Fatal intracranial hemorrhage after carotid artery stenting: Three case reports and a literature review

Introduction We herein describe three patients who developed fatal intracranial hemorrhage (ICH) after carotid artery stenting (CAS). Case Presentation: We retrospectively reviewed 126 patients who underwent CAS from January 2016 to December 2018 and identified 3 patients (2.4%) (all male, mean age of 59 years) who developed ICH after CAS. Two of them developed left basal ganglia hemorrhage with extension into the ventricle and subarachnoid space, and the third patient developed primary ventricular bleeding. One hemorrhage occurred immediately after CAS, whereas the other two occurred 3 hours and 8 hours after the procedure, respectively. The mean stenosis of the treated carotid arteries was 91%. All three hemorrhages were fatal, and the mean time from hemorrhage to death was 50 hours. Conclusion ICH is a potentially fatal complication of CAS and often occurs several hours after the procedure. Headache, vomiting, and consciousness disorders are the most common symptoms of ICH. Careful screening to identify high-risk patients and strict management of perioperative blood pressure are important to prevent this complication.

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Management of Mobile Floating Carotid Plaque Using Carotid Artery Stenting

Journal of Endovascular Therapy ◽

10.1177/152660280301000336 ◽

2003 ◽

Vol 10 (3) ◽

pp. 653-656 ◽

Cited By ~ 12

Author(s):

Elie Y. Chakhtoura ◽

Jonathan E. Goldstein ◽

Robert W. Hobson

Keyword(s):

Carotid Artery ◽

Carotid Artery Stenting ◽

Carotid Plaque ◽

Case Reports ◽

Duplex Ultrasound ◽

Carotid Stenting ◽

Clinical Results ◽

Unique Nature ◽

Risk Patients ◽

Ischemic Attack

Purpose: To present management techniques for dealing with mobile floating carotid plaque (MFCP), which represents an indeterminate risk of embolic cerebrovascular events. Case Reports: Two high-risk patients with a history of carotid endarterectomy were diagnosed with MFCP by duplex ultrasound scanning. One patient had a left hemispheric transient ischemic attack while the other was asymptomatic with a moderate stenosis. Both were successfully treated with carotid artery stenting, achieving complete coverage of the MFCP. Their outcomes were uneventful, and sustained patency of the stented arteries has been observed during an event-free survival of 32 and 44 months, respectively. Conclusions: Based upon the unique nature of these lesions and our satisfactory clinical results, we believe that carotid stenting may be a viable option for the treatment of MFCP.

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Intravascular Lithotripsy for Treatment of Calcified Lesions During Carotid Artery Stenting

Journal of Endovascular Therapy ◽

10.1177/1526602820954244 ◽

2020 ◽

pp. 152660282095424

Author(s):

Stefanos Giannopoulos ◽

Francesco Speziale ◽

Giuseppe Vadalà ◽

Peter Soukas ◽

Brian A. Kuhn ◽

...

Keyword(s):

Carotid Artery ◽

Carotid Artery Stenting ◽

De Novo ◽

Duplex Ultrasound ◽

Carotid Artery Lesions ◽

Risk Patients ◽

History Of ◽

Protection Devices ◽

The Mean ◽

Symptomatic Bradycardia

Purpose: To report the use of intravascular lithotripsy (IVL) in the treatment of calcified carotid artery lesions. Materials and Methods: The records of 21 high-surgical-risk patients (mean age 75.1±8.1 years; 17 men) who were treated at 8 centers for carotid artery stenosis ≥70% were retrospectively reviewed. Twelve patients had a history of cerebrovascular disease. All patients had heavily calcified carotid artery lesions: 19 de novo and 2 in-stent restenoses (ISR). The mean baseline stenosis was 82.3%±9.7%. IVL was utilized at the discretion of the operator, followed by balloon angioplasty. Embolic protection devices were used in all cases. Results: In 19 patients, IVL was followed by stent implantation; the 2 ISR lesions were dilated only. The mean IVL balloon diameter was 4.64±1.13 mm, and the mean number of IVL pulses applied was 67.2±61.4 (range 10–180). All procedures were technically successful (<30% residual stenosis). No patients developed symptomatic bradycardia or hypotension due to IVL, and there were no adverse events associated with IVL delivery. All patients were discharged on dual antiplatelet therapy. Seventeen days after the procedure, 1 patient experienced an ischemic stroke that was deemed due to aortic arch manipulation during transfemoral access. Carotid duplex ultrasound examination identified significant restenosis (>70%) in 1 asymptomatic patient at 12 months after the index procedure. No patients required reintervention during a median follow-up of 6 months (range 1–12). Conclusion: This preliminary experience demonstrates that IVL can be a safe and effective approach for the management of severely calcified carotid lesions. Further research is warranted to determine the longer-term safety and efficacy of IVL for dilation of calcified carotid artery lesions as an adjunct to carotid artery stenting.

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Pre-Procedural Statin Use Is Associated with Improved Long-Term Survival and Reduced Major Cardiovascular Events in Patients Undergoing Carotid Artery Stenting: A Retrospective Study

Journal of Clinical Medicine ◽

10.3390/jcm7090286 ◽

2018 ◽

Vol 7 (9) ◽

pp. 286 ◽

Cited By ~ 3

Author(s):

GianLuca Colussi ◽

Francesca Zuttion ◽

Bruno Bais ◽

Pierluigi Dolso ◽

Mariarosaria Valente ◽

...

