Reversible cerebral hyperperfusion syndrome after stenting of the carotid artery—Two case reports

Abstract

Hyperperfusion syndrome can complicate carotid revascularization, be it endarterectomy or carotid artery stenting (CAS). Although extensive effort has been devoted to reducing the incidence of ischemic stroke complicating CAS, little is known about the incidence, etiology, and prevention strategies for hyperperfusion following CAS. We report two cases (female patients 72 and 81 years) presenting severe internal carotid stenosis (> 90%), who underwent presurgical and therapeutic intervention with CAS. Both patients developed hyperperfusion symptoms at 2 hours and at 30 minutes, respectively, following stenting, in both cases unilateral hyperperfusion was CCT confirmed. Case 1 was presenting with acute edema of the right hemisphere, case 2 with distended focal edema (left fronto-temporoparietally). Hyperperfusion syndrome and neurological symptoms retroceded in both cases (conservative therapy) and both patients returned to full activity (case 2 within 48 hours).

Brain Edema after Carotid Revascularization: Benign Syndrome or Prelude to Hemorrhage?

“…In our opinion, the main conclusion of this communication is that BE post CR is not always a benign syndrome that tends to resolve spontaneously (as suggested by several previous reports [3][4][5][6] , but rather more a dangerous situation that can be reversible (patients 1 and 2), but also severely worsened by hemorrhage (patient 3). This fact should be strongly considered by neurologists dealing with this complication, as spontaneous resolution should not be routinely expected and strict clinical and radiologic follow-up of these patients should be maintained.…”

“…It includes unilateral headache, seizures, cerebral hemorrhage, and symptomatic brain edema (BE) [1][2][3][4][5][6] . BE is an uncommon presentation of HS and has been related to the production of vasogenic edema, and speculated to have a benign course with spontaneous resolution of the neurologic deficits and radiologic findings [3][4][5][6] . Its mechanism has been studied by magnetic resonance 5 and linked to hypertensive encephalopathy and other related reversible conditions 6 .…”

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

“…14,31,33,35,40,43,45,50 Carotid artery angioplasty with stent placement has been proposed as an alternative technique for revascularization in cases of ICA stenosis. 38 Although there have been multiple reports of CHS following CAS, 1,2,6,11,12,18,[21][22][23][24]34,37 study populations have been too small for the proper characterization of clinical attributes. Moreover, it is unclear whether there are differences in clinical features when comparing those who experience postoperative CHS after CAS versus those who have the condition following CEA.…”

Cerebral Hyperperfusion Syndrome After Angioplasty

“…Several investigators have analyzed the characteristics of this ICH when it appears in the first few hours and without prodromes, attributing it to the rupture of deep penetrating arteries as a result of the sudden normalization of the pressure of cerebral perfusion after angioplasty, similar to what occurs in hemorrhage due to hypertension (Buhk et al, 2006;Coutts et al, 2003). Many cases of SAH after CAS have been reported (Abou-Chebl et al, 2004;Coutts et al, 2003;Hartmann et al, 2004;Ho et al, 2000;McCabe et al, 1999;Meyers et al, 2000;Morrish et al, 2000;Nikolsky et al, 2002;Pilz et al, 2006;Qureshi et al, 2002); these have a better prognosis than ICH. It is logical to assume that CBF increases substantially after CAS in a severely stenosed carotid artery.…”