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CLINICAL RESEARCH: PERIPHERAL VASCULAR DISEASE

Intracranial hemorrhage and hyperperfusion syndrome following carotid artery stenting

Risk factors, prevention, and treatment

Alex Abou-Chebl, MD, Jay S. Yadav, MD^*,*, Joel P. Reginelli, MD^*, Christopher Bajzer, MD^*, Deepak Bhatt, MD^* and Derk W. Krieger, MD

^* Department of Cardiovascular Medicine, Cleveland, OhioUSA
Department of Neurology, The Cleveland Clinic Foundation, Cleveland, Ohio, USA

Manuscript received August 20, 2003; revised manuscript received December 5, 2003, accepted December 9, 2003.

^* Reprint requests and correspondence: Dr. Jay S. Yadav, Director, Vascular Intervention, Department of Cardiovascular Medicine, F25, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, Ohio, USA 44195.
yadavj{at}ccf.org

OBJECTIVES: The study defined the incidence of cerebral hyperperfusion syndrome and intracranial hemorrhage (ICH) and the risk factors for their development following carotid artery stenting (CAS).

BACKGROUND: Hyperperfusion syndrome and ICH can complicate carotid revascularization, be it endarterectomy or CAS. Although extensive effort has been devoted to reducing the incidence of ischemic stroke complicating CAS, little is known about the incidence, etiology, and prevention strategies for hyperperfusion and ICH following CAS.

METHODS: We retrospectively reviewed the prospective database of 450 consecutive patients who were treated with CAS in our department to identify patients who developed hyperperfusion syndrome and/or ICH.

RESULTS: The mean age of the patients was 72.7 ± 10.9 years, and the mean diameter narrowing was 84 ± 12.8%. Five (1.1% [95% confidence interval 0.4% to 2.6%]) patients developed hyperperfusion. Three (0.67%) of the five developed ICH. Two of these patients died (0.44%). Symptoms developed within a median of 10 h (range, 6 h to 4 days) following stenting. All five patients had correction of a severe internal carotid stenosis (mean 95.6 ± 3.7%) with a concurrent contralateral stenosis >80% or contralateral occlusion and peri-procedural hypertension. These same risk factors are involved in cerebral hyperperfusion following carotid endarterectomy. The use of platelet glycoprotein IIb/IIIa receptor blockers did not appear to increase the risk ICH.

CONCLUSIONS: The hyperperfusion syndrome occurs infrequently following CAS, and ICH occurs in 0.67% of patients. Patients with severe bilateral carotid stenoses may be predisposed to ICH, particularly if there is concurrent arterial hypertension. Patients with these factors may require more intensive hemodynamic monitoring after CAS, including prolongation of hospitalization in some cases.

Abbreviations and Acronyms   ACT = activated clotting time   CAS = carotid artery stenting   CBF = cerebral blood flow   CEA = carotid endarterectomy   GPIIb/IIIa = platelet glycoprotein IIb/IIIa receptor blockers   HPS = hyperperfusion syndrome   ICA = internal carotid artery   ICH = intracranial hemorrhage   MCA = middle cerebral artery   SBP = systolic blood pressure   TCD = transcranial Doppler ultrasound

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