Hyperperfusion Syndrome after Carotid Endarterectomy

doi:10.1007/s10016-005-4644-3

Annals of Vascular Surgery

Volume 19, Issue 4, July 2005, Pages 479-486

https://doi.org/10.1007/s10016-005-4644-3 Get rights and content

The hyperperfusion syndrome is a rare delayed postoperative complication of carotid endarterectomy (CEA) characterized by headache and seizure, with or without intracranial edema or hemorrhage. Between January 1996 and December 2003, 1,602 CEAs were performed. Six patients (0.4%) developed symptoms of hyperperfusion within 2 weeks of surgery. All patients had critical stenoses, five ≥90% and one 80-90%, with poor backbleeding from the distal internal carotid artery noted at operation in all cases. Five patients were asymptomatic prior to operation; one had a hemispheric transient ischemic attack. Three patients had severe contralateral internal carotid disease (two occlusions and one severe stenosis). Two patients developed severe, self-limiting headache that prolonged hospitalization. Three patients had ipsilateral intracranial bleeding, two occurring after an uneventful postoperative course. After initial discharge from the hospital, severe intracranial hemorrhage caused death in two patients. One patient experienced focal seizures 1 week after discharge. Hypertension did not appear to be related to the symptoms in any case. During the study period, the hyperperfusion syndrome caused three of five perioperative strokes (60%) and two of seven deaths (29%) in the entire endarterectomy population. Although rare, the hyperperfusion syndrome accounts for a significant percentage of the neurological morbidity and mortality following CEA.

Section snippets

INTRODUCTION

In 1975, Sundt et al.¹ proposed a syndrome of hyperperfusion as the cause of seizures after carotid endarterectomy (CEA) in five patients with high-grade stenoses and small preoperative infarcts All patients had a significant increase in ipsilateral cerebral blood by xenon-133 washout and marked increases in retinal artery pressure. During the same year, Leviton et al.² described a patient who complained of severe frontal headaches lasting 2 weeks that began 3 days after endarterectomy. The

PATIENTS AND METHODS

Basic demographic information was accumulated prospectively for the 1,602 CEAs performed by a single practice from January 1, 1996, until December 31, 2003. Ninety-seven percent of the procedures were primary operations; 3% were for recurrent stenosis. The indications for operation were asymptomatic stenosis ≥60 in 72%, transient ischemic attack in 14%, ipsilateral amaurosis fugax in 5%, and recovered small stroke in 9%. All patients were on aspirin or clopidogrel prior to endarterectomy unless

RESULTS

During the 7-year study period, there were seven deaths (0.4%) and five strokes (0.3%), three major and two minor. Three of the major strokes caused death, resulting in a combined stroke/mortality rate of 0.6%. Six patients were diagnosed with hyperperfusion syndrome, resulting in one minor stroke and two fatal strokes. The history and clinical course for each patient are given in chronological order and summarized in Table I. None of the patients was significantly hypertensive (>160 mm Hg

DISCUSSION

As techniques improve and the indications for intervention have been refined, the perioperative stroke and mortality rates associated with CEA have declined significantly over the last 20 years.43, 44, 45, 46, 47, 48 Between 1991 and 2000, the national 30-day mortality rates after CEA in Medicare patients declined by >50%.⁴⁸ Although national stroke data are not available, audits of large institutional experiences have confirmed the downward trend in surgical stroke risk.47, 49 Between 1984 and