Keyword(s):

Cardiovascular Risk ◽

Carotid Artery ◽

Carotid Artery Stenting ◽

Time Dependent ◽

Term Survival ◽

Long Term Survival ◽

Risk Patients ◽

Mean Time ◽

Statin Use

Carotid artery stenting (CAS) is a minimal invasive procedure used to resolve carotid occlusion that can be affected by peri-procedural complications. Statin use before CAS has shown to reduce peri-procedural risk and improve survival, though time-dependent cofactors that influence mortality has not been considered. The aim of this study was to evaluate long-term survival of patients who undergo CAS considering new occurred major adverse cardiovascular event (MACE) as time-dependent cofactor. In this study, 171 high cardiovascular risk patients (age 72 ± 8 years, 125 males) were enrolled after CAS procedure and were followed for a median of 8.4 years. Death occurred in 44% of patients with a mean time to death of 69 ± 39 months and MACE in 34% with a mean time of 35 ± 42 months. In patients who used or not statins at baseline, death occurred in 33% and 65%, respectively (p < 0.001). Survival analysis showed that statin use reduced risk of death (hazard ratio HR 0.36, 95% confidence interval CI 0.23–0.58, p < 0.0001). Including MACE as time-dependent variable did not change beneficial effects of statins. Additionally, statin use was associated with a protective effect on MACE (HR 0.48, 95% CI 0.27–0.85, p = 0.012); particularly, the prevalence of stroke was reduced by 59% (p = 0.018). In multivariate analysis, effects of statins were independent of demographic and anthropometric variables, prevalence of cardiovascular risk factors, renal function, antiplatelet use, and MACE occurrence. In conclusion, use of statins before CAS procedure is associated with increased long-term survival and reduced MACE occurrence. This evidence supports the hypothesis that statin use before CAS might be beneficial in high risk patients.

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Treatment and Outcome of Intracranial Hemorrhage after Carotid Artery Stenting

Interventional Neuroradiology ◽

10.1177/159101990901500309 ◽

2009 ◽

Vol 15 (3) ◽

pp. 316-324 ◽

Cited By ~ 6

Author(s):

Y. Xu ◽

Y. Wanga ◽

L. Feng ◽

Z. Miao ◽

F. Ling

Keyword(s):

Carotid Artery ◽

Intracranial Hemorrhage ◽

Carotid Artery Stenting ◽

Neurocritical Care ◽

Onset Time ◽

Surgical Drainage ◽

Good Recovery ◽

Fatal Complication ◽

The Mean

Intracranial hemorrhage following carotid artery stenting (CAS) is a rare but potentially devastating complication. The present study reviewed intracranial hemorrhage cases from patients undergoing CAS in ten years to find the methods to rescue patients from this fatal complication. Patients with postoperative intracranial hemorrhage following CAS were retrospectively selected, and clinical features, treatments and outcomes were studied. Ten patients with intracranial hemorrhage were identified. The mean onset time of hemorrhage was 6.1 ± 7.1 h. Intracerebral hemorrhage occurred in eight patients and SAH in two patients. The patients were treated by stopping anti-platelet and anticoagulant for at least three days, and surgical drainage of the hematoma/ventricle drainage or conservative treatment. Six patients survived, two had left moderate paralysis, four had a good recovery at four week follow-up, and four patients died. No patients underwent thrombosis in stent after withdrawing of antiplatelet and anticoagulant. Intracranial hemorrhage after CAS occurs usually in a few hours and leads to catastrophic results. Once patients have intracranial hemorrhage, good neurocritical care may help to save them. Stopping antiplatelet and anticoagulant for at least three days may avoid thrombosis in the stenting site.

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Protected Carotid-Artery Stenting Versus Endarterectomy in High-Risk Patients

Yearbook of Neurology and Neurosurgery ◽

10.1016/s0513-5117(08)70247-3 ◽

2006 ◽

Vol 2006 ◽

pp. 19-23

Author(s):

A.A. Rabinstein ◽

M.R. Mayberg

Keyword(s):

High Risk ◽

Carotid Artery ◽

Carotid Artery Stenting ◽

High Risk Patients ◽

Risk Patients

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Cerebral microembolization after protected carotid artery stenting in surgical high-risk patients: Results of a 2-year prospective study

Yearbook of Vascular Surgery ◽

10.1016/s0749-4041(08)70558-x ◽

2007 ◽

Vol 2007 ◽

pp. 288-289

Author(s):

G.L. Moneta

Keyword(s):

High Risk ◽

Carotid Artery ◽

Prospective Study ◽

Carotid Artery Stenting ◽

High Risk Patients ◽

Risk Patients

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Risk factors for hyperperfusion-induced intracranial hemorrhage after carotid artery stenting in patients with symptomatic severe carotid stenosis evaluation

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2018-013998 ◽

2018 ◽

Vol 11 (5) ◽

pp. 474-478 ◽

Cited By ~ 5

Author(s):

Lei Zhang ◽

Dongwei Dai ◽

Zifu Li ◽

Guoli Duan ◽

Yong-wei Zhang ◽

...

Keyword(s):

Risk Factors ◽

Carotid Artery ◽

Carotid Stenosis ◽

Intracranial Hemorrhage ◽

Carotid Artery Stenting ◽

Ct Perfusion ◽

Treatment Strategies ◽

Imaging Features ◽

Anterior Circulation ◽

Total Occlusion

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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