Intracranial hemorrhage and hyperperfusion syndrome following carotid artery stenting: risk factors, prevention and treatment

BackgroundAnalyzing risk factors for hyperperfusion-induced intracranial hemorrhage (HICH) after carotid artery stenting (CAS) in patients with symptomatic severe carotid stenosis.MethodsThis study retrospectively analyzed clinical data of 210 patients, who had symptomatic severe carotid stenosis (70–99%) and received CAS treatment between June 2009 and June 2015, and evaluated the relationship of HICH with patients’ clinical baseline data, imaging features, and treatment strategies.ResultsSeven patients (3.3%) developed HICH after CAS. The incidence of HICH among patients with near total occlusion was significantly higher than among those without (10.1% vs 0%, P<0.001). Out of the seven, five had no development of either anterior or posterior circulations, and two had no development of anterior circulation and poor development of posterior circulation. Results showed that patients with poor compensation of Willis’ Circle were more likely to develop HICH compared with other patients (P<0.001). All patients received preoperative CT perfusion. TTP index was defined as the TTP ratio between the affected and contralateral side. The results showed that the TTP index was significantly different between the HICH group and non-HICH group (1.15±0.10 vs 1.30±0.15, P<0.001). An analysis of the ROC curve indicated that patients with TTP index >1.22 were more likely to develop HICH compared with other patients (sensitivity 100%, specificity 75.9%).ConclusionsPatients with severe unilateral carotid stenosis, the presence of near total occlusion, poor compensation of Willis’ Circle, and preoperative TTP index>1.22, have a higher risk of developing HICH after CAS.

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Intracranial hemorrhage and hyperperfusion syndrome following carotid artery stenting

Journal of the American College of Cardiology ◽

10.1016/j.jacc.2003.12.039 ◽

2004 ◽

Vol 43 (9) ◽

pp. 1596-1601 ◽

Cited By ~ 227

Author(s):

Alex Abou-Chebl ◽

Jay S Yadav ◽

Joel P Reginelli ◽

Christopher Bajzer ◽

Deepak Bhatt ◽

...

Keyword(s):

Carotid Artery ◽

Intracranial Hemorrhage ◽

Carotid Artery Stenting ◽

Hyperperfusion Syndrome

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

Journal of Neurosurgery ◽

10.3171/jns-07/12/1130 ◽

2007 ◽

Vol 107 (6) ◽

pp. 1130-1136 ◽

Cited By ~ 172

Author(s):

Kuniaki Ogasawara ◽

Nobuyuki Sakai ◽

Terumasa Kuroiwa ◽

Kohkichi Hosoda ◽

Koji Iihara ◽

...

Keyword(s):

Blood Pressure ◽

Carotid Artery ◽

Carotid Endarterectomy ◽

Intracranial Hemorrhage ◽

Carotid Artery Stenting ◽

Clinicopathological Features ◽

Cerebral Hyperperfusion Syndrome ◽

Hyperperfusion Syndrome ◽

Cerebral Hyperperfusion ◽

Postoperative Control

Object Intracranial hemorrhage associated with cerebral hyperperfusion syndrome (CHS) following carotid endarterectomy (CEA) or carotid artery stenting (CAS) is a rare but potentially devastating complication. In the present study the authors evaluated 4494 patients with carotid artery stenosis who had undergone CEA or CAS to clarify the clinicopathological features and outcomes of those with CHS and associated intracranial hemorrhage. Methods Patients with postoperative CHS were retrospectively selected, and clinicopathological features and outcomes were studied. Results Sixty-one patients with CHS (1.4%) were identified, and intracranial hemorrhage developed in 27 of them (0.6%). The onset of CHS peaked on the 6th postoperative day in those who had undergone CEA and within 12 hours in those who had undergone CAS. Results of logistic regression analysis demonstrated that poor postoperative control of blood pressure was significantly associated with the development of intracranial hemorrhage in patients with CHS after CEA (p = 0.0164). Note, however, that none of the tested variables were significantly associated with the development of intracranial hemorrhage in patients with CHS after CAS. Mortality (p = 0.0010) and morbidity (p = 0.0172) rates were significantly higher in patients with intracranial hemorrhage than in those without. Conclusions 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.

