Machine learning to detect intraoperative ischemia from electroencephalography in carotid endarterectomy surgery

Cerebral ischemia is a significant concern during high-risk surgeries, such as carotid endarterectomy (CEA). Continuous electroencephalography, monitored by neurophysiological experts, is used to detect cerebral ischemia during surgery; however, real-time visual interpretation is resource-intensive and error-prone. We evaluated machine learning (ML) models, including random forest (RF), eXtreme Gradient Boosting with a random forest base classifier (XGB), elastic-net logistic regression (LR), support vector classifier (SVC) with a radial basis function kernel, and naive Bayes (NB) classifier, for automated detection of cerebral ischemia during CEA using quantitative electroencephalographic (qEEG) features. RF achieved the highest sensitivity (0.79–0.83) and an area under the precision–recall curve (AUPRC) of 0.44, while XGB demonstrated the highest specificity (0.93–0.96) with an AUPRC of 0.36. Both models showed high negative predictive values and high area under the receiver operating characteristic (AUROC) scores. Feature-importance analysis identified alpha-band activity and hemispheric asymmetry as the most discriminative qEEG predictors of ischemia. These results highlight the potential of ML-assisted monitoring to support neurophysiology experts and enhance patient safety during high-risk surgical procedures.