Hyperperfusion Syndrome after Stent/Coiling of a Ruptured Carotid Bifurcation Aneurysm

Ecker, Robert D.; Murray, Richard D.; Seder, David B.

doi:10.1007/s12028-012-9733-x

Cited by 12 publications

(10 citation statements)

References 27 publications

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“…Yet no earlier reports have described CHS after obliteration of an extracranial ICA aneurysm or the importance of perioperative CBF studies to assess the CHS risk in the treatment of extracranial ICA aneurysms. CHS in such cases probably results from a sudden restoration of blood flow to a chronically hypoperfused area with unbalanced autoregulation, as a giant aneurysm traps and reduces anterograde distal blood flow 16, 17. The same mechanism may apply to our case.…”

Section: Discussionsupporting

confidence: 52%

“…CHS is a serious postoperative complication of carotid endarterectomy or carotid artery stenting 13, 14. Surgical obliteration of intracranial giant aneurysm is also known to cause CHS 1, 15, 16, 17. Yet no earlier reports have described CHS after obliteration of an extracranial ICA aneurysm or the importance of perioperative CBF studies to assess the CHS risk in the treatment of extracranial ICA aneurysms.…”

Section: Discussionmentioning

confidence: 99%

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

Hirai¹,

Saigusa²,

Norisue³

et al. 2015

Journal of Vascular Surgery Cases

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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,...

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Section: Discussionsupporting

confidence: 52%

Section: Discussionmentioning

confidence: 99%

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

Hirai¹,

Saigusa²,

Norisue³

et al. 2015

Journal of Vascular Surgery Cases

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“…A few case reports have described CHS development in patients with large cerebral aneurysm treated by stent assisted coiling or flow diverter. 52 53 Therefore, larger series are required to clarify the relationship between the procedures and CHS.…”

Section: Cerebral Hyperperfusion Syndrome In Specific Conditionsmentioning

confidence: 99%

Update on cerebral hyperperfusion syndrome

Lin

Liu

2020

J NeuroIntervent Surg

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Cerebral hyperperfusion syndrome (CHS) is a clinical syndrome following a revascularization procedure. In the past decade, neurointerventional surgery has become a standard procedure to treat stenotic or occluded cerebral vessels in both acute and chronic settings, as well as endovascular thrombectomy in acute ischemic stroke. This review aims to summarize relevant recent studies regarding the epidemiology, diagnosis, and management of CHS as well as to highlight areas of uncertainty. Extracranial and intracranial cerebrovascular diseases in acute and chronic conditions are considered. The definition and diagnostic criteria of CHS are diverse. Although impaired cerebrovascular autoregulation plays a major role in the pathophysiology of CHS, the underlying mechanism is still not fully understood. Its clinical characteristics vary in different patients. The current findings on clinical and radiological presentation, pathophysiology, incidence, and risk factors are based predominantly on carotid angioplasty and stenting studies. Hemodynamic assessment using imaging modalities is the main form of diagnosis although the criteria are distinct, but it is helpful for patient selection before an elective revascularization procedure is conducted. After endovascular thrombectomy, a diagnosis of CHS is even more complex, and physicians should consider concomitant reperfusion injury. Management and preventative measures, including intensive blood pressure control before, during, and after revascularization procedures and staged angioplasty, are discussed in detail.

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“…It is caused by exhaustion of the cerebral autoregulation mechanisms (Normal Perfusion Pressure Breakthrough theory, NPPB) 9 and it can present with focal neurologic deficits, headache, confusion, seizures or intracerebral hemorrhage. 10 Although it has been widely reported after carotid endarterectomy (CEA) 11,12 and stenting, 13 it seems to be less common following interventions for arteriovenous malformations (AVMs). 14 NIRS is a non-invasive and objective technology that continuously monitors regional oxygen saturation (rSO 2 ).…”

Section: Discussionmentioning

confidence: 99%