Cerebral Hyperperfusion after Carotid Endarterectomy is Associated with Preoperative Hemodynamic Impairment and Intraoperative Cerebral Ischemia

Komoribayashi, Nobukazu; Ogasawara, Kuniaki; Kobayashi, Masatoshi; Saitoh, Hideo; Terasaki, Kazunori; Inoue, Takashi; Ogawa, Akira

doi:10.1038/sj.jcbfm.9600244

Cited by 106 publications

(62 citation statements)

References 38 publications

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“…15,25) Both CEA 8,11,13,25,28) and CAS can improve CBF impairment. 12,18,29) However, hyperperfusion syndrome (HPS) has been reported after both procedures, 1,2,10,16,17,22,23) so prevention and treatment of HPS are important issues in the perioperative management of patients undergoing CAS.…”

Section: Discussionmentioning

confidence: 99%

“…However, marked hemodynamic changes in the cerebral circulation associated with the reconstruction of the blood flow in the carotid artery may occur and may require intensive post-procedure management after CAS, 1,2,10,12,16,18,29) as seen in patients treated by CEA. 8,11,13,25,28) Therefore, mild hypertension to keep sufficient cerebral perfusion pressure is recommended in postoperative care for patients with preceding impaired cerebral circulation if adequate improvement in cerebral blood flow (CBF) is not observed after carotid revascularization. On the other hand, prompt and strict control of blood pressure within normal or slightly subnormal values should be adopted if excessive increase of the CBF is observed postoperatively in the same patient to prevent hyperperfusion syndrome.…”

Section: Introductionmentioning

confidence: 99%

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Intraprocedural Changes in Angiographic Cerebral Circulation Time Predict Cerebral Blood Flow After Carotid Artery Stenting

Aikawa

Kaneda

Tsutsumi

et al. 2010

Neurol. Med. Chir.(Tokyo)

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Changes in the cerebral blood flow (CBF) are important for planning postoperative care in patients treated by carotid artery stenting (CAS). The relationship between intraprocedural changes in the angiographic cerebral circulation time (CCT) and perioperative CBF changes were retrospectively studied in 49 CAS procedures performed in 46 patients with carotid artery stenosis. The CCT, defined as the interval between the timing of maximal opacification at the terminal portion of the internal carotid artery and at the cortical vein, was determined by referring to time-density curves of data obtained from routine intraprocedural digital subtraction angiography. The intraoperative change in CCT (DCCT) was calculated for each of the 49 procedures. CBF studies, using dynamic perfusion computed tomography, were performed 10-2 days before and 2-4 days after CAS. Perioperative changes in the ratio of the CBF in the territory of the middle cerebral artery on the affected side to CBF on the contralateral side (%CBF) were calculated by subtracting pre-from postoperative %CBF (D%CBF) and the correlation between DCCT and D%CBF was evaluated. Mean CCT was shortened by 1.1 seconds from 5.3 to 4.2 seconds after CAS. Mean %CBF increased by 11.9% from 91.8% to 103.7% after the procedure. DCCT and D%CBF showed a significant positive correlation (r ＝ 0.61, p ＝ 0.008). Intraprocedural changes in angiographic CCT are predictive of postoperative CBF in patients with CAS.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Intraprocedural Changes in Angiographic Cerebral Circulation Time Predict Cerebral Blood Flow After Carotid Artery Stenting

Aikawa

Kaneda

Tsutsumi

et al. 2010

Neurol. Med. Chir.(Tokyo)

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“…Hyperperfusion syndrome (associated with increased CBF compared with preoperative values) results in headache, focal seizure activity, cerebral edema, and intracerebral hemorrhage and is associated with significant mortality and morbidity. 29 Komoribayashi et al 109 reported hyperperfusion immediately after CEA in 56% of patients with reduced preoperative CVR. Another study measured concentrations of malondialdehyde-modified low-attenuation lipoprotein (MDA-LDL), a biochemical marker of oxidative damage, in serum samples and CVR measurements in 90 patients undergoing CEA.…”

Section: Hyperperfusion Syndromementioning

confidence: 99%

The Acetazolamide Challenge: Techniques and Applications in the Evaluation of Chronic Cerebral Ischemia

