Positive Awake Test Incidence in Carotid Endarterectomy under Regional Anesthesia: a Systematic Review and Meta-analysis

Abstract

ABSTRACT PURPOSE Carotid endarterectomy (CEA) reduces stroke risk in carotid stenosis but carries the risk of intraoperative neurological deficits (IND). The awake test, used with regional anesthesia (RA), reliably monitors cerebral ischemia, but data on IND incidence is scarce. Therefore, this systematic review with meta-analysis aims to determine the incidence of a positive awake test in patients undergoing RA. SOURCE We used four electronic databases to search for studies assessing positive awake tests in the intraoperative setting of patients undergoing CEA surgery under RA. The incidence of the positive awake test was pooled by random-effects meta-analysis, with sources of heterogeneity being explored by meta-regression. Assessment of studies' quality was performed using the National Heart, Lung, and Blood Institute (NHLBI) Study Quality Assessment Tool for observational cohorts and cross-sectional studies and Risk of Bias 2 tools. PRINCIPAL FINDINGS One hundred and twenty studies were included, totaling 34 068 participants. One randomized controlled trial (RCT), while the remaining were cohort studies. The meta-analytical incidence of positive awake test after carotid endarterectomy under RA, among the studies from 1980 - 2024, was 12.4% (95% CI, 10.6% to 14.1%), but severe heterogeneity was observed (I2 = 97%). CONCLUSION This meta-analysis found a 12.4% incidence of positive awake tests, which remained stable in the period 2014-2024 (10.8%) alongside a decrease in stroke risk (14% vs. 4.5%). These improvements likely reflect advancements in surgical techniques and perioperative care, highlighting the need for advancements in preoperative patient selection and event prediction.