Correlation between hemodynamic characteristics or dynamic cerebral autoregulation and postoperative hyperperfusion in patients undergoing carotid endarterectomy / 中华超声影像学杂志

Objective:To investigate the hemodynamic characteristics and dynamic cerebral autoregulation(dCA) of patients with severe carotid stenosis before carotid endarterectomy(CEA), and to analyze their correlations with hyperperfusion after CEA.Methods:A total of 63 patients with unilateral severe carotid artery atherosclerotic stenosis who underwent CEA were consecutively recruited prospectively in Xuanwu Hospital, Capital Medical University from January 2021 to August 2021. According to postoperative hyperperfusion, patients were divided into hyperperfusion group (13 cases) and non-hyperperfusion group (50 cases). The general clinical data and hemodynamic parameters were compared between the two groups. The dCA was evaluated by the transfer function analysis that measured the fluctuation amplitude of mean cerebral blood flow velocity(CBFV) with blood pressure change, the time difference of phase with blood pressure change, and the correlation between mean CBFV and blood pressure change. The value of dCA for predicting postoperative hyperperfusion was analyzed through the ROC curve and the area under the curve(AUC).Results:①The proportion of hypertension in hyperperfusion group was higher than that in non-hyperperfusion group ( P<0.05). ②The peak systolic velocity (PSV) at the stenosis lesion of the internal carotid artery, the end-diastolic velocity (EDV) at the stenosis lesion of the internal carotid artery and the ratio of PSV at the stenosis lesion of the internal carotid artery to the distal internal carotid artery in the hyperperfusion group were higher than the non-hyperperfusion group.And the PSV of the ipsilateral middle cerebral artery in the hyperperfusion group was lower than the non-hyperperfusion group (all P<0.05). ③In the very low-frequency and low-frequency region, the phase in the hyperperfusion group was lower than that in the non-hyperperfusion group (all P<0.05), while there was no significant difference in the high-frequency regions( P>0.05). In the three regions of very low-frequency, low-frequency and high-frequency, there were no significant differences in the gain and coherence between the two groups(all P>0.05). ④The best cutoff value of phase in the very low-frequency was 33.28 for predicting hyperperfusion after CEA (AUC=0.766, 95% CI=0.629-0.904, P=0.03), with the specificity of 0.700, and sensitivity of 0.846. Conclusions:There are differences in hemodynamics and dCA between the hyperperfusion group and the non-hyperperfusion group after CEA. The impaired preoperative dynamic cerebral autoregulation is an independent predictor of postoperative hyperperfusion.

Supratentorial Primary Central Nervous System Lymphoma with Hyperperfusion:Report of One Case / 中国医学科学院学报

We reported a case of supratentorial primary central nervous system lymphoma with hyperperfusion.Computed tomography revealed hyperdense lesions on the bilateral centrum semiovale with obvious edema.Magnetic resonance imaging demonstrated that the lesion presented slightly long and iso-T1 signal and slightly long and long T2 signals;hyperintensity was found on diffusion-weighted imaging,with relatively high apparent diffusion coefficient value compared with the adjacent normal white matter.Contrast-enhanced imaging revealed bilateral evenly enhanced lesions,along with patchy non-enhanced shadows in right-sided lesion.The perfusion-weighted imaging revealed hyperperfusion in bilateral lesions.

Revascularization of Concurrent Renal and Cerebral Artery Stenosis in a 14-Year-Old Girl with Takayasu Arteritis and Moyamoya Syndrome

Concurrent involvement of bilateral renal and cerebral arteries, usually incurred as stenosis, is rare in childhood-onset Takayasu arteritis (c-TA). We report the case of a 14-year-old girl, with c-TA, presenting with transient ischemic attack after endovascular revascularization for renal artery stenosis and cerebrovascular stroke after surgical revascularization for cerebral artery stenosis associated with childhood-onset moyamoya syndrome. We deem that decrease of blood pressure by endovascular revascularization and improvement of cerebral perfusion by surgical revascularization may have jeopardized the cerebral deep watershed zone to cerebral ischemia followed by cerebral hyperperfusion syndrome and caused transient ischemic attack and cerebrovascular stroke in our patient. Revascularization could be a double-edge sword for c-TA patients presenting with concomitant renal artery stenosis and cerebral artery stenosis, and should be performed with caution. Quantitative analysis of cerebral blood flow by brain magnetic resonance imaging and angiography should be performed within 48 hours after surgical revascularization in c-TA.

