颈动脉狭窄血管重建术后过度灌注综合征

随着颈动脉狭窄血管重建术 (包括颈动脉内膜切除术、颈动脉成形术和支架置入术 )的开展 ,术后过度灌注综合征已引起广泛重视。对于其发生机制、临床监测和治疗方法等问题尚在研究探索中。     

颈动脉内膜切除术后高灌注综合征的诊断与治疗

目的探讨颈动脉内膜切除术后高灌注综合征的机制、临床表现和治疗方法。方法回顾性分析3例颈动脉内膜切除术后高灌注综合征患者的临床资料，特别是术中和术后的血压管理、经颅多普勒超声（TCD）监测脑血流速度和最终的治疗及转归。结果2例患者经严格控制血压1～3d后，脑血流速度恢复正常，脑高灌注状态得以缓解。1例患者因血压控制不佳，导致脑高灌注状态，诱发脑出血而死亡。结论颈动脉内膜切除术后高灌注综合征有潜在的危险，经严格控制血压后，多于术后1～3d缓解。     

Cerebral hyperperfusion after angioplasty and stenting of a totally occluded left subclavian artery: a case report

Cerebral hyperperfusion syndrome is documented after angioplasty of carotid and vertebral artery lesions. The authors report the first instance of cerebral hyperperfusion syndrome in the posterior cerebral circulation after angioplasty and stenting of a totally occluded left subclavian artery.     

Intracranial hemorrhage and hyperperfusion syndrome following carotid artery stenting: risk factors, prevention, and treatment

OBJECTIVES: The study defined the incidence of cerebral hyperperfusion syndrome and intracranial hemorrhage (ICH) and the risk factors for their development following carotid artery stenting (CAS). BACKGROUND: Hyperperfusion syndrome and ICH can complicate carotid revascularization, be it endarterectomy or CAS. Although extensive effort has been devoted to reducing the incidence of ischemic stroke complicating CAS, little is known about the incidence, etiology, and prevention strategies for hyperperfusion and ICH following CAS. METHODS: We retrospectively reviewed the prospective database of 450 consecutive patients who were treated with CAS in our department to identify patients who developed hyperperfusion syndrome and/or ICH. RESULTS: The mean age of the patients was 72.7 +/- 10.9 years, and the mean diameter narrowing was 84 +/- 12.8%. Five (1.1% [95% confidence interval 0.4% to 2.6%]) patients developed hyperperfusion. Three (0.67%) of the five developed ICH. Two of these patients died (0.44%). Symptoms developed within a median of 10 h (range, 6 h to 4 days) following stenting. All five patients had correction of a severe internal carotid stenosis (mean 95.6 +/- 3.7%) with a concurrent contralateral stenosis >80% or contralateral occlusion and peri-procedural hypertension. These same risk factors are involved in cerebral hyperperfusion following carotid endarterectomy. The use of platelet glycoprotein IIb/IIIa receptor blockers did not appear to increase the risk ICH. CONCLUSIONS: The hyperperfusion syndrome occurs infrequently following CAS, and ICH occurs in 0.67% of patients. Patients with severe bilateral carotid stenoses may be predisposed to ICH, particularly if there is concurrent arterial hypertension. Patients with these factors may require more intensive hemodynamic monitoring after CAS, including prolongation of hospitalization in some cases.     

颈动脉支架置入术后过度灌注综合征的危险因素分析

目的探讨颈动脉支架置入术(CAS)后发生过度灌注综合征(CHS)的危险因素。方法纳入419例患者的临床资料,其中48例同时行双侧CAS,共计行467次CAS。根据是否发生CHS分为CHS组15例和无CHS组404例。采用分层分析法分析术后发生CHS的危险因素。结果与无CHS组比较,CHS组糖尿病、术后高血压比例明显升高,差异有统计学意义(P<0.05,P<0.01)。单因素分析显示,术前糖尿病、术后高血压与CHS相关(P<0.05)。经分层分析显示,术前糖尿病(OR=3.168,95%CI:1.008～9.222,P=0.025)及术后高血压(OR=5.033,95%CI:1.733～14.646,P=0.001)为术后发生CHS的主要危险因素。结论 CAS术前糖尿病及术后伴高血压的患者更容易出现CHS。临床上对于术前有糖尿病史及术后出现高血压的CAS患者必须加以重视,尽早发现和处理CHS。     

Early recognition of cerebral hyperperfusion syndrome after carotid stenting--a case report

The hyperperfusion syndrome is a recognized complication of carotid endarterectomy. Reports of cerebral hyperperfusion injury following internal carotid artery angioplasty and stenting are few We report a case of 76-year-old hypertensive man who was admitted to our hospital for assessment 2 years after experiencing an ischemic stroke of right hemisphere. Angiography confirmed 60% stenosis of left internal carotid artery (ICA). Percutaneous transluminal stenting of left internal carotid artery was performed without any immediate complications. Two hours after the procedure, the patient suddenly deteriorated. Computed tomography (CT) of the brain revealed extensive intracerebral hemorrhage and he died 5 days later. There was precipitating migranous headache, and his blood pressure was moderately elevated at the time of deterioration. Sentinel headache could solely indicate the early sign of hyperperfusion injury after carotid stenting, especially in the presence of arterial hypertension. Patients with sentinel headache after angioplasty should be recognized early and they deserve intensive study for other features of cerebral hyperperfusion injury and prompt early management.     

