Cerebral Hyperperfusion Syndrome After Endovascular Reperfusion Therapy in a Patient with Acute Internal Carotid Artery and Middle Cerebral Artery Occlusions

Cerebral hyperperfusion syndrome is a rare but severe complication of carotid artery stenting or carotid endarterectomy. Staged angioplasty is reportedly an effective strategy to avoid cerebral hyperperfusion syndrome. We encountered a case of internal carotid artery stenosis with a rare clinical presentation of limb shaking that was successfully improved by staged angioplasty. To our knowledge, there are no reported cases of limb shaking treated with staged angioplasty. A 76-year-old woman presented with continuous chorea in her left lower limb and shoulder. Medical examination revealed a tiny cerebral infarction in the right corona radiata and severe right internal carotid artery stenosis. Angiography showed near occlusion of the right internal carotid artery. Staged angioplasty was performed to avoid the risk of cerebral hyperperfusion syndrome. The first angioplasty resulted in an expanded diameter of 2.5 mm and was followed by definitive carotid artery stenting using a closed-cell stent 3.5 weeks later. Limb shaking improved in a stepwise manner along with an improvement in internal carotid artery stenosis and distal flow state with no signs of cerebral hyperperfusion syndrome. Patients with internal carotid artery stenosis or occlusion presenting with limb shaking have been suggested to have impaired cerebrovascular reactivity, which is also thought to be a risk factor for cerebral hyperperfusion syndrome. The stepwise improvement in limb shaking observed in this case supports the idea that the pathophysiology of limb shaking is related to cerebral haemodynamic impairment. Measures to prevent cerebral hyperperfusion syndrome, including staged angioplasty, should be actively considered in patients with limb shaking because the symptoms themselves suggest severe hypoperfusion.

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Cerebral Hyperperfusion Syndrome following Protected Carotid Artery Stenting

Case Reports in Vascular Medicine ◽

10.1155/2013/207602 ◽

2013 ◽

Vol 2013 ◽

pp. 1-4

Author(s):

Rainer Knur

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Carotid Artery Stenting ◽

Internal Carotid ◽

Rare Complication ◽

Left Internal Carotid Artery ◽

Cerebral Hyperperfusion Syndrome ◽

Hyperperfusion Syndrome ◽

Cerebral Hyperperfusion ◽

Almost All

The cerebral hyperperfusion syndrome is a very rare complication after revascularization of the carotid artery and accompanied by postoperative or postinterventional hypertension in almost all patients. We report a case of a 77-year-old man who developed a complete aphasia and increased right-sided weakness following endovascular treatment of severe occlusive disease of the left internal carotid artery. We discuss the risk and management of cerebral hyperperfusion syndrome after carotid artery stenting.

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Cerebral Hyperperfusion Syndrome After Superficial Temporal Artery-middle Cerebral Artery Bypass for Severe Intracranial Steno-occlusive Disease: A Case Control Study

Neurosurgery ◽

10.1227/neu.0b013e31828bb8b3 ◽

2013 ◽

Vol 72 (6) ◽

pp. 936-943 ◽

Cited By ~ 8

Author(s):

Kejia Teo ◽

David K.S. Choy ◽

Sein Lwin ◽

Chou Ning ◽

Tseng Tsai Yeo ◽

...

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Bypass Surgery ◽

Internal Carotid ◽

Artery Bypass ◽

Neurological Deficits ◽

External Carotid ◽

Cerebral Hyperperfusion Syndrome ◽

Hyperperfusion Syndrome ◽

Cerebral Hyperperfusion

Abstract BACKGROUND: Intracranial stenoses carry increased risk for cerebral ischemia. We perform external carotid-internal carotid (EC-IC) artery bypass in our patients with severe stenosis of the intracranial internal carotid (ICA) or middle cerebral artery (MCA) with impaired cerebral vasodilatory reserve (CVR). OBJECTIVE: To evaluate cerebral hemodynamics and cerebral hyperperfusion syndrome (HPS) in patients who develop focal neurological deficits after EC-IC bypass surgery. METHODS: Patients with severe intracranial ICA or MCA stenosis and impaired CVR on transcranial Doppler (TCD) derived breath-holding index (BHI) were evaluated with acetazolamide-challenged technetium-99m hexamethylpropyleneamineoxime–single-photon emission computed tomography (SPECT). EC-IC bypass surgery was offered to patients with impaired CVR on SPECT. Close monitoring was performed in patients developing focal neurological deficits within 7 days of surgery. RESULTS: Of 112 patients with severe intracranial ICA/MCA stenosis, 77 (69%) showed impaired CVR and 46 (41%) underwent EC-IC bypass. Transient neurological deficits within 7 days of surgery developed in 8 (17%). HPS was confirmed by CT perfusion and/or SPECT in 7 cases. A strong correlation was observed between HPS and preoperative TCD-BHI values (0%, 6.3%, and 41% in patients with BHI 0.3-0.69, 0-0.3 and <0, respectively; P = .012). HPS patients showed more than a 50% increase in MCA flow velocity on TCD (compared with preoperative values) on the operated side (63.3% vs 3.3% on control side, P < .001). Meticulous control of blood pressure and hydration led to rapid and complete resolution of neurological deficits in all cases. CONCLUSION: Symptomatic cerebral HPS is common in the early postoperative period after EC-IC bypass surgery. Early diagnosis and appropriate management might prevent the complications of this syndrome.

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