Risk assessment of hyperperfusion induced intracranial hemorrhage after stenting in patients with severe carotid stenosis / 中国脑血管病杂志

Objective To assess the risk of hyperperfusion induced intracranial hemorrhage (HICH) after carotid artery stenting (CAS) in patients with symptomatic severe carotid stenosis.Methods From June 2009 to June 2015,the clinical data of 210 patients with symptomatic severe carotid stenosis (70％-99％) treated with CAS at Department of Neurosurgery,Changhai Hospital,the Second Military Medical University,were analyzed retrospectively.Seven of them (3.3 ％) developed HICH after operation.The relationship between the clinical baseline and imaging characteristics and HICH were assessed.All patients received the evaluation of cerebral CT perfusion examination.The time to peak (TTP) index of cerebral blood flow was defined as the TTP ratio of the affected and contralateral sides,t test was used to conduct the comparison of measurement data,and Poisson test was used to conduct the comparison of the enumeration data.Results There was significant difference in the TTP index between the HICH group and non-HICH group (1.15 ± 0.10 vs.1.30 ± 0.15,t =4.461,P ＜ 0.01).The receiver operating characteristic (ROC)curve analysis results suggested that the TTP index ＞ 1.22 could be used as a risk factor for predicting HICH (sensitivity 100％,specificity 75.9％).Conclusion Under the condition of prompting the preoperative TTP index ＞ 1.22,the risk of HICH may be higher after CAS in patients with severe carotid stenosis.

Octreotide therapeutic strategy to attenuate portal hyperperfusion resulted from small-for-size graft in infant liver transplantation / 中华器官移植杂志

Objective To explore the effectiveness of octreotide therapeutic strategy to attenuate portal hyperperfusion resulted from small-for-size graft in infant liver transplantation.Methods A total of 22 infants received small-for-size liver graft (defined as GV/SLV＜0.5,and GV＜ 150 g) in our hospital from December 2013 to August 2016.Twelve cases (octreotide group) were treated with intravenous octreotide infusion (300 g daily for 24-96 h) to attenuate the portal hyperperfusion after transplantation,and the rest 10 cases given liver transplantation at the early stage did not receive the intervention of octreotide and served as control group.Results The initial portal vein flows (PVFs) in octreotide group and control group were (413.43 ± 76.24) (390.83 ± 107.89) ml/(min 100 g),and there was no significant difference between two groups (P＞0.05).The PVFs on postoperative day (POD) 3 and POD5 in octreotide group and control group were (334.90 ± 96.67) and (441.04 ± 117.41),and (322.20 ± 81.04) and (423.23 ± 100.81) mL/(min 100 g) respectively (P＜0.05 for all).However,there were no significant differences in serum AST and bilirubin levels at four time points (initial,POD3,POD5 and POD7) after transplantation between two groups (P＞0.05).The incidence of hepatic artery occlusion,and biliary complications in octreotide group and ontrol group was 33.33％ and 44.44％,and 33.33％ and 11.11％ respectively (P ＞ 0.05 for all).Conclusion Octreotide treatment attenuated portal hyperperfusion resulted from small-for-size graft in infant liver transplantation.However,the effects of octreotide therapy on graft biochemical tests,the hepatic artery and biliary complications were still unclear,and further investigation is needed.

Octreotide therapeutic strategy to attenuate portal hyperperfusion resulted from small-for-size graft in infant liver transplantation / 中华器官移植杂志

Objective To explore the effectiveness of octreotide therapeutic strategy to attenuate portal hyperperfusion resulted from small-for-size graft in infant liver transplantation.Methods A total of 22 infants received small-for-size liver graft (defined as GV/SLV＜0.5,and GV＜ 150 g) in our hospital from December 2013 to August 2016.Twelve cases (octreotide group) were treated with intravenous octreotide infusion (300 g daily for 24-96 h) to attenuate the portal hyperperfusion after transplantation,and the rest 10 cases given liver transplantation at the early stage did not receive the intervention of octreotide and served as control group.Results The initial portal vein flows (PVFs) in octreotide group and control group were (413.43 ± 76.24) (390.83 ± 107.89) ml/(min 100 g),and there was no significant difference between two groups (P＞0.05).The PVFs on postoperative day (POD) 3 and POD5 in octreotide group and control group were (334.90 ± 96.67) and (441.04 ± 117.41),and (322.20 ± 81.04) and (423.23 ± 100.81) mL/(min 100 g) respectively (P＜0.05 for all).However,there were no significant differences in serum AST and bilirubin levels at four time points (initial,POD3,POD5 and POD7) after transplantation between two groups (P＞0.05).The incidence of hepatic artery occlusion,and biliary complications in octreotide group and ontrol group was 33.33％ and 44.44％,and 33.33％ and 11.11％ respectively (P ＞ 0.05 for all).Conclusion Octreotide treatment attenuated portal hyperperfusion resulted from small-for-size graft in infant liver transplantation.However,the effects of octreotide therapy on graft biochemical tests,the hepatic artery and biliary complications were still unclear,and further investigation is needed.