Hyperperfusionssyndrom nach Karotisstentangioplastie bei einem 77-jährigen Patienten

Cerebral hyperperfusion following carotid artery stenting represents a rare neurological complication. It is characterized by ipsilateral headache, focal neurological symptoms, seizures and intracerebral oedema or haemorrhaging. Restriction of the intracerebral perfusion caused by high grade ipsilateral and/or contralateral carotid stenosis, previous contralateral carotid revascularization and preinterventional, peri-interventional and postinterventional hypertension are regarded to be risk factors. Cranial computed tomography (CT) and diffusion-weighted magnetic resonance imaging (MRI) might show normal findings for hyperperfusion syndrome. The most important aspects of prophylaxis and treatment are controlling the hypertension in a specialized intensive care unit.     

Can the diameter of endoluminal shunt influence the risk of hyperperfusion syndrome after carotid endarterectomy?

AIM: The aim of this study was to evaluate if there is a possible relation between the size of endoluminal shunt, in carotid endarterectomy (CEA), and the risk of postoperative hyperperfusion syndrome. METHODS: We retrospectively studied prospectively collected data from 156 patients, who were subjected to CEA using shunting and vein patch angioplasty. One hundred and thirty-eight of the patients had bilateral, high grade (> or = 90%) internal carotid lesions and the remaining 18 had a high-grade stenosis (> or = 90%) and a contralateral internal carotid artery (ICA) occlusion. In 81 patients varying diameters of shunts were used (8-14 Fr) according to the diameter of ICA (group A) and in the other 75 patients (group B) only the smallest shunt was used (8 Fr). Development of hyperperfusion syndrome was evaluated both clinically and radiologically with magnetic resonance imaging. RESULTS: Fifteen patients developed hyperperfusion syndrome (9.6%), between 0 to 6 days postoperatively. Thirteen belonged to group A (86.6%), and 2 (13.3%) belonged to group B (P<0.05). One had an intracerebral hemorrhage (0.6% of the study group) the 3rd postsurgical day. CONCLUSIONS: During CEA in patients with high-grade bilateral lesions, we recommend the use of a shunt with small diameter: this aims at reducing the risk of hyperperfusion syndrome.     

Bilateral carotid angioplasty and stenting.

Bilateral carotid stenosis is generally treated by staged stenting procedure and rarely simultaneously due to concerns about hemodynamic impairment from stimulation of the carotid sinus baroreflex (severe bradycardia, hypotension) and the risk of cerebral hyperperfusion syndrome. Most of the accounts of bilateral carotid stenting are of small series. The aim of this study was to evaluate the feasibility and safety of simultaneous bilateral carotid angioplasty and stenting (CAS) in comparison with staged procedure. We retrospectively analyzed the procedural outcome and complications of bilateral CAS done between February 1995 and June 2004 in a consecutive series of 57 high-risk patients. Mean age was 64 +/- 9 years (male, 43; female 14). One hundred fifteen arteries were treated (one patient had bilateral internal carotid artery stenosis associated to an ostial common carotid artery stenosis). Thirty-nine patients were symptomatic (70%). Thirty-six patients had severe coronary artery disease. Seventeen patients underwent a simultaneous bilateral CAS (group 1), 40 in a staged manner (group 2). Among these 40 patients 10 were treated with a time interval of 24 hr, while the 30 other ones were treated with a time interval of 2 days to 2 months. A neuroprotection device was used in the last 42 patients. There was technical success in all patients and transient bradycardia and/or hypotension in 25 patients (44%). There was no prolonged bradycardia or hypotension. At 30 days, we observed in group 1 (simultaneous bilateral CAS) no transient ischemic attack (TIA), no minor stroke, one (5.8%) major stroke (hyperperfusion syndrome with brain hemorrhage leading to death in a patient under IIb/IIIa inhibitors), one myocardial infarction leading to death, and two (11.7%) death/stroke/myocardial infarction; in group 2 (staged procedure), two (5%) TIAs, no minor stroke, no major stroke, and one (2.5%) hyperperfusion syndrome with rapid recovery. Among the 10 patients treated with a time interval of 24 hr, we observed one TIA. Among carefully selected patients, bilateral CAS is feasible simultaneously or the day after, with a safety and complication rate comparable to that of large published series of CAS or endarterectomies in high-risk patients. Nevertheless, careful monitoring of the patient, blood pressure, and heart rate is mandatory to avoid complications related to hyperperfusion syndrome. Routine use of neuroprotection device and meticulous technique should improve the outcomes of bilateral CAS.     

