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Hirooka R, Ogasawara K, Sasaki M, Yamadate K, Kobayashi M, Suga Y, Yoshida K, Otawara Y, Inoue T, Ogawa A. Magnetic resonance imaging in patients with cerebral hyperperfusion and cognitive impairment after carotid endarterectomy. J Neurosurg 2008; 108:1178-83. [DOI: 10.3171/jns/2008/108/6/1178] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Cerebral hyperperfusion after carotid endarterectomy (CEA) impairs cognitive function and is often detected on cerebral blood flow (CBF) imaging. The purpose of the present study is to investigate structural brain damage seen on magnetic resonance (MR) images obtained in patients with cerebral hyperperfusion and cognitive impairment after CEA.
Methods
One hundred and fifty-eight patients with ipsilateral internal carotid artery stenosis (≥ 70%) underwent CEA. Neuropsychological testing was performed preoperatively and at the 1st postoperative month. Cerebral blood flow was measured using single-photon emission computed tomography before, immediately after, and 3 days after surgery. Magnetic resonance imaging was performed before and 1 day after surgery. In patients with post-CEA hyperper-fusion (defined as a CBF increase ≥ 100% compared with preoperative values) on CBF imaging, MR images were also obtained on the 3rd postoperative day, the day on which hyperperfusion syndrome developed, and 1 month after the operation.
Results
The incidence of postoperative cognitive impairment was significantly higher in patients with post-CEA hyperperfusion on CBF imaging (12 [75%] of 16 patients) than in those without (6 [4%] of 142 patients; p < 0.0001). Only 1 of 5 patients with cerebral hyperperfusion syndrome developed reversible brain edema in the cerebral hemisphere ipsilateral to the CEA on MR images obtained on the day hyperperfusion syndrome occurred. However, postoperative cognitive impairment developed in all 5 patients with cerebral hyperperfusion syndrome regardless of the presence or absence of new lesions on MR images. In addition, postoperative cognitive impairment developed in 5 (45%) of 11 patients with asymptomatic cerebral hyperperfusion on CBF imaging despite the absence of new lesions on any postoperative MR images.
Conclusions
Although cerebral hyperperfusion syndrome after CEA sometimes results in reversible brain edema visible on MR imaging, postoperative cerebral hyperperfusion—even when asymptomatic—often results in impaired cognitive function without structural brain damage on MR imaging.
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Affiliation(s)
| | | | | | - Keiko Yamadate
- 3Department of Clinical Psychology, Tochinai Daini Hospital, Morioka, Japan
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Ogasawara K, Sakai N, Kuroiwa T, Hosoda K, Iihara K, Toyoda K, Sakai C, Nagata I, Ogawa A, _ _. Intracranial hemorrhage associated with cerebral hyperperfusion syndrome following carotid endarterectomy and carotid artery stenting: retrospective review of 4494 patients. J Neurosurg 2007; 107:1130-6. [PMID: 18077950 DOI: 10.3171/jns-07/12/1130] [Citation(s) in RCA: 185] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Intracranial hemorrhage associated with cerebral hyperperfusion syndrome (CHS) following carotid endarterectomy (CEA) or carotid artery stenting (CAS) is a rare but potentially devastating complication. In the present study the authors evaluated 4494 patients with carotid artery stenosis who had undergone CEA or CAS to clarify the clinicopathological features and outcomes of those with CHS and associated intracranial hemorrhage.
Methods
Patients with postoperative CHS were retrospectively selected, and clinicopathological features and outcomes were studied.
Results
Sixty-one patients with CHS (1.4%) were identified, and intracranial hemorrhage developed in 27 of them (0.6%). The onset of CHS peaked on the 6th postoperative day in those who had undergone CEA and within 12 hours in those who had undergone CAS. Results of logistic regression analysis demonstrated that poor postoperative control of blood pressure was significantly associated with the development of intracranial hemorrhage in patients with CHS after CEA (p = 0.0164). Note, however, that none of the tested variables were significantly associated with the development of intracranial hemorrhage in patients with CHS after CAS. Mortality (p = 0.0010) and morbidity (p = 0.0172) rates were significantly higher in patients with intracranial hemorrhage than in those without.
Conclusions
Cerebral hyperperfusion syndrome after CEA and CAS occurs with delayed classic and acute presentations, respectively. Although strict control of postoperative blood pressure prevents intracranial hemorrhage in patients with CHS after CEA, there appears to be no relationship between blood pressure control and intracranial hemorrhage in those with CHS after CAS. Finally, the prognosis of CHS in patients with associated intracerebral hemorrhage is poor.
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Affiliation(s)
| | | | - Terumasa Kuroiwa
- 3Department of Neurosurgery, Asahikawa Red Cross Hospital, Asahikawa
| | - Kohkichi Hosoda
- 4Department of Neurosurgery, Hyogo Emergency Medical Center/Kobe Red Cross Hospital, Kobe
| | - Koji Iihara
- 5Department of Neurosurgery, National Cardiovascular Center
| | - Kazunori Toyoda
- 6Cerebrovascular Division, Department of Medicine, National Cardiovascular Center, Osaka; and
| | - Chiaki Sakai
- 2Department of Neurosurgery, Kobe City General Hospital
| | - Izumi Nagata
- 7Department of Neurosurgery, Nagasaki University School of Medicine, Nagasaki, Japan
| | - Akira Ogawa
- 1Department of Neurosurgery, Iwate Medical University, Morioka
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