Therapeutic Controversy The Ischemic Tolerance of Neural Tissue and the Need for Monitoring and Selective Shunting During Carotid Endarterectomy

DR. FERGUSON'S RECENT provocative editorial on the subject of monitoring and shunting during carotid endarterectomy was both puzzling and troubling.' It appears that his "inescapable conclusion that neither intraoperative monitoring nor the use of internal shunts are necessary to avoid intraoperative stroke in the carotid endarterectomy, as a usual cause for such a stroke is an embolus" was based largely on: a comparison of reported series, his own experience with the use of intraoperative electroencephalography and cerebral blood flow measurements, and his interpretation of clinical and laboratory studies concerning the ischemic tolerance of neural tissue. He recommends "skillful general anesthesia together with a relatively short occlusion time" as the preferred method of management. These components of his thesis will be considered sequentially.