Contributions of anesthesiology to the surgical treatment of cerebrovascular disease: the role of Arthur S. Keats, M.D.

Increased tolerance to cerebral ischemia produced by general anesthesia during temporary carotid occlusion. By B. A. Wells, A. S. Keats, and D. A. Cooley. Surgery 1963; 54:216-23. Local anesthesia with little or no preoperative sedation is currently recommended as the anesthetic of choice for temporary carotid occlusion during carotid endarterectomy. Purported advantages include minimal circulatory and respiratory changes from the local anesthetic, and constant verbal contact can be maintained with the patient so that neurologic changes are promptly recognized. However, local anesthesia may not be satisfactory in uncooperative or semiconscious patients. We therefore undertook a trial of general anesthesia in 56 consecutive patients undergoing carotid endarterectomy. Patients were induced in standardized fashion using intravenous thiopental (100-400 mg), atropine (0.2 mg), and succinylcholine (40-80 mg). Cyclopropane, along with deliberate hypercapnia and hypertension, was used for anesthesia maintenance. All patients tolerated carotid occlusion for periods of up to 30 min during general anesthesia without shunt, bypass, or hypothermia. Except for one patient, electroencephalogram evidence of cerebral ischemia was not apparent during occlusion, and no patient suffered postoperative neurologic sequela. Twenty percent of patients who had their carotid arteries occluded preoperatively for 30-60 s without general anesthesia suffered convulsions. These data suggest that general anesthesia increased the tolerance to cerebral ischemia. Potential mechanisms involved might include: 1) decreased cerebral metabolic rate for oxygen; 2) increased cerebral blood flow from hypercapnia; 3) increased arterial oxygen tension; and 4) recruitment of new routes of collateral circulation.