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

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.1097374.553397 ◽

2007 ◽

Author(s):

Nicolas Bruder

Keyword(s):

Carotid Artery ◽

Carotid Endarterectomy ◽

Intracranial Hemorrhage ◽

Retrospective Review ◽

Carotid Artery Stenting ◽

Cerebral Hyperperfusion Syndrome ◽

Hyperperfusion Syndrome ◽

Cerebral Hyperperfusion

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Staged angioplasty: A sensible approach to prevent hyperperfusion syndrome after carotid artery stenting? A meta-analysis

Interventional Neuroradiology ◽

10.1177/15910199211018328 ◽

2021 ◽

pp. 159101992110183

Author(s):

Bingyang Zhao ◽

Xinzhao Jiang ◽

Pei Wang ◽

Zhongyu Zhao ◽

Jing Mang ◽

...

Keyword(s):

Carotid Artery ◽

Carotid Artery Stenting ◽

Meta Analysis ◽

Random Effect ◽

Thromboembolic Events ◽

Current Recommendation ◽

Hyperperfusion Syndrome ◽

Asian Populations ◽

Significant Difference ◽

Vessel Dissection

Objective To investigate whether staged angioplasty (SAP) is a safe and effective treatment to prevent hyperperfusion syndrome after carotid artery stenting (CAS). Methods A systematic literature search was performed according to established criteria to identify eligible articles published before October 2020. Pooled dichotomous data were presented as odds ratios (OR) and corresponding 95% confidence intervals (CI) using random-effect models. The efficacy endpoints were hyperperfusion syndrome (HPS), hyperperfusion phenomenon (HPP), and intracerebral hemorrhage (ICH). The safety endpoint was post-procedural thromboembolic events. The feasibility of the procedure was assessed by device-related adverse events (vessel dissection and failed angioplasty) in SAP. Results Ten studies (1030 participants) were eligible. SAP was superior to regular CAS in preventing HPS (OR = 0.35, 95% CI 0.14–0.86, P = 0.02). There was no significant difference in the rate of thromboembolic events between the SAP group and the regular CAS group. The rates of vessel dissection and failed angioplasty with the use of a 3.0-mm-diameter balloon were 5.4% and 0.4%, respectively. Conclusion SAP may reduce the incidence of post-CAS HPS without increasing procedure-related complications. A 3.0-mm-diameter balloon used in SAP may be appropriate for Asian populations. However, the confounded study design and confused definitions of reporting items hinder the current recommendation of SAP in clinical use.

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Increased Rates of Hemorrhages after Endovascular Stroke Treatment with Emergency Carotid Artery Stenting and Dual Antiplatelet Therapy

Cerebrovascular Diseases ◽

10.1159/000512204 ◽

2021 ◽

pp. 1-9

Author(s):

Felix Hadler ◽

Raveena Singh ◽

Martin Wiesmann ◽

Arno Reich ◽

Omid Nikoubashman

Keyword(s):

Risk Factors ◽

Carotid Artery ◽

Antiplatelet Therapy ◽

Carotid Artery Stenting ◽

Dual Antiplatelet Therapy ◽

Stroke Treatment ◽

Systemic Thrombolysis ◽

Stroke Registry ◽

Increased Risk ◽

Arterial Thrombolysis

Background: While endovascular stroke treatment (EST) of large vessel occlusions in acute ischemic stroke (AIS) is proven to be safe and effective, there are subgroups of patients with increased rates of hemorrhages. Our goal was to identify risk factors for intracerebral hemorrhage and to assess whether acute carotid artery stenting (CAS) was associated with increased bleeding rates. Methods: We performed a retrospective analysis of our monocentric prospective stroke registry in the period from May 2010 to May 2018 and compared AIS patients receiving EST with (n = 73) versus without acute CAS (n = 548). Patients with intracranial stents, intra-arterial thrombolysis, or dissection of the carotid artery were excluded. Results: Parenchymal hemorrhage rates (PH2 according to the ECASS classification) and symptomatic hemorrhage (sICH) rates were increased in EST patients receiving CAS with odds being 6.3 (PH2) and 6.5 (sICH) times higher (PH2 17.8 vs. 3.3%, p < 0.001 and sICH: 16.4 vs. 2.9%, p < 0.001). Additional systemic thrombolysis with rtPA (IVRTPA) was no risk factor for cerebral hemorrhage (p = 0.213). Conclusion: AIS patients receiving EST with acute CAS and consecutive tirofiban or dual antiplatelet therapy suffered from an increased risk of relevant secondary intracranial bleeding. After adjusting for confounders, tirofiban and dual antiplatelet therapy were associated with higher bleeding rates.

