Risk Factors for Cerebral Hyperperfusion Syndrome following Carotid Revascularization
Ashley C Hsu1, Brian Williams2, Li Ding3
1Division of Vascular Surgery and Endovascular Therapy, Keck Medicine of USC, Los Angeles, CA.
Insights
Cerebral hyperperfusion syndrome (CHS) risk is similar for carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), and transfemoral carotid artery stenting (TFCAS). Certain patient factors increase CHS risk, but ACE inhibitors/ARBs may offer protection.
Area of Science:
- Vascular Surgery
- Neurology
- Cardiology
Background:
- Cerebral hyperperfusion syndrome (CHS) is a rare but serious complication following carotid revascularization procedures.
- While known after carotid endarterectomy (CEA) and transfemoral carotid artery stenting (TFCAS), CHS incidence after transcarotid artery revascularization (TCAR) remains undelineated.
Purpose of the Study:
- To compare the incidence of CHS across different carotid revascularization techniques: CEA, TCAR, and TFCAS.
- To identify perioperative risk factors associated with the development of CHS.
Main Methods:
- Analysis of the Society for Vascular Surgery Vascular Quality Initiative database (2015-2021) for elective CEA, TCAR, and TFCAS procedures in patients aged 18 years and older.
- Utilized logistic regression to identify factors associated with CHS, defined as postoperative seizures or intracerebral hemorrhage due to hyperperfusion.
Main Results:
- Out of 156,003 procedures, CHS incidence was 0.15% for CEA, 0.18% for TCAR, and 0.53% for TFCAS.
- No significant difference in CHS risk was found between TCAR and CEA, or between TFCAS and CEA.
- Increased CHS risk was associated with prior transient ischemic attack/stroke, urgent intervention, treatment of total occlusion, and need for postoperative blood pressure medication.
Conclusions:
- TCAR and TFCAS are not statistically associated with a higher risk of postoperative CHS compared to CEA.
- Patients with a history of stroke, those requiring urgent intervention or postoperative blood pressure support, or treated for total occlusion face elevated CHS risk.
- Discharge on ACE inhibitors or ARBs may be protective against CHS, warranting consideration for high-risk individuals.
Background:
Cerebral hyperperfusion syndrome (CHS) is a rare but known complication of carotid revascularization that can result in severe postoperative disability and death. CHS is a well-described sequela of carotid endarterectomy (CEA) and, more recently, of transfemoral carotid artery stenting (TFCAS), but its incidence after transcarotid artery revascularization (TCAR) has not been delineated. The aims of this study were to determine the impact of procedure type (CEA versus TCAR versus TFCAS) on the development of CHS as well as to identify perioperative risk factors associated with CHS.
Methods:
The Society for Vascular Surgery Vascular Quality Initiative was queried for patients aged ≥18 years who underwent CEA, TCAR, or TFCAS from 2015-2021. Emergent procedures were excluded. The primary outcome was postoperative development of CHS, defined as the presence of postoperative seizures, intracerebral hemorrhage due to hyperperfusion, or both. Bivariate and multivariable logistic regression analyses were performed to identify factors associated with CHS.
Results:
156,003 procedures were included (72.7% CEA, 12.4% TCAR, and 14.9% TFCAS). The incidence of CHS after CEA, TCAR, and TFCAS were 0.15%, 0.18%, and 0.53%, respectively. There was no significant difference in risk of CHS after TFCAS compared to CEA (odds ratio [OR]: 1.21; 95% confidence interval [CI] 0.76-1.92; P = 0.416), nor was there a difference between TCAR and CEA (OR: 0.91; 95% CI 0.57-1.45; P = 0.691). Perioperative risk factors associated with an increased risk of CHS included previous history of transient ischemic attack or stroke (OR: 2.50; 95% CI 1.69-3.68; P < 0.0001), necessity for urgent intervention within 48 hr (OR: 2.03; 95% CI 1.43-2.89; P < 0.0001), treatment of a total occlusion (OR: 3.80; 95% CI 1.16-12.47; P = 0.028), and need for postoperative intravenous blood pressure medication (OR: 5.45; 95% CI 3.97-7.48; P < 0.0001). Age, preoperative hypertension, degree of ipsilateral stenosis less than or equal to 99%, and history of prior carotid procedures were not statistically associated with an increased risk of CHS. Discharging patients on an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker was associated with a decreased risk of developing CHS (OR: 0.47; 95% CI 0.34-0.65; P < 0.0001).
Conclusions:
Compared with CEA, TCAR and TFCAS were not statistically associated with an increased risk of postoperative CHS. Patients with a previous history of transient ischemic attack or stroke, who require urgent intervention or postoperative intravenous blood pressure medication, or who are treated for a total occlusion are at a higher risk of developing CHS. Using an angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker on discharge appears to be protective against CHS and should be considered for the highest risk patients.