Delayed Cerebral Hyperperfusion Syndrome after Carotid Artery Stenting: the Finding of Multimodal MRI

A 78-year-old right handed man with hypertension presented with sudden onset dysarthria and right hemiparesis. Magnetic resonance angiography revealed near-occlusion of left proximal internal carotid artery. Emergent carotid stenting was performed. On the 17th day after carotid stenting, he showed decreased consciousness. Magnetic resonance imaging (MRI) showed edematous change with high signal and increased perfusion in the left hemisphere. Our case shows that delayed cerebral hyperperfusion syndrome can occur even 2 weeks after carotid artery stenting and multimodal MRI can help accurate diagnosis.

Hyperperfusion in DWI Abnormality in a Patient with Acute Symptomatic Hypoglycemic Encephalopathy

The perfusion change in acute symptomatic hypoglycemic encephalopathy (ASHE) is not well known. We present the perfusion-weighted imaging of a patient with ASHE. The area of diffusion-weighted imaging abnormalities and adjacent normal-appearing white matter showed increased cerebral blood volume and flow, and shortening of time-to-peak.

Hyperperfusion in DWI Abnormality in a Patient with Acute Symptomatic Hypoglycemic Encephalopathy

The perfusion change in acute symptomatic hypoglycemic encephalopathy (ASHE) is not well known. We present the perfusion-weighted imaging of a patient with ASHE. The area of diffusion-weighted imaging abnormalities and adjacent normal-appearing white matter showed increased cerebral blood volume and flow, and shortening of time-to-peak.

Acute Subdural Hematoma after Carotid Artery Stenting

Cerebral hyperperfusion syndrome is a major cause of morbidity and mortality following carotid artery stenting (CAS). We present a case of acute subdural hematoma (SDH) 2 hours after CAS. In this case, arterial origin of bleeding was verified during operation. To our knowledge, there is no prior case report of SDH without intraparenchymal nor subarachnoid hemorrhage subsequent to CAS. We postulate that SDH was caused by sudden rise in intracranial pressure due to the hyperperfusion which disrupted a corticodural bridging artery.

Perioperative complications of stent angioplasty for intracranial arterial stenosis：clinical analysis and therapeutic strategy / 介入放射学杂志

Intracranial artery stenosis is one of the main causes inducing transient ischemic attack (TIA) or cerebral ischemic stroke. Being a minimally-invasive and reliably-effective technique, intracranial artery stent angioplasty has brought about a new approach for the treatment of intracranial artery stenosis , and thus provides more opportunities to the patients who are not suitable for intracranial vascular bypass surgery. However, the higher occurrence of perioperative complications caused by stent angioplasty should be seriously taken into consideration by clinical physicians. In order to reduce the occurrence of complications , in this paper the perioperative complications of stent angioplasty for intracranial artery stenosis are analyzed , and the therapeutic strategies as well as the proper approaches are discussed.

The nursing care for patients with hyperperfusion syndrome occurring after carotid artery stenting;initial experience in 9 cases / 介入放射学杂志

Objective To analyze the clinical features of hyperperfusion syndrome occurring after carotid artery stenting, and to discuss its nursing measures. Methods Among 220 patients who received carotid artery stenting, nine developed hyperperfusion syndrome after stent implantation. Their clinical materials were retrospectively analyzed. The nursing measures, including properly controlling blood pressure, relieving brain edema, monitoring cerebral blood flow, medication with sedation drug, stopping or reducing antiplatelet therapy, close observation of blood pressure and clinical symptoms, cooperation with physicians to control the blood pressure and to dynamically make reexamination, etc. Results Of the nine patients with hyperperfusion syndrome, complete recovery was achieved in eight at the time of discharge and death due to intracranial hemorrhage occurred in one. Conclusion The key point of nursing for patients with hyperperfusion syndrome is close cooperation with physicians to control the patient ’s blood pressure so as to ensure a proper cerebral blood flow.

