Subarachnoid Hemorrhage Due to Cerebral Hyperperfusion Syndrome after Carotid Endarterectomy Performed in the Acute Phase of a Cerebral Infarction: A Case Report

Abstract

Intracranial hemorrhages can occur after carotid revascularization due to cerebral hyperperfusion syndrome (CHS). Subarachnoid hemorrhages associated with CHS after carotid artery stenting (CAS) have been reported in many cases; however, they are rare after carotid endarterectomy (CEA). We report a case of subarachnoid hemorrhage (SAH) associated with CHS after CEA performed in the acute phase of a cerebral infarction. A 50-year-old man was admitted to our hospital with transient right hemiparesis and dysarthria. Magnetic resonance imaging (MRI) demonstrated a cerebral infarction in the left cerebral hemisphere. Digital subtraction angiography revealed a severe stenosis in the right cervical internal carotid artery. Medical treatment was started; however, cerebral infarction progressed. CEA was performed on the 7th day after admission. On the first postoperative day, MRI demonstrated SAH in the sulcus of the frontal and parietal lobes. Xenon CT revealed an increased cerebral blood flow (CBF) in the left cerebral hemisphere. We diagnosed CHS after CEA. We continued sedation using Propofol and maintained the systolic blood pressure below 120 mmHg using nicardipine. Sedation was stopped on postoperative day 3. The patient was discharged with slight dysarthria on postoperative day 17. SAH due to CHS is rare but can occur early after CEA. Careful patient management is required after CEA in consideration of SAH due to CHS.

Asymptomatic subarachnoid hemorrhage following carotid endarterectomy: illustrative case

“…With regard to patch use, Ishida et al 3 reported a case of CHS similar to ours. They suggested that the use of a patch contributed to local increases in CBF and SAH.…”

“…We found only four previous reports of similar cases ( Table 1 ). 3–6 All cases were symptomatic, and two cases had poor outcomes with impaired consciousness or seizures. In addition, all four cases were accompanied by CHS.…”

“… 2 The incidence of ICH after CEA is reported to be between 0.2% and 0.6%, whereas reports of subarachnoid hemorrhage (SAH) are extremely rare. 1 , 3–6 Herein, we report a case of non-aneurysmal SAH that occurred after CEA without any symptoms and review the literature.…”