Blood pressure manipulation during awake carotid surgery to reverse neurological deficit after carotid cross-clamping

We describe the management of three patients undergoing awakecarotid surgery who developed signs of cerebral ischaemia aftercarotid cross-clamping. Drug treatment to increase arterialblood pressure above baseline reversed the neurological deficitand an internal carotid artery shunt was not needed. Shunt insertionis less frequent with regional rather than general anaesthesia,and blood pressure control can reduce this even more. Coincidentally,one of the patients, who gave a history of angina of effortafter walking 100 m, complained of chest pain after cross-clamprelease. This was treated successfully with sublingual nitroglycerinbefore ST segment changes became apparent on the ECG. Thesereports suggest that regional anaesthesia for carotid surgeryallows potential complications to be identified earlier thanunder general anaesthesia using reports from the patient, sothat treatment may be modified to prevent morbidity and evenmortality. Br J Anaesth 2001; 87: 641–4