Delayed Cerebral Hyperperfusion Syndrome Three Weeks after Carotid Artery Stenting Presenting as Status Epilepticus

Cerebral hyperperfusion syndrome (CHS) is increasingly recognized as an uncommon, but serious, complication subsequent to carotid artery stenting (CAS) and carotid endarterectomy (CEA). The onset of CHS generally occurs within two weeks of CEA and CAS, and a delay in the onset of CHS of over one week after CAS is quite rare. We describe a patient who developed CHS three weeks after CAS with status epilepticus.

Fatal Propofol Infusion Syndrome Associated with Refractory Partial Status Epilepticus in a Patient with Cerebral Hyperperfusion Syndrome

Status epilepticus is rare complication of cerebral hyperperfusion syndrome and is a critical medical emergency that requires potent anesthetics. Propofol has the advantages of being rapid-acting and possessing a weaker cardiopulmonary suppression profile, but its use is associated with serious propofol infusion syndrome. We report herein a case of cerebral hyperperfusion syndrome after carotid endarterectomy presenting with refractory partial status epilepticus and fatal outcome associated with propofol infusion syndrome.

Post-Carotid Endarterectomy Cerebral Hyperperfusion Syndrome : Is It Preventable by Strict Blood Pressure Control?

OBJECTIVE: Cerebral hyperperfusion syndrome (CHS) is a serious complication after carotid endarterectomy (CEA). However, the prevalence of CHS has decreased as techniques have improved. This study evaluates the role of strict blood pressure (BP) control for the prevention of CHS. METHODS: All 18 patients who received CEA from February 2009 through November 2012 were retrospectively reviewed. All patients were routinely managed in an intensive care unit by a same protocol. The cerebral perfusion state was evaluated on the basis of the regional cerebral blood flow (rCBF) study by perfusion computed tomography (pCT) and mean velocity by transcranial doppler (TCD). BP was strictly controlled (100% increase in the rCBF by pCT or in the mean velocity by TCD compared with preoperative values) or CHS was detected, BP was maintained below 120/80 mm Hg. RESULTS: TCD and pCT data on the patients were analyzed. Ipsilateral rCBF was significantly increased after CEA in the pCT (p=0.049). Post-CEA hyperperfusion was observed in 3 patients (18.7%) in the pCT and 2 patients (12.5%) in the TCD study. No patients developed clinical CHS for one month after CEA. Furthermore, no patients developed additional neurological deficits related to postoperative cerebrovascular complications. CONCLUSION: Intensive care with strict BP control (<140/90 mm Hg) achieved a low prevalence of post-CEA hyperperfusion and prevented CHS. This study suggests that intensive care with strict BP control can prevent the prevalence of post-CEA CHS.

Hyperperfusion Syndrome after Carotid Stent-Supported Angioplasty in Patients with Autonomic Dysfunction

Cerebral hyperperfusion syndrome (CHS) is a rare, serious complication of carotid revascularization either after carotid endarterectomy or carotid stent placement. Although extensive effort has been devoted to reducing the incidence of CHS, little is known about the prevention. Postprocedural hypertension is very rare due to autoregulation of carotid baroreceptors but may occur if presented with autonomic dysfunction. We present two cases of CHS after cerebral revascularization that presented autonomic dysfunction.

Hyperacute hyperperfusion intracerebral hemorrhage complicating carotid endarterectomy: A case report

Most complications of carotid endarterectomy originate from either thrombotic or embolic ischemia. Although the incidence of hemorrhagic hyperperfusion syndrome after carotid endarterectomy is extremely rare, it can cause significant morbidity and mortality. Several mechanisms are involved in the pathophysiology of cerebral hyperperfusion syndrome including impaired cerebral autoregulation and normal pressure breakthrough. Presently, a different mechanism is suggested. Unfortunately, suggestions for prevention are limited to strict perioperative control of hypertension in patients with critical stenosis and chronic cerebral hypoperfusion. We report hypertensive-like ipsilateral basal ganglia hemorrhage after carotid endarterectomy.