Vagal¹,

Leach²,

Fernández-Ulloa³

et al. 2009

AJNR Am J Neuroradiol

159

116

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SUMMARY:The acetazolamide (ACZ) challenge test is a useful clinical tool and a reliable predictor of critically reduced perfusion. In patients with chronic steno-occlusive disease, the ability to maintain normal cerebral blood flow by reducing vascular resistance secondary to autoregulatory vasodilation is compromised. Identification of the presence and degree of autoregulatory vasodilation (reflecting the cerebrovascular reserve) is a significant prognostic factor in patients with chronic cerebrovascular disease. The pharmacologic challenge of a vasodilatory stimulus such as ACZ can also be used to optimize the treatment strategies for these patients. The pathophysiology, methods, and clinical applications of the ACZ challenge test are discussed in this article. Viability of the cerebral parenchyma is dependent on the ability of the brain vasculature to provide adequate levels of cerebral blood flow (CBF). In patients with chronic stenoocclusive disease, the ability to maintain normal CBF by reducing vascular resistance is compromised. Identification of the degree of autoregulatory vasodilation reflects cerebrovascular reserve (CVR), which is a significant prognostic factor in chronic cerebrovascular disease.1-5 Flow reserve can be assessed with the use of paired blood flow measurements, with the initial measurement obtained at baseline and the second, after a vasodilatory stimulus, such as acetazolamide (ACZ). 6 Pathophysiology of Chronic Cerebrovascular DiseaseChronic cerebral hypoperfusion is usually the result of occlusion or stenosis of large arteries in the neck or the circle of Willis. Clinical symptoms and manifestations of brain ischemia in patients with chronic cerebrovascular disease (CVD) develop as a consequence of 2 main mechanisms: embolic events from atherosclerotic plaques resulting in local compromise of blood flow and systemic hemodynamic alterations that further reduce an already compromised cerebral perfusion state. 7The hemodynamic changes due to a decline in cerebral perfusion pressure have been studied by many investigators. 6,[8][9][10][11] Chronic CBF restriction causes a progressive decrease in cerebral perfusion pressure (CPP). Initially, decreases of CPP cause varying degrees of autoregulatory vasodilation of small distal arterioles.12 Powers 10 and Powers et al 11 proposed a 2-stage classification of hemodynamic impairment in patients with CVD. In stage I (autoregulatory vasodilation), autoregulation reduces cerebral vascular resistance. CBF and oxygen extraction fraction (OEF) are not significantly changed. Increases of cerebral blood volume (CBV) and mean transit time (MTT) are 2 parameters that reflect this initial phase of compensatory autoregulatory vasodilation. Further decreases of CPP beyond cerebral autoregulatory vasodilation capacity eventually result in stage II (autoregulatory failure), characterized by decreases of CBF and increases of OEF. When the CBF decreases, neurons increase the fraction of oxygen extracted from the blood to maintain normal neurologic function. ...

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“…3,15,19,22) Patients with poor cerebrovascular reactivity are known to have higher risk for hyperperfusion syndrome. 12,18,23) The severity of intraoperative ischemia is also reported to be one of the predictive factors for hyperperfusion syndrome after CEA. 12) In contrast, hyperperfusion syndrome after superficial temporal arterymiddle cerebral artery (STA-MCA) anastomosis for atherosclerotic diseases is thought to be rare, since STA-MCA anastomosis usually provides low-flow revascularization.…”

Section: Introductionmentioning

confidence: 99%

Cerebral Hyperperfusion Syndrome Associated With Non-convulsive Status Epilepticus Following Superficial Temporal Artery-Middle Cerebral Artery Anastomosis -Case Report-

Hamamura

Morioka

Sayama

et al. 2010

Neurol. Med. Chir.(Tokyo)

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A 77-year-old man developed cerebral hyperperfusion syndrome with temporal deterioration of consciousness and worsening of left hemiparesis on the 6 th postoperative day following superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis for right M 1 occlusion. Electroencephalography (EEG) revealed frequent ictal discharges in the right hemisphere, although convulsive seizures were not apparent. Administration of anticonvulsants was performed based on the diagnosis of non-convulsive status epilepticus (NCSE). Complete recovery from hyperperfusion syndrome was achieved with rapid improvement of EEG findings. The present case demonstrates the pathophysiological mechanism of hyperperfusion syndrome associated with NCSE after STA-MCA anastomosis.

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Cerebral Hyperperfusion after Carotid Endarterectomy is Associated with Preoperative Hemodynamic Impairment and Intraoperative Cerebral Ischemia

Cited by 106 publications

References 38 publications

Intraprocedural Changes in Angiographic Cerebral Circulation Time Predict Cerebral Blood Flow After Carotid Artery Stenting

Intraprocedural Changes in Angiographic Cerebral Circulation Time Predict Cerebral Blood Flow After Carotid Artery Stenting

The Acetazolamide Challenge: Techniques and Applications in the Evaluation of Chronic Cerebral Ischemia

Cerebral Hyperperfusion Syndrome Associated With Non-convulsive Status Epilepticus Following Superficial Temporal Artery-Middle Cerebral Artery Anastomosis -Case Report-

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