Introduction: Cerebral hyperperfusion syndrome (CHS) is a preventable cause of stroke after carotid endarterectomy (CEA). There are currently no pooled data available on the incidence of CHS after carotid artery stenting (CAS). The aim of this review was to assess the relevance of CHS in the procedural stroke rate following CAS.Method: A systematic search on incidence rates of CHS after CAS was conducted in the MEDLINE, EMBASE, and Cochrane databases in November 2017. A meta-regression analysis was performed on CHS to explain heterogeneity and determine the impact of potential risk factors on observed CHS. The methodological quality of the included studies was assessed using the Cowley criteria.Results: The pooled CHS risk across 33 studies concerning 8731 CAS patients was 4.6% (3.1e6.8%). Stroke occurred in 47% of CHS patients, of which 54% were fatal or disabling. Average time from procedure to symptoms was 12 h (IQR 8e36 h). Impaired cerebrovascular reserve (CVR) was associated with a higher risk of CHS after CAS (RR 5.18; 95% CI 1.0e26.8; p = .049). Symptomatic status was associated with a lower risk of CHS (RR 0.20; 95% CI 0.07e0.59; p = .001).Conclusion: CHS is a serious and frequent complication in patients undergoing carotid angioplasty with stenting, and is most likely to occur in the very early post-procedural period. Future studies are encouraged to investigate the effect of intensive haemodynamic monitoring, including blood pressure control and assessment of cerebral blood flow, on the incidence of stroke caused by CHS after CAS.
Objective: Cerebral white matter lesions (WMLs) and lacunar infarcts are surrogates of cerebral small vessel disease (SVD). WML severity as determined by trained radiologists predicts post-operative stroke or death in patients undergoing carotid endarterectomy (CEA). It is unknown whether routine pre-operative brain imaging reports as part of standard clinical practice also predict short and long term risk of stroke and death after CEA.Methods: Consecutive patients from the Athero-Express biobank study that underwent CEA for symptomatic high degree stenosis between March 2002 and November 2014 were included. Pre-operative brain imaging (computed tomography [CT] or magnetic resonance imaging [MRI]) reports were reviewed for reporting of SVD, defined as WMLs or any lacunar infarcts. The primary outcome was defined as any stroke or any cardiovascular death over three year follow up. The secondary outcome was defined as the 30 day peri-operative risk of stroke or cardiovascular death.Results: A total of 1038 patients were included (34% women), of whom 659 (63.5%) had CT images and 379 (36.5%) MRI images available. Of all patients, 697 (67%) had SVD reported by radiologists. Patients with SVD had a higher three year risk of cardiovascular death than those without (6.5% vs. 2.1%, adjusted HR 2.52 [95% CI 1.12e5.67]; p = .026) but no association was observed for the three year risk of stroke (9.0% vs. 6.7%, for patients with SVD vs. those without, adjusted HR 1.24 [95% CI 0.76e2.02]; p = .395). No differences in 30 day peri-operative risk were observed for stroke (4.4% vs. 2.9%, for patients with vs. those without SVD; adjusted HR 1.49 [95% CI 0.73e3.05]; p = .28), and for the combined stroke/cardiovascular death risk (4.4% vs. 3.5%, adjusted HR 1.20 [95% CI 0.61e2.35]; p = .59).Conclusion: Presence of SVD in pre-operative brain imaging reports can serve as a predictor for the three year risk of cardiovascular death in symptomatic patients undergoing CEA but does not predict peri-operative or long term risk of stroke.
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