The value of transcranial Doppler in carotid endarterectomy: report of 58 cases / 中华普通外科杂志

Objective To evaluate the role of transcranial Doppler (TCD) in carotid endarterectomy and the effect of carotid endarterectomy on extracranial carotid artery stenosis.Methods From January 2002 to December 2008, fifty eight patients (40 males and 18 females)with mean age of 64.5 years were treated in our hospital. Of these patients, forty had symptoms of cerebral ischemia, eighteen were asymptomatic. All the patients had 70% and up carotid artery stenosis. Forty one patients underwent simple suture closure of the arterial incision while nine patients had angioplasty with arterial patch (polyester) and eight with autologous great saphenous vein. TCD monitoring was used in the surgery of 32 patients excluding two patients using arterial shunt. Results Surgery was successful in all 58 cases except for deflected tongue-protrusion in five patients after operation, of which three recovered conservatively and two recovered after administration of cortical steroids for two weeks. Cerebral ischemic symptoms improved to a certain degree in all the 40 preoperative symptomatic patients. Cerebral hyperperfusion occurred in five of no TCD-monitoring patients ( 19.2% ), no hyperperfusion was found in TCD-monitored patients. Fifty three patients were followed up for a mean time of 42.5 months. Five patients died and three patients had carotid artery restenosis, of which two underwent PTA and stenting, one is still under surveillance.Conclusions Carotid endarterectomy is a safe and effective procedure for treating extracranial carotid artery stenosis. TCD monitoring is valuable for determining the use of arterial shunt and preventing postoperative cerebral hyperperfusion.

Fatal Subarachnoid Hemorrhage After Early Carotid Stenting For Progressive Stroke: Case Report / 대한뇌혈관외과학회지

Subarachnoid hemorrhage (SAH) after surgical or interventional treatment for carotid stenosis is rare, with only a few cases reported in the literature. Our department treated a 78-year-old female with symptoms of deteriorated mental functioning and focal neurological signs. Despite medical treatment, serial magnetic resonance imaging (MRI) studies revealed a progressive extension of multiple infarctions in her left cerebral hemisphere. Cerebral angiography revealed greater than 95% stenosis in the proximal left internal carotid artery (ICA), accompanied by multiple stenoses of the contralateral ICA. For this progressive stroke, we performed early carotid stenting in the left ICA stenosis. Two hours after the procedure, the patient suddenly collapsed, and a computed tomography (CT) scan showed a diffuse SAH with acute hydrocephalus. Despite medical and surgical treatment, the patient died six days after the procedure. The case presented here and a review of the reports on the previous instances suggest that long-standing, severe carotid stenosis with contralateral multiple severe stenoses, persistent hypertension, and the extensive use of heparin and antithrombotic agents may predispose patients to SAH.

Acetazolamide-Challenged Brain CT Perfusion before and after Carotid Stenting / 신경중재치료의학

PURPOSE: To test hypothesis that pre-stenting measurement of reactivity index by using acetazolamide-challenged CT perfusion could identify patients at risk for hyperperfusion after carotid stenting. MATERIALS AND METHODS: For 24 regions of interest in 12 patients with symptomatic unilateral high-grade carotid stenosis, asymmetric indexes for cerebral blood volume, cerebral blood flow, and mean transit time and reactivity index were calculated from resting and acetazolamide-challenged CT perfusion before and 1 day after carotid stenting. We subsequently compared pre-stenting asymmetric indexes and reactivity index with percent increase of cerebral blood flow 1 day after carotid stenting. RESULTS: Percent increase of cerebral blood flow on the first post-stenting day was not significantly different between visually decreased and normal cerebrovascular reserve groups. There was no significant correlation between pre-stenting asymmetric indexs of resting CT perfusion parameters and percent increase of cerebral blood flow 1 day after carotid stenting. On the other hand, pre-stenting reduction of reactivity index showed fair correlation with 1 day cerebral blood flow increase. However, hyperperfusion or hyperperfusion syndrome was not observed in any patient with reduced reactivity index. CONCLUSION: Pre-stenting measurements of resting CT perfusion parameters and reactivity index could not predict hyperperfusion after carotid stenting. However, pre-stenting reduction of reactivity index seems to fairly correlate with immediate post-stenting cerebral blood flow increase. Further studies with larger population should be performed to validate this preliminary result.