Hyperperfusion Syndrome after Stent/Coiling of a Ruptured Carotid Bifurcation Aneurysm

• Published in: Neurocritical care Vol. 18; no. 1; pp. 54 - 58
• Main Authors: Ecker, Robert D., Murray, Richard D., Seder, David B.
• Format: Journal Article
• Language: English
• Published: New York Humana Press Inc 01.02.2013; Springer Nature B.V
• Subjects: Aneurysm, Ruptured - surgery; Aneurysms; Brain Edema - diagnostic imaging; Brain Edema - etiology; Carotid Artery Diseases - surgery; Cerebral Angiography; Cerebrum - blood supply; Critical Care Medicine; Doppler effect; Endovascular Procedures - adverse effects; Female; Humans; Intensive; Internal Medicine; Medical imaging; Medicine; Medicine & Public Health; Middle Aged; Middle Cerebral Artery - surgery; Neurology; Original Article; Reperfusion Injury - diagnostic imaging; Reperfusion Injury - etiology; Stents; Syndrome; Tomography, X-Ray Computed; Veins & arteries; Endothelial dysfunction; Cerebral edema; Subarachnoid hemorrhage; Hyperperfusion; Stent; Coil
• ISSN: 1541-6933; 1556-0961
• DOI: 10.1007/s12028-012-9733-x

The authors report a syndrome of regional, symptomatic cerebral hyperperfusion, and edema mimicking infarction in a 54-year-old woman following coiling of a ruptured right carotid bifurcation aneurysm and stenting of the right middle cerebral artery. The patient presented with a Hunt and Hess grade III subarachnoid hemorrhage 7 days after developing thunderclap headache. She underwent successful coiling under general anesthesia of the 1.6 × 1.5 × 1.6 cm aneurysm, but immediately after the coil was placed occlusion of the proximal M1 segment was developed. This occlusion was stented after ~5-min delay, and flow restored without angiographic evidence of distal emboli. Following the procedure, she was extubated and noted to have left hemiparesis, neglect, and mutism without a CT correlate. Cerebral infarction was suspected, but urgent repeat angiography demonstrated patent cerebral vasculature. On the following day, symptoms persisted, and non-contrast head CT now showed cerebral edema localized to the right middle cerebral artery territory mimicking subacute infarction. CT perfusion imaging and angiography showed a widely patent MCA circulation, and suggested a regional hyperperfusion syndrome. The blood pressure was incrementally lowered, with rapid and sustained neurological improvement. Hyperperfusion events following aneurysm repair and related circumstances are reviewed.