Intracranial hemorrhage associated with cerebral hyperperfusion syndrome following carotid endarterectomy and carotid artery stenting: retrospective review of 4494 patients

Abstract

Cerebral hyperperfusion syndrome after CEA and CAS occurs with delayed classic and acute presentations, respectively. Although strict control of postoperative blood pressure prevents intracranial hemorrhage in patients with CHS after CEA, there appears to be no relationship between blood pressure control and intracranial hemorrhage in those with CHS after CAS. Finally, the prognosis of CHS in patients with associated intracerebral hemorrhage is poor.

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

“…Previous data showed the hyper-acute nature of HPS after CAS, 20) suggesting that postoperative CBF evaluation must be performed more promptly and with fixed timing after the procedure to study the relationship between CBF and HPS after CAS.…”

“…3) A review of 4494 patients who had undergone CEA or CAS demonstrated a high incidence and acute nature of HPS after CAS. 20) Therefore, a quick and simple method for the estimation of CBF changes is important for the postoperative management of patients undergoing CAS. Conventional methods to determine the CBF, such as perfusion CT, perfusion magnetic resonance imaging, and SPECT, might be too slow to assess cerebral perfusion before such acute HPS.…”

Preoperative Cerebral Oxygen Extraction Fraction Imaging Generated from 7T MR Quantitative Susceptibility Mapping Predicts Development of Cerebral Hyperperfusion following Carotid Endarterectomy

“…34 This may explain the low positive predictive value for the prediction of post-CEA hyperperfusion when only preoperative measurements of cerebral hemodynamics, such as the QSM-OEF ratio, are used. 34 Regarding management for cerebral hyperperfusion after CEA, several investigators have noted the following: 1) Twothirds of patients with cerebral hyperperfusion on brain perfusion imaging performed immediately after surgery develop intracerebral hemorrhage within 15 days after the operation if intensive blood pressure control is not started immediately afterwards, 5 and this intensive blood pressure control prevents the development of intracerebral hemorrhage due to cerebral hyperperfusion; 5,13 2) carotid artery stenosis and other vascular atherosclerotic diseases, including coronary artery disease or lower extremity atherosclerotic occlusive disease, often coexist, and the intensive blood pressure control (eg, intentional hypotension) for such patients induces ischemic events involving the other atherosclerotic steno-occlusive lesions, suggesting that only patients who are preoperatively determined to have a high risk of cerebral hyperperfusion or are identified as having cerebral hyperperfusion on brain perfusion imaging done immediately after surgery should undergo intensive blood pressure control to minimize the risk of hypotension-induced ischemic events; 13 and 3) an intraoperative administration of a free radical scavenger, edaravone, significantly prevents the development of cerebral hyperperfusion itself, 35 thus reducing the incidence of postoperative cognitive impairment, as well as postoperative intracerebral hemorrhage. 36 On the basis of these previous findings and the present data, we propose a practical clinical algorithm to manage cerebral hyperperfusion: A patient scheduled to undergo CEA first undergoes preoperative OEF imaging generated from MR QSM.…”

“…[1][2][3][4] Intracerebral hemorrhage has a low incidence (1%), but patients with this condition have a poor prognosis. 5 Moreover, several studies have found that post-CEA hyperperfusion, even when asymptomatic, causes slight but diffuse damage to the ipsilateral cerebral cortex and white matter. 3,6,7 This damage that occurs after CEA hyperperfusion is a principal cause of the postoperative cognitive impairment observed in 10% of patients following CEA.…”

A case of iliac artery injury treated by covered stent during carotid artery stenting

“…Cerebral infarction, hyperperfusion syndrome, hypotension or bradycardia are listed as the complication of CAS [7]. The puncture site complication is one of the most common complication of the CAS and it may result in severe condition.…”