Cerebral Hyperperfusion Syndrome following Protected Carotid Artery Stenting

The cerebral hyperperfusion syndrome is a very rare complication after revascularization of the carotid artery and accompanied by postoperative or postinterventional hypertension in almost all patients. We report a case of a 77-year-old man who developed a complete aphasia and increased right-sided weakness following endovascular treatment of severe occlusive disease of the left internal carotid artery. We discuss the risk and management of cerebral hyperperfusion syndrome after carotid artery stenting. 1. Introduction Neurological complications following carotid artery stenting (CAS) are usually ischemic in nature, due to embolization or occlusion of the carotid artery. However, in a small subset of patients, cerebral hyperperfusion causes postinterventional neurological dysfunction, characterized by ipsilateral headache, focal seizure activity, focal neurological deficit, and ipsilateral intracerebral edema or hemorrhage. A high clinical suspicion and early diagnosis will allow early initiation of therapy and preventing fatal brain swelling or bleeding in patients with peri- and postinterventional cerebral hyperperfusion syndrome (CHS). 2. Case Report A 77-year-old man was referred for endovascular treatment after a transient ischemic attack with a right-sided facial and limb weakness. This episode occurred while the patient was undergoing medical treatment consisting of 100？mg acetylsalicylic acid and 75？mg clopidogrel 4 weeks after coronary stenting of the left anterior descending artery. The patient had a history of hyperlipidemia, hypertension, and familiar disposition with coronary heart disease. The neurological examination during the ischemic event revealed a mild right-sided hemiparesis. Brain CT and MRI showed no abnormalities. All hematological and biochemical tests were normal, with a normal platelet count and coagulation screen. When assessed in our hospital, his blood pressure sometimes jumped up to 180/100？mm？Hg. Therefore, the antihypertensive medication consisting of -blocker, diuretic, and AT1-antagonist was intensified. Another neurological examination was normal. Color Doppler ultrasound showed a severe stenosis of the left internal carotid artery (ICA) with elevation of the peak systolic velocity at 3.9？m/s and an end diastolic velocity of 1.4？m/s (Figure 1). The patient got a loading dose of 500？mg ASS and 300？mg clopidogrel and underwent left carotid stenting the next day via a femoral approach under local anesthesia. The angiography confirmed 95% stenosis of the left ICA (Figure 2(a)). CAS was frictionless performed with distal