Pathophysiology and management of reperfusion injury and hyperperfusion syndrome after carotid endarterectomy and carotid artery stenting

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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Differential Effects of Carotid Artery Stenting Versus Carotid Endarterectomy on External Carotid Artery Patency

Journal of Endovascular Therapy ◽

10.1583/1545-1550(2007)14[208:deocas]2.0.co;2 ◽

2007 ◽

Vol 14 (2) ◽

pp. 208-213 ◽

Cited By ~ 1

Author(s):

Edward Y. Woo ◽

Jagajan Karmacharya ◽

Omaida C. Velazquez ◽

Jeffrey P. Carpenter ◽

Christopher L. Skelly ◽

...

Keyword(s):

Carotid Artery ◽

Carotid Endarterectomy ◽

Carotid Artery Stenting ◽

External Carotid Artery ◽

External Carotid ◽

Differential Effects

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Faculty Opinions recommendation of Late outcomes after carotid artery stenting versus carotid endarterectomy: insights from a propensity-matched analysis of the Reduction of Atherothrombosis for Continued Health (REACH) Registry.

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

10.3410/f.5152956.5134054 ◽

2010 ◽

Author(s):

Bruce Biccard ◽

Reitze Rodseth

Keyword(s):

Carotid Artery ◽

Carotid Endarterectomy ◽

Carotid Artery Stenting

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Comparison of results between carotid endarterectomy versus carotid artery stenting using propensity score matching analysis

Journal of Vascular and Endovascular Surgery ◽

10.21767/2573-4482-c1-001 ◽

2018 ◽

Vol 03 ◽

Author(s):

Dong Ik Kim

Keyword(s):

Carotid Artery ◽

Propensity Score ◽

Carotid Endarterectomy ◽

Propensity Score Matching ◽

Carotid Artery Stenting ◽

Propensity Score Matching Analysis ◽

Comparison Of Results

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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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Distribution of Care and Hospital Incidence of Carotid Endarterectomy and Carotid Artery Stenting: A Secondary Analysis of German Hospital Episode Data

European Journal of Vascular and Endovascular Surgery ◽

10.1016/j.ejvs.2021.03.021 ◽

2021 ◽

Author(s):

Christoph Knappich ◽

Pavlos Tsantilas ◽

Michael Salvermoser ◽

Sofie Schmid ◽

Michael Kallmayer ◽

...

Keyword(s):

Carotid Artery ◽

Carotid Endarterectomy ◽

Carotid Artery Stenting ◽

Secondary Analysis ◽

German Hospital ◽

Hospital Episode

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Prospective validation of Canadian TIA Score and comparison with ABCD2 and ABCD2i for subsequent stroke risk after transient ischaemic attack: multicentre prospective cohort study

BMJ ◽

10.1136/bmj.n49 ◽

2021 ◽

pp. n49

Author(s):

Jeffrey J Perry ◽

Marco L A Sivilotti ◽

Marcel Émond ◽

Ian G Stiell ◽

Grant Stotts ◽

...

Keyword(s):

Emergency Department ◽

Cohort Study ◽

Carotid Artery ◽

Confidence Interval ◽

Carotid Endarterectomy ◽

Likelihood Ratio ◽

Transient Ischaemic Attack ◽

Carotid Artery Stenting ◽

Stroke Risk ◽

Ischaemic Attack

Abstract Objective To validate the previously derived Canadian TIA Score to stratify subsequent stroke risk in a new cohort of emergency department patients with transient ischaemic attack. Design Prospective cohort study. Setting 13 Canadian emergency departments over five years. Participants 7607 consecutively enrolled adult patients attending the emergency department with transient ischaemic attack or minor stroke. Main outcome measures The primary outcome was subsequent stroke or carotid endarterectomy/carotid artery stenting within seven days. The secondary outcome was subsequent stroke within seven days (with or without carotid endarterectomy/carotid artery stenting). Telephone follow-up used the validated Questionnaire for Verifying Stroke Free Status at seven and 90 days. All outcomes were adjudicated by panels of three stroke experts, blinded to the index emergency department visit. Results Of the 7607 patients, 108 (1.4%) had a subsequent stroke within seven days, 83 (1.1%) had carotid endarterectomy/carotid artery stenting within seven days, and nine had both. The Canadian TIA Score stratified the risk of stroke, carotid endarterectomy/carotid artery stenting, or both within seven days as low (risk ≤0.5%; interval likelihood ratio 0.20, 95% confidence interval 0.09 to 0.44), medium (risk 2.3%; interval likelihood ratio 0.94, 0.85 to 1.04), and high (risk 5.9% interval likelihood ratio 2.56, 2.02 to 3.25) more accurately (area under the curve 0.70, 95% confidence interval 0.66 to 0.73) than did the ABCD2 (0.60, 0.55 to 0.64) or ABCD2i (0.64, 0.59 to 0.68). Results were similar for subsequent stroke regardless of carotid endarterectomy/carotid artery stenting within seven days. Conclusion The Canadian TIA Score stratifies patients’ seven day risk for stroke, with or without carotid endarterectomy/carotid artery stenting, and is now ready for clinical use. Incorporating this validated risk estimate into management plans should improve early decision making at the index emergency visit regarding benefits of hospital admission, timing of investigations, and prioritisation of specialist referral.

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