Sugammadex Vs. Neostigmine for Cerebral Perfusion During Emergence From General Anesthesia in Patients Undergoing Carotid Endarterectomy: A Double-Blind Randomized Controlled Trial

Background: Carotid endarterectomy (CEA) is the standard treatment for carotid stenosis, but has the risk of cerebral hyperperfusion syndrome (CHS). Postoperative residual neuromuscular blockade can trigger cerebral hyperperfusion (CH), and the effects of neostigmine and sugammadex on cerebral perfusion during CEA are unclear. Objective: This study aimed to compare the efficacy of neostigmine combined with atropine and sugammadex in reversing neuromuscular blockade in CEA patients under general anesthesia and evaluate the superiority of sugammadex in maintaining normal cerebral perfusion during anesthesia emergence. Methods: A single-center, prospective, randomized controlled study was carried out and registered on the Chinese Clinical Trial Registry website (ChiCTR2300078579). Between December 2023 and June 2024, 90 patients were recruited. After exclusions, 82 patients were randomly assigned to the sugammadex group or the neostigmine group at a 1:1 ratio. The primary outcome was the difference in the area under the curve of the percentage of middle cerebral artery velocity relative to baseline (MCAV% S) during emergence. Secondary outcomes included multiple hemodynamic and clinical parameters, as well as pulmonary and CH-related complications within 48 h post-operation. Mediation analysis, ROC analysis, and multivariate linear regression analysis were used to illustrate the differences in MCAV%S between the two groups and subsequent analysis. Results: The MCAV% S in the sugammadex group was significantly lower than in the neostigmine group (24,600 [14,940–38,040] vs. 31,575 [24,210–50,040], p = 0.044), and this difference persisted after adjusting for variables (Estimate (95% CI): −10,896 [−21,387 ~ −405]; p = 0.042). The sugammadex group had shorter eye-opening and extubation times, and a lower incidence of hypoxemia and overall pulmonary complication score. Mediation analysis showed that extubation time mediated part of the effect on MCAV% S, and the ROC analysis indicated good predictive performance of MCAV% S for CH. Conclusion: In CEA patients, sugammadex is more advantageous than neostigmine in reversing neuromuscular blockade during emergence, as it shortens extubation time, reduces excessive cerebral blood flow, and potentially lowers the incidence of postoperative complications.