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Risk Factors for Cerebral Embolization After Carotid Artery Stenting With Embolic Protection

Circulation Cardiovascular Interventions ◽

10.1161/circinterventions.112.000093 ◽

2013 ◽

Vol 6 (3) ◽

pp. 311-316 ◽

Cited By ~ 24

Author(s):

Klaudija Bijuklic ◽

Andreas Wandler ◽

Yuriy Varnakov ◽

Thilo Tuebler ◽

Joachim Schofer

Keyword(s):

Risk Factors ◽

Carotid Artery ◽

Carotid Artery Stenting ◽

Embolic Protection ◽

Cerebral Embolization

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Risk Factors Predictive of Carotid Artery Stenting–Associated Subclinical Microemboli

International Journal of Angiology ◽

10.1055/s-0031-1272546 ◽

2011 ◽

Vol 20 (01) ◽

pp. 025-032 ◽

Cited By ~ 7

Author(s):

Wei Zhou ◽

Rosa Zareie ◽

Maureen Tedesco ◽

Simin Gholibeikian ◽

Barton Lane ◽

...

Keyword(s):

Risk Factors ◽

Carotid Artery ◽

Carotid Artery Stenting

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Abstract W P115: Utilization of Blood Sampling Global Oxygen Extraction Fraction and SPECT to Anticipate Cerebral Hyperperfusion Syndrome Following Elective Carotid Artery Stenting

Stroke ◽

10.1161/str.46.suppl_1.wp115 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Takahisa Mori ◽

Tomonori Iwata ◽

Yuhei Tanno ◽

Shigen Kasakura ◽

Yoshinori Aoyagi ◽

...

Keyword(s):

Carotid Artery ◽

Carotid Artery Stenting ◽

Blood Sampling ◽

Oxygen Extraction Fraction ◽

Oxygen Extraction ◽

Cerebral Hyperperfusion Syndrome ◽

Hyperperfusion Syndrome ◽

Cerebral Hyperperfusion ◽

Arterial Blood ◽

Extraction Fraction

Background: It is required to anticipate cerebral hyperperfusion syndrome (CHS) following carotid artery stenting (CAS). Purpose: The purpose of our retrospective study was to investigate whether or not blood sampling oxygen extraction fraction (OEF) and post-CAS CBF increase in SPECT had relation to CHS following CAS. Methods: Included in our analysis were patients (1) who underwent elective CAS in our institution between October 2010 and May 2014, and (2) who underwent blood sampling for OEF calculation before and immediately after CAS, and (3) who underwent SPECT before and just after CAS. OEF was calculated from cerebral arteriovenous oxygen difference. Arterial blood was sampled from the common carotid artery and venous blood from the dominant-sided superior jugular bulb. CHS was defined as pulsatile headaches, restlessness, convulsion, and/or new neurological symptoms not due to cerebral ischemia within seven days following CAS. CBF was measured before and just after CAS. CBF increase in the CAS side was defined as follows; (post-CAS CBF ratio - pre-CAS CBF ratio) of more than 10%, where CBF ratio was defined as CAS-sided fronto-parietal CBF divided by ipsilateral cerebellar CBF (%). Evaluated were baseline features in patients, pre-CAS OEF, post-CAS OEF, CBF ratio, CBF increase and CHS. Results: During the study period, 134 patients matched our criteria for analysis. Pre-CAS OEF was 0.41+-0.06, post-CAS OEF was 0.42+-0.08, pre-CAS CBF ratio: 88.7+-15.4%, CBF increase: 1.86+-12.3%. Nine patients presented CHS. Among them, pre-CAS OEF, CBF ratio and CBF increase were significant. ROC curves showed that pre-CAS OEF of 0.46 (p<0.001, OR: 9.3), CBF ratio of 92%(p<0.05, OR: 6.5), CBF increase of 8.8% (p<0.005, OR: 6.6) were cut-off values. Among 10 patients with pre-CAS OEF of more than 0.46 and CBF increase of more than 8.8%, 4 patients presented CHS (p<0.0001, OR;15.9). Conclusion: Elevation of pre-CAS OEF and increase of post-CAS CBF were strongly related to CHS.

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