Reversible cerebral vasoconstriction complicated with brain infarction immediately after carotid artery stenting

'Diagnostic anchoring' and a delayed diagnosis of reversible cerebral vasoconstriction syndrome

We present a case of a woman in her 60s with acute left hemispheric ischaemic stroke syndrome due to tandem occlusions of the proximal left internal carotid artery and left middle cerebral artery. This was treated with emergent carotid artery stenting and endovascular clot retrieval. The patient made a complete recovery and was discharged home only to represent a few days later with focal neurological symptoms, profound headache and labile blood pressure. The diagnostic and management challenges of reversible cerebral vasoconstriction syndrome, including imaging assessment and the importance of avoiding 'diagnostic anchoring' are discussed.

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.

Two Patients with Reversible Cerebral Vasoconstriction after Carotid Artery Stenting

OBJECTIVE

We herein report two cases of transient cerebral vasoconstriction after carotid artery stenting (CAS).

CASE PRESENTATION

An 81-year-old man presented with asymptomatic severe stenosis in the right carotid artery accompanied by a slight reduction in cerebrovascular reactivity. CAS was performed, but the patient had a generalized seizure because of transient cerebral ischemia caused by intolerance to carotid artery occlusion with balloon protection. Confusion and left hemiparesis persisted. DSA suggested cerebral ischemia due to vasoconstriction as the cause of these prolonged symptoms. A 66-year-old man presented with asymptomatic severe stenosis in the right carotid artery with slight hypoperfusion. CAS was performed. The patient developed left hemispatial neglect, dysarthria, and left hemiparesis 12 hours after the procedure. DSA revealed cerebral vasoconstriction in the responsible territory. The conditions of both patients improved within several days with medical treatment and they were discharged without neurological deficits.

CONCLUSION

The cases presented herein show that transient ischemic complications caused by cerebral vasoconstriction may develop after CAS.

Asymptomatic Cerebral Vasoconstriction after Carotid Artery Stenting

BACKGROUND AND PURPOSE

Carotid artery stent placement is widely performed for treatment of carotid stenosis. The purpose of this study is to present our observations on cerebral vasoconstriction in ipsilateral anterior circulation during immediate poststenting angiography in patients with near-total occlusion of the proximal ICA.

MATERIALS AND METHODS

We retrospectively reviewed patient data from December 2008 to December 2018. There were 28 patients with carotid near-total occlusion. Two neuroradiologists reviewed the final cerebral angiographic finding of carotid artery stent placement to evaluate the presence of vasoconstriction or vasodilation.

RESULTS

A total of 28 patients with near-total occlusion (mean ± standard deviation age, 69.0 ± 6.5 years; 92.9% male) were analyzed. Ten patients showed vasoconstriction in the treated territory, and 18 patients did not show vasoconstriction after carotid artery stenting. There were no statistically significant differences in comorbidity, frequency of symptomatic lesions, antiplatelet medication, mean procedure time, and initial NIHSS and baseline modified Rankin scale scores between the 2 groups. However, vasoconstriction is more likely to happen in patients with isolated territory from the contralateral anterior and posterior circulation (66.7% in the isolated territory group and 12.5% in the not-isolated territory group; P < .05). No headache or neurologic deficit was noted in all 10 patients with cerebral vasoconstriction.

CONCLUSIONS

Cerebral vasoconstriction may occur after carotid artery stenting more frequently than expected. It occurs more frequently in patients with near-total occlusion and with isolation of the cerebral circulation. A large-scale study is necessary to assess the clinical implications of cerebral vasoconstriction after carotid artery stenting.