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Citation Excerpt :
SCACTO patients who lack a collateral cerebral supply, with hemodynamic failure and concomitant contralateral carotid disease, can benefit the most from recanalization. However, they also have the risk factors of hyperperfusion syndrome.21,22 Furthermore, the prognosis in hyperperfusion syndrome is poor, with a high mortality and morbidity.
Symptomatic carotid artery chronic total occlusion (SCACTO) can lead to neurocognitive function decline and carries a high risk or recurrent stroke. The treatment option is limited, endovascular intervention may be an alternative treatment but still controversial. To our knowledge, the staged carotid angioplasty and stenting (SCAS) did not previously reported. The purpose of this study was to report our experiences in this novel technique.
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Insight into the cerebral hyperperfusion syndrome following carotid endarterectomy from the national Vascular Quality Initiative
2017, Journal of Vascular Surgery
Citation Excerpt :
Severe contralateral stenosis of ≥70% was also significantly associated with CHS. The idea of CHS risk being higher in those with decreased cerebral reserve has been published by multiple other studies2,9,17,18 and is supported by findings from this investigation. The significance of the relationship between postoperative blood pressure lability and CHS mirrors findings from other studies, which cite the importance of preventing hypertension to decrease intracranial hemorrhage after CEA.5,9,12,13,19
Cerebral hyperperfusion syndrome (CHS), characterized by severe ipsilateral headache, seizures, and intracranial hemorrhage, is a rare, poorly understood complication that can be fatal following carotid endarterectomy (CEA). The purpose of the study was to determine the factors associated with CHS as captured in the Vascular Quality Initiative.
Analysis was conducted on 51,001 procedures captured from the CEA module of the Vascular Quality Initiative from 2003 to 2015. Preoperative, operative, and postoperative variables were considered for inclusion in logistic regression analyses to determine possible associations with CHS. The relative contribution of each variable to the overall model was determined using dominance analysis.
The mean age was 70.2 ± 9.4 years; there were 39.6% female patients, 93.1% of white race, with 29.6% of CEAs being performed for symptomatic status. The overall rate of CHS was 0.18% (n = 94), with 55.1% occurring in asymptomatic and 44.9% occurring in symptomatic patients with an associated mortality rate of 38.2%. Multivariable analysis including preoperative variables showed that female gender (odds ratio [OR], 1.65; 95% confidence interval [CI], 1.09-2.51; P = .019), <1 month major ipsilateral stroke (OR, 5.36; 95% CI, 2.35-12.22; P < .001), coronary artery disease (OR, 1.77; 95% CI, 1.15-2.71; P = .009), and contralateral stenosis ≥70% (OR, 1.54; 95% CI, 1.00-2.36; P = .050) were independently associated with CHS and that <1 month major stroke was the most important contributor to the model. With the additional inclusion of operative and postoperative variables, female gender (OR, 1.75; 95% CI, 1.14-2.67; P = .010), <1 month ipsilateral major stroke (OR, 3.20; 95% CI, 1.32-7.74; P = .010), urgency (OR, 2.25; 95% CI, 1.38-3.67; P = .001), re-exploration (OR, 2.98; 95% CI, 1.27-6.97; P = .012), postoperative hypertension (OR, 4.09; 95% CI, 2.65-6.32; P < .001), postoperative hypotension (OR, 3.21; 95% CI, 1.97-5.24; P < .001), dysrhythmias (OR, 3.23; 95% CI, 1.64-6.38; P = .001), and postoperative myocardial infarction (OR, 2.84; 95% CI, 1.21-6.67; P = .017) were significantly associated with CHS, with postoperative blood pressure lability and cardiac complications having the strongest associations with CHS.
The risk of CHS was highest in female patients and in those with a recent major stroke, coronary artery disease, and contralateral stenosis ≥70%. In addition, in adjusting for operative and postoperative variables, CHS was most significantly associated with postoperative blood pressure lability and cardiac complications. These data lend insight into a high-risk population for this devastating complication.
Pseudo-continuous arterial spin labeling quantifies cerebral blood flow in patients with acute ischemic stroke and chronic lacunar stroke
2014, Clinical Neurology and Neurosurgery
We employed non-invasive pseudo-continuous arterial spin labeling (pCASL) to quantify cerebral blood flow (CBF) in infarcted and nearby neural regions in patients with acute ischemic stroke (AIS) and chronic lacunar stroke (CLS). The results were compared with CBF in healthy individuals.
AIS and CLS patients were imaged with ASL, diffusion-weighted imaging (DWI) and conventional MRI. CBF maps were created with 3DASL software. Two expert readers identified AIS and CLS lesions on conventional images, DWI images and CBF maps. A senior radiologist calculated CBF values for lesions and nearby regions. Lesion, nearby regions and normal corresponding region values were analyzed using a two-sample t-test.
Fifty-six stroke patients (21 with AIS and 35 with CLS) and 30 healthy subjects participated in this study. In the AIS group, AIS lesions appeared in the cortex/white matter, external/internal capsule (EC/IC), and basal ganglia. AIS lesions had lower CBF values than the normal corresponding regions (p < 0.05). The mean CBF values in AIS nearby regions were significantly higher than those in normal corresponding regions (p < 0.05). In the CLS group, the CBF values in white matter and EC/IC were lower than the CBF values in normal corresponding regions (p = 0.063 and 0.052, respectively). The CBF values in CLS nearby regions and normal corresponding regions were not significantly different (p > 0.05).
