Failure of intraoperative jugular bulb S-100B and neuron-specific enolase sampling to predict cognitive injury after carotid endarterectomy

Abstract

Objective: Cognitive decline occurs in 25% of patients after carotid endarterectomy (CEA). Elevated serum concentrations of S-100B and neuron-specific enolase (NSE) occur after stroke, and serum S-100B levels at 24 hours are associated with clinical outcome after both stroke and CEA. We hypothesized that we could detect acute elevations in serum levels of these markers obtained intraoperatively from the jugular bulb (JB) and that these elevations would predict cognitive dysfunction postoperatively as measured by neuropsychometric test performance.

Methods: Forty-three patients scheduled for elective CEA were assessed with a battery of neuropsychometric tests before and 1 day after surgery. Before the carotid artery was clamped, a 6-French Fogarty catheter was inserted into the facial vein and threaded 6 cm rostrally into the JB. Serum samples were withdrawn from this catheter and simultaneously from a radial arterial catheter (A-line) at three time points: before clamping, 15 minutes into clamping, and after unclamping the carotid artery. Concentrations between groups were compared by analysis of variance and paired t tests.

Results: Total deficit scores were significantly worse in 13 (30%) of the 43 patients 1 day after surgery. There was a trend toward elevations in JB concentrations of S-100B relative to A-line levels 15 minutes after cross-clamping (11% elevation, P = 0.079, paired t test). In addition, 15 minutes after clamping of the carotid artery, levels of S-100B from the JB were significantly elevated compared with levels at baseline (P = 0.040, one-way analysis of variance). No significant changes were found between any time point in levels of S-100B from the A-line blood or of NSE from either the JB or the A-line. Subtle cognitive decline after CEA was not correlated with intraoperative levels of S-100B or NSE, but there was a weak, statistically nonsignificant, association between a rise in 15-minute S-100B levels and cognitive injury that was not seen with JB samples.

Conclusion: Although intraoperative levels of S-100B and NSE from the JB failed to predict cognitive injury, carotid cross-clamping, independent of injury, seems to be associated with early elevations in S-100B.

Figures

FIGURE 1

Diagram of cross-clamped carotid artery (red) with 6-French irrigating catheter inserted in the stump of the facial vein and advanced through the jugular vein (blue) to the level of the JB. The jugular vein was clamped beneath the facial vein during blood draws to ensure a venous sample from brain-perfused blood.

FIGURE 2

A, graph showing S-100B concentrations from A-line and JB for all time points. There is a statistically significant difference between preclamp JB and 15-minute JB (*, P = 0.040, one-way ANOVA). There was a trend toward significance for 11% higher JB S-100B concentrations than peripheral (P = 0.079, paired t test). B, graph showing NSE concentrations from A-line and JB for all time points. There are no significant differences between any time points. Error bars, standard error of the mean.

FIGURE 3

A, bar graph showing S-100B and NSE in A-line versus JB for injured and uninjured groups at 15 minutes as a proportion of baseline values. There are no significant differences in proportionate changes for either S-100B or NSE. B, bar graph showing S-100B and NSE in A-line versus JB for injured and uninjured groups at postclamp as a proportion of baseline values (uninjured, 43.0 ± 17.9 min; injured, 42.2 ± 16.9 min, means ± standard deviation). There are no significant proportionate changes seen in either marker at postclamp. Error bars, standard error of the mean.

FIGURE 4

A, graph showing S-100B from A-line for injured versus uninjured group at each time point. There was a trend toward significance for elevated 15-minute concentrations in the injured group (**, P = 0.075, one-way ANOVA) but not in the uninjured group. B, graph showing NSE from A-line for injured group versus uninjured group at each time point. There are no statistically significant differences by one-way ANOVA. C, graph showing S-100B from JB for injured group versus uninjured group at each time point. There was a significant difference between uninjured baseline concentrations and uninjured 15-minute concentrations (*, P = 0.041, one-way ANOVA). D, graph showing NSE from JB for injured group versus uninjured group at each time point. There are no statistically significant differences by one-way ANOVA. Error bars, standard error of the mean.