Comparison of Catecholamine Hormone Release in Patients Undergoing Carotid Artery Stenting or Carotid Endarterectomy

Relationship between cerebral hyperperfusion syndrome and the immediate change of cerebral blood flow after carotid artery stenting evaluated by single-photon emission computed tomography

PURPOSE

Cerebral hyperperfusion syndrome (CHS) is a critical complication after carotid artery stenting (CAS). However, few CAS studies have evaluated immediate and temporary changes in ipsilateral cerebral blood flow (CBF) quantitatively. The study was performed to evaluate immediate changes in CBF after CAS and subsequent CBF changes in patients with cerebral hyperperfusion (HP) using ¹²³I-IMP SPECT.

METHODS

The subjects were 223 patients with chronic extracranial carotid artery stenosis who underwent CAS in our department between March 2010 and March 2020. Quantitative CBF and cerebrovascular reactivity to acetazolamide in the middle cerebral artery were assessed before CAS by ¹²³I-IMP SPECT. CBF was also measured immediately after CAS by ¹²³I-IMP SPECT. When HP was detected, CBF was measured again 3 and 7 days after CAS.

RESULTS

The median (interquartile range) ipsilateral quantitative CBF change after CAS was - 0.1% (- 9.5-8.2%), and the upper value of the 95% CI of the quantitative CBF change was 48.2%. Thus, we defined HP after CAS as an increase in quantitative CBF of > 48.2% compared with the preoperative value. Of 223 patients, 5 (2.2%) had HP, and 4 of these patients (80%) developed CHS. In the CHS patients, HP was maintained for about 3 days and improved after about 7 days.

CONCLUSION

An immediate CBF increase of > 48.2% after CAS may lead to development of CHS. In CHS after CAS, HP persisted for about 1 week and postoperative management may be required for at least 1 week.

Syncope and hypotension associated with carotid sinus hypersensitivity in a patient with nasopharyngeal carcinoma: A case report

RATIONALE

Carotid sinus hypersensitivity (CSH) is traditionally classified into 3 subgroups: cardioinhibitory, vasodepressor, and mixed subtypes. However, the underlying mechanism of CSH in head and neck cancer is controversial. Several pathological mechanisms of CSH have been proposed: atherosclerotic noncompliance, sternocleidomastoid proprioceptive denervation, and generalized autonomic dysfunction.

PATIENT CONCERNS

We reported a 75-year-old man who had recurrent syncope attacks secondary to hypotension and reduced plasma norepinephrine (NE) levels. CSH was suspected when carotid massage induced syncope-like symptom.

DIAGNOSES

Nasopharynx carcinoma with regional lymph node involvement and CSH.

INTERVENTIONS

On admission, dopamine was administered to maintain the blood pressure. When NE deficiency was confirmed, intravenous NE combined with oral midodrine replaced the dopamine treatment.

OUTCOMES

The syncopal episodes completely resolved with periodic occurrence of hypertension.

LESSONS

Our case suggests a potential role of carotid sinus in regulating the release of NE in adrenal gland and that the monitoring of catecholamine level is recommended in the CSH cases either from head and neck tumors or other mechanical manipulation of carotid sinus.