Effect of perioperative blood pressure variability on cerebral hyperperfusion syndrome after carotid artery stenting: A retrospective study

Objective To investigate the effect of perioperative blood pressure variability on cerebral hyperperfusion syndrome after carotid artery stenting. Methods A retrospective analysis was conducted of data collected from 418 patients who underwent carotid artery stenting in Guangxi Zhuang Autonomous Region People's Hospital in China. The blood pressure data were collected during operation (after balloon dilation, before stent release, after stent release) and within 3 days after the operation. The blood pressure variability was evaluated by measuring the mean, maximum, minimum, max–min, standard deviation (SD) of systolic blood pressure (SBP) and diastolic blood pressure (DBP). The correlation between blood pressure variability and cerebral hyperperfusion syndrome was analysed. Results Blood pressure data from 418 patients were analysed. Twenty patients (4.8%) developed cerebral hyperperfusion syndrome. The parameters of blood pressure variability were divided into four groups according to quartile. After adjusting for age, symptomatic carotid stenosis, unilateral carotid stenosis, bilateral carotid stenosis, collateral circulation, diabetes mellitus and chronic kidney disease, multivariate analysis showed that SBPMax, SBPMin, SBPMax−Min, SBPCV, DBPSD, DBPMax, DBPMin, DBPMax−Min and DBPCV were associated with the occurrence of cerebral hyperperfusion syndrome ( P < 0.05), respectively. Conclusion This study suggests that blood pressure variability during the perioperative period may increase the risk of cerebral hyperperfusion syndrome.

Pre-operative Cerebral Small Vessel Disease on MR Imaging Is Associated With Cerebral Hyperperfusion After Carotid Endarterectomy

Objectives: To determine whether pre-operative cerebral small vessel disease is associated with cerebral hyperperfusion (CH) after carotid endarterectomy (CEA).Methods: Seventy-seven patients (mean age of 66 years and 58% male) undergoing CEA for carotid stenosis were investigated using brain MRI before and after surgery. CH was defined as an increase in cerebral blood flow &gt; 100% compared with pre-operative values on arterial spin labeling MR images. The grade or the number of four cerebral small vessel disease markers (white matter hyperintensities, lacunes, perivascular spaces, and cerebral microbleeds) were evaluated based on pre-operative MRI. Cerebral small vessel disease markers were correlated with CH by using multivariate logistic regression analysis. The cutoff values of cerebral small vessel disease markers for predicting CH were assessed by receiver-operating characteristic curve analysis.Results: CH after CEA was observed in 16 patients (20.78%). Logistic regression analysis revealed that white matter hyperintensities (OR 3.09, 95% CI 1.72–5.54; p &lt; 0.001) and lacunes (OR 1.37, 95% CI 1.06–1.76; p = 0.014) were independently associated with post-operative CH. Receiver-operating characteristic curve analysis showed that Fazekas score of white matter hyperintensities ≥3 points [area under the curve (AUC) = 0.84, sensitivity = 81.3%, specificity = 73.8%, positive predictive value (PPV) = 44.8% and negative predictive value (NPV) = 93.8%] and number of lacunes ≥ 2 (AUC = 0.73, sensitivity = 68.8%, specificity = 78.7%, PPV = 45.8% and NPV = 90.6%) were the optimal cutoff values for predicting CH.Conclusion: In patients with carotid stenosis, white matter hyperintensities and lacunes adversely affect CH after CEA. Based on the NPVs, pre-operative MR imaging can help identify patients who are not at risk of CH.

Atypical Perfusion Manifestation in Migraine with Aura

Migraine with aura may be confused with a stroke. Magnetic resonance imaging is an important tool for the differential diagnosis. Cerebral hypoperfusion has been described in classic migraine, mainly during the aura. A 47-year-old male had an unremarkable past medical history. After sneezing, he developed a left hemi hypoesthesia, bitemporal vision loss, photopsia, and some distortion in the position of letters and words. This lasted &#x3c;1 h, and it was followed by a severe headache. A magnetic resonance angiography was performed during the headache. It showed a left hemispheric hypoperfusion that did not correlate with the symptoms described by the patient. It is believed that during the aura, cerebral blood flow decreases, leading to hypoxia and decreased cellular energy generation, and these metabolic alterations define the symptoms of the patient. In our case, we documented brain hypoperfusion during the headache in the ipsilateral brain hemisphere to the symptoms, which has no clinical correlation. This condition could be due to spasm in the capillary arteries, and it may persist and influence the clinical manifestations during the headache phase in migraine with aura. A state of generalized cerebral hyperperfusion has been suggested, and there may be a coexistence of both phenomena for some period. This may open a new line of research regarding the pathophysiology and vascular changes of migraine with aura.

TP10.1.12Personal Protective Equipment impairs pulmonary gas exchange causing systemic hypercapnia-hypoxaemia and cerebral hyperperfusion-induced cephalalgia

Aims To what extent Personal Protective Equipment (PPE) impacts integrated cardiopulmonary-cerebrovascular function has not been examined. The hypothesis tested was that PPE adversely influences pulmonary gas exchange, resulting in systemic hypercapnic-hypoxaemia and cerebral hyperperfusion-induced cephalalgia. Methods Eight male Higher Surgical Trainees (aged 33 ± 2y) participated in a repeated measures crossover study, completing two-hour laparoscopic simulation tasks, on two separate occasions (separate days), once in standard operating attire, and once in full PPE (including FFP3 mask). Results Following two hours of simulation, full PPE (compared with standard operating attire) was associated with increased FICO2 (7.9% (±0.8%) vs. 7.1% (±1.2%); p = 0.025), decreased FIO2 (16.0% (±0.4%) vs. 16.6% (±0.5%); p = 0.011), and decreased peripheral O2 saturation (95% (± 1%) vs. 98% (±1%); p = 0.001). Headaches were reported by three participants in PPE (Chi2 3.692, p = 0.055), and was associated with increased Middle Cerebral Artery flow velocity; 82 (±4) cm/s, compared with 63 (±9) cm/s in the remaining five participants (p = 0.008). Skin temperature increased by 1.3 °C during simulation in PPE (p = 0.001), with an equal mean insensible fluid loss of 300ml under both conditions (p = 0.049). Conclusions Collectively, these findings highlight the integrated cardiopulmonary-cerebrovascular complications associated with PPE-induced impairment in pulmonary gas exchange. Protective countermeasures should be designed to prevent risk to healthcare staff and patients alike.

Stepwise improvement in limb shaking achieved by staged angioplasty for severe carotid stenosis

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.