Cerebral hyperperfusion syndrome after endovascular covered stent grafting for a giant extracranial aneurysm of the internal carotid artery

Abstract

Symptomatic giant extracranial internal carotid artery (ICA) aneurysm is a rare and surgically intractable disease. Several authors have described successful treatments for extracranial ICA aneurysm. None, however, have described a perioperative evaluation of cerebral perfusion or a postoperative complication of cerebral hyperperfusion syndrome (CHS). We present a rare case of CHS after endovascular covered stent grafting for a giant extracranial ICA aneurysm. The CHS was successfully managed on the basis of hemodynamic monitoring. CHS can appear after endovascular reconstruction of an extracranial ICA aneurysm, and perioperative repeated evaluation of cerebral perfusion allows safe and effective management of CHS. (J Vasc Surg Cases 2015;1:46-9.) Cerebral hyperperfusion syndrome (CHS) is reportedly caused by rapidly increased cerebral blood flow (CBF) in a chronically hypoperfused area. 1,2 Various revascularization procedures are known to induce CHS, but CHS after the surgical obliteration of an extracranial internal carotid artery (ICA) aneurysm has not been previously described. 1,2 Extracranial ICA aneurysms are rare and tend to be manifested with pulsatile cervical masses, cranial nerve palsy, or thromboembolic stroke. 3 Recent reports have advocated endovascular covered stent grafting as a safe and effective alternative to direct surgery. 4,5 We report a rare case of CHS after endovascular covered stent grafting for a giant extracranial ICA aneurysm and discuss the perioperative management of CHS. The patient gave consent to publish the data. CASE REPORTA 45-year-old man with no previous medical history presented with an acute onset of right hemiparesis and dysarthria. Magnetic resonance diffusion-weighted imaging and magnetic resonance angiography revealed a hyperintense lesion in the left corona radiata and occlusion of the left middle cerebral artery (MCA), respectively (Fig 1, A and B). The patient's initial National Institutes of Health Stroke Scale score was 8. Intravenous systemic thrombolysis was administered 90 minutes after onset, and the patient's National Institutes of Health Stroke Scale score improved from 8 to 2. One day later, computed tomography (CT) images showed an infarction in the left corona radiata (Fig 1, C). CT angiography revealed a left giant extracranial ICA aneurysm (5.5 cm in diameter) with recanalization but poor visualization of the left MCA and ICA, probably linked to stagnant blood flow in the aneurysm (Fig 1, D and E). CT perfusion imaging 3 weeks after stroke onset to minimize the effect of reperfusion of the occluded MCA demonstrated decreased ipsilateral CBF, cerebral blood volume (CBV) in the normal range, delayed mean transit time, and delayed time to peak (Fig 1, F-I). We surmised that the regional hypoperfusion resulted from stagnant blood flow within the aneurysm and that the MCA occlusion resulted from a thromboembolism from the aneurysm.The patient received 100 mg of aspirin and 75 mg of clopidogrel daily for 1 week before the intervention. We were concerned,...

Cerebral hyperperfusion syndrome after endovascular stent graft reconstruction for postirradiated carotid blowout syndrome: a case report

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Quantitative Assessment of Changes in Hemodynamics After Obliteration of Large Intracranial Carotid Aneurysms Using Computational Fluid Dynamics

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