In some regions of the brain, CLS lesions, AIS lesions, and their nearby regions have different perfusion statuses. In particular, the AIS nearby regions perfusion in our subjects was significantly higher than that previously reported. pCASL can be a robust imaging technique for diagnosing strokes in clinical practices.
Carotid artery occlusive diseaserfvt
2013, Surgical Clinics of North America
Citation Excerpt :
Mechanical thrombectomy has been described of the distal ICA with a 60% to 70% recanalization rate and improved neurologic outcome in those patients that were recanalized.32,33 Intra-arterial thrombolysis for distal embolization has been described after intracranial hemorrhage is ruled out, although this carries a significant risk of hemorrhage and should be used only in select patients.34 Hyperperfusion syndrome is a rare postoperative complication that manifests as postoperative headache, with potential seizure and intracranial hemorrhage.
Delayed post-operative epileptic seizure after carotid endarterectomy: A case of cerebral hyperperfusion syndrome?
2012, Revista Espanola de Anestesiologia y Reanimacion
El denominado síndrome de hiperperfusión cerebral, se debe fundamentalmente a un fallo de la autorregulación cerebral, incapaz de controlar la restauración del flujo tras la cirugía de revascularización. Se presenta clínicamente en forma de cefalea intensa, crisis epilépticas o focalidad neurológica. Puede progresar incluso a una hemorragia intracerebral. Aparece normalmente días después de la cirugía. Presentamos el caso de un paciente sometido a endarterectomía carotídea, que presentó una crisis epiléptica en el postoperatorio tardío. Atribuimos como causa más probable de la crisis epiléptica al síndrome de hiperperfusión cerebral. El conocimiento de este síndrome puede ayudar a orientar y tratar correctamente las complicaciones neurológicas que aparecen después de este tipo de cirugía.
The so-called cerebral hyperperfusion syndrome is basically due to a lack of cerebral autoregulation, inability to control the restoring of flow after revascularisation surgery. It present clinically as intense migraine, epileptic seizures, or neurological focality. It may even progress to an intracerebral haemorrhage. It usually appears a few days after surgery. We present the case of a patient subjected to a carotid endarterectomy, who had an epileptic episode in the late post-operative period. We attributed a cerebral hyperperfusion syndrome as the most likely cause. Knowledge of this syndrome may help to correctly orientate and treat the neurological complications that appear after this type of surgery.
Hypertension and the post-carotid endarterectomy cerebral hyperperfusion syndrome
2011, European Journal of Vascular and Endovascular Surgery
Cerebral hyperperfusion syndrome is a preventable cause of stroke after carotid endarterectomy (CEA). It manifests as headache, seizures, hemiparesis or coma due to raised intracranial pressure or intracerebral haemorrhage (ICH). There is currently no consensus on whether to control blood pressure, blood pressure thresholds associated with cerebral hyperperfusion syndrome, choice of anti-hypertensive agent(s) or duration of treatment.
A systematic review of the PubMed database (1963–2010) was performed using appropriate search terms according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.
A total of 36 studies were identified as fitting a priori inclusion criteria. Following CEA, the incidence of severe hypertension was 19%, that of cerebral hyperperfusion 1% and ICH 0.5%. The postoperative mean systolic blood pressure of patients, who went on to develop cerebral hyperperfusion syndrome, was 164 mmHg (95% confidence interval (CI) 150–178 mmHg) and the cumulative incidence of cases rose appreciably above a postoperative systolic blood pressure of 150 mmHg. The mean systolic blood pressure of cerebral hyperperfusion cases was 189 mmHg (95% CI 183–196 mmHg) at presentation. The incidence of cerebral hyperperfusion in the first week was 92% with a median time to presentation of 5 days (interquartile range (IQR) 3–6 days). 36% of patients presented with seizures 31% with hemiparesis and 33% with both. The proportion of patients with severe hypertension was significantly higher in cases than in post-CEA controls (p < 0.0001, Odds ratio 19 (95% CI 9–41)). Three large case-control studies identify postoperative hypertension as a risk factor for ICH.
There is currently level-3 evidence for the prevention of ICH through control of postoperative blood pressure. From the available data, we suggest a definition for cerebral hyperperfusion syndrome, blood pressure thresholds, duration of monitoring and a postoperative blood pressure control strategy for validation in a prospective study. The implications of this are that one in five patients would need intravenous anti-hypertensives and home blood pressure monitoring for 1 week.

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: Presented at the Twenty-second Annual Meeting of the Southern California Vascular Surgery Society, La Jolla, CA, April 30-May 2, 2004.

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