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ModerateGeneral AnaesthesiaAwake CEA Neurological TestingFRCA Final

A 55-year-old man (ASA III) is undergoing awake carotid endarterectomy under cervical plexus block. The surgeon is preparing to clamp the operated carotid artery. Which monitoring method should be performed as a baseline immediately before clamping and repeated after and during clamping to provide the most reliable detection of cerebral ischaemia?

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Correct answer: E — Serial assessment of speech and contralateral hand grip

The correct answer is E. In an awake, cooperative patient, serial direct neurological examination is the most reliable method of detecting cerebral ischaemia during carotid cross-clamping. A pre-clamp baseline is compared with repeated assessment of contralateral hand grip, speech, comprehension and consciousness after clamping and throughout the clamp period. New weakness, dysphasia or reduced responsiveness suggests inadequate collateral cerebral perfusion; reversible causes such as hypotension, hypoxaemia or excessive sedation should be addressed while the surgeon considers shunt insertion. NIRS is a useful adjunct but, when used alone, may give false-positive or false-negative results. BIS is designed primarily to estimate hypnotic depth and does not reliably detect focal cerebral ischaemia. Pupillary changes are insensitive and usually late, while transcranial magnetic stimulation is not a standard intraoperative monitoring technique for carotid endarterectomy.

Reference: United Lincolnshire Hospitals NHS Trust, Local Anaesthesia for Carotid Endarterectomy, issued March 2024. https://www.ulh.nhs.uk/patients/patient-information-library/local-anaesthesia-for-carotid-endarterectomy/