Transient Cerebral Vasospasm After Carotid Artery Stenting: A Case Report and Literature Review

Thrombosis or vasospasm: The utility of intraoperative neuromonitoring during TCAR

OBJECTIVES

Transcarotid artery revascularization (TCAR) has become more prevalent as a treatment modality for carotid stenosis. Many centers perform TCAR without any adjunctive neuromonitoring, for example, somatosensory-evoked potential (SSEP) and electroencephalogram (EEG).

METHODS

We present a case of transcarotid artery revascularization (TCAR) performed with concomitant somatosensory-evoked potential (SSEP) and electroencephalogram (EEG) neuromonitoring in the setting of concerning intraoperative angiographic images.

RESULTS

TCAR was undertaken for a 58 year-old man presenting with symptomatic left carotid stenosis and right ICA occlusion. Based on his comorbidities, pre-existing conditions, and the need for dual antiplatelet therapy, TCAR was offered as an alternative to standard carotid endarterectomy. Intraoperatively, following stent delivery, no flow was appreciated through the carotid stent or distal ICA. Neuromonitoring remained stable and was reassuring for distal ICA spasm with no-reflow phenomenon. The patient tolerated the procedure well and has had no stent-related complications through 10 months of follow-up.

CONCLUSION

This case highlights the utility of neuromonitoring with TCAR as an adjunct to intraoperative decision-making in the setting of suspected internal carotid artery (ICA) vasospasm versus thrombosis after stent delivery.

A Case of Cerebral Hyperperfusion Syndrome during Treatment of Transient Cerebral Vasospasm Following Carotid Artery Stenting

Objective

We report a case in which transient cerebral vasospasm after carotid artery stenting (CAS) was effectively treated using arterial and intravenous infusion of fasudil hydrochloride, but cerebral hyperperfusion syndrome (CHS) developed during subsequent treatment.

Case Presentation

The patient was a 79-year-old man who underwent right CAS to treat symptomatic right carotid artery stenosis. After the procedure, the patient developed left paresis and unilateral spatial neglect. The following day, he developed diffuse cerebral vasospasm in the right middle cerebral artery that improved immediately upon arterial infusion of fasudil hydrochloride. Intravenous infusion of fasudil hydrochloride was then started, but CHS with epileptic seizures developed after 1 day of treatment. After 23 days of medical treatment, the condition of the patient improved to mild hemiparesis.

Conclusion

The present case suggests that transient cerebral vasospasm after CAS may turn into CHS during treatment and that continuous monitoring for cerebral perfusion is important.

Intra-arterial infusion of fasudil hydrochloride for cerebral vasospasm secondary to carotid artery stenting: illustrative case

BACKGROUND

Hypoperfusion due to intracranial cerebral vasospasm after carotid artery stenting (CAS) is rare. The authors presented a case of selective intraarterial infusion of fasudil hydrochloride for cerebral vasospasm after CAS.

OBSERVATIONS

A 73-year-old man received CAS for asymptomatic right cervical internal carotid artery stenosis. Twelve hours after CAS, disturbance of consciousness, left hemiplegia, and right conjugate deviation appeared in the patient. Head computed tomography angiography showed diffuse vasospasm of the right middle cerebral artery (MCA). The authors hypothesized that the cause of the symptoms was hypoperfusion due to intracranial cerebral vasospasm. Medical treatment was started; however, the focal symptoms worsened rapidly. Therefore, the authors decided to infuse fasudil intraarterially. This treatment resulted in a remarkable improvement in blood flow and gradual recovery from neurological symptoms. Head magnetic resonance angiography on the day after fasudil infusion showed improved visualization of the right MCA. The neurological symptoms almost completely disappeared 22 hours after fasudil infusion (40 hours after CAS).

LESSONS

As a complication after CAS, the possibility of hypoperfusion due to cerebral vasospasm should be considered. If symptoms due to hypoperfusion worsen even after medical treatment, intraarterial infusion of fasudil may be an effective option.

Vasoconstriction and hyperperfusion syndrome after carotid artery stenting

Background

Common complications of carotid artery stenting (CAS) are cerebral ischemia and hyperperfusion syndrome. To date, only a few cases of late-onset cerebral vasoconstriction occurring several hours after CAS have been reported. However, there are no reports of developed vasoconstriction and hyperperfusion syndrome.

Case presentation

A 79-year-old man developed vasoconstriction 1 day after carotid artery stenting. Vasoconstriction improved immediately with glucocorticoid. However, a week later, the patient developed hyperperfusion syndrome.

Conclusions

Postoperative vasoconstriction and hyperperfusion syndrome is an unrecognized complication and surgeons should be aware of it.