颈动脉支架置入术围手术期血压调控的探讨

目的探讨粥样硬化性颈动脉狭窄患者,经皮血管内支架置入血管成形术(PTAS)围手术期血压调控的必要性及初步经验。方法回顾性分析293例粥样硬化性颈动脉狭窄患者经全脑数字减影血管造影术诊断后,采用自膨式支架经股动脉入路行PTAS,围手术期对血压严密监控,并根据血压的高低采取综合措施及时进行调整,以避免发生高灌注性脑病或心、脑缺血。结果 293例患者中支架置入成功292例(99.7%)。术前狭窄率70%～95%平均(82.0±13.1)%,术后残余狭窄率为0～20%,平均(9.2±6.8)%,术后患者脑缺血症状及体征均有明显改善。有1例患者在术中及术后血压控制不理想,发生了高灌注性脑出血而死亡。通过采取综合措施调节血压后未再发生高灌注性脑病,血压降至90～120/60～90 mm Hg(1 mm Hg=0.133 kPa)后,所有患者均未发生心、肾、脑等脏器缺血。结论 PTAS微创安全有效,但术中及术后调整血压非常必要,围手术期有效地调控血压是减少术后高灌注性综合征发生的重要手段之一。     

颈动脉血管成形和支架置入术的并发症及其处理

颈动脉狭窄是导致脑梗死的重要原因之一。颈动脉血管成形和支架置入术(CAS)已被证实能够预防卒中发生,临床应用越来越广。尽管CAS是一种微创治疗方法,但仍然有许多潜在的并发症,如血流动力学异常、过度灌注综合征、脑梗死和再狭窄等。文章对CAS的并发症及其处理方法进行了综述。     

Postcarotid endarterectomy symptoms. Pre- and postoperative clinical and MRI findings.

BACKGROUND: The hyperperfusion syndrome represents a highly debated clinical entity, without having yet any clinically identifiable limits. The correlation of clinical with pre- and postoperative magnetic resonance imaging (MRI) findings following carotid endarterectomy in patients with a possible hyperperfusion syndrome was investigated. METHODS: Design: Prospective clinical and laboratory study. Setting: At the Aretaieio University Hospital. Measures: Comparison to the postoperative clinical symptomatic and MRI findings. Patients. We studied 30 patients (mean age 66.6) of whom 14 (46.6%) were asymptomatic, 16 (53.4%) were symptomatic, 17 (56.6%) were hypertensive, 18 (60%) hyperlipidaemic, 5 (16.6%) diabetic and 17 (56.6%) had coronary artery disease. RESULTS: Twenty-one patients (70%) exhibited disturbances such as ipsilateral headache, seizures, vomiting or facial pain; immediate postoperative MRI scans revealed new ischaemic foci in 4 (19%) without any objective neurological findings. Lesions displayed in postoperative MRI scans did not always cause symptoms and normal findings on MRI did not exclude the presence of symptoms. Hypertension favoured the presence of subjective disturbances, without necessarily any change in the MRI appearances. Preoperative MRI and clinical findings did not contribute to the identification of patients who might have exhibited postoperative symptoms. Thus, the symptomatology remains unclear and open to debate, as a variety of other conditions may produce the same clinical picture postoperatively. CONCLUSIONS: Subjective disturbances, objective neurological findings and MRI abnormalities with or without hypertension may appear independently after carotid endarterectomy, a fact which makes the pathogenesis of the hyperperfusion syndrome more difficult to elucidate.     

Carotid artery reconstruction for Takayasu's arteritis the necessity of all-autogenous-vein graft policy and development of a new operation.

BACKGROUND: We have adopted an all-autogenous-vein-graft policy in carotid reconstruction for Takayasu arteritis, namely an ascendo-right carotid and right subclavian (axillary) arteries bypass using a pantaloon vein graft for patients all of whose arch branches are occluded, and an extra-anatomical bypass from the right subclavian artery for patients whose brachiocephalic artery is the only arch branch that remains patent. This report is to elaborate on these operations and to assess the long-term outcome. METHODS: Six patients were operated on according to this policy; (5 women, 1 man, age range: 14 to 59 years (mean: 30). The indications for surgery were severe cerebral ischaemia that significantly interfered with their daily lives. The pantaloon vein graft bypass was performed in four patients, and an extra-anatomical bypass in two. The specific management protocol to prevent the "postbypass hyperperfusion syndrome" and cerebral oedema included a shunt procedure to the internal carotid artery using one limb of the pantaloon vein graft, induced hypotension just before the completion of the carotid reconstruction and the administration of a glycerine-fructose solution. RESULTS: Cerebral ischaemic symptoms disappeared in all patients. All but one, who died of a ruptured thoraco-abdominal aneurysm on the 35th postoperative month, are living a normal life with a patent graft. No suture line complications have as yet been encountered (follow-up: 10 to 205 months, mean: 126 months). CONCLUSIONS: Carotid vein bypass for Takayasu arteritis, particularly, the pantaloon vein graft bypass is recommended for those of whom all aortic arch branches are occluded, resulting in severe brain ischaemia. Perioperative blood pressure control is important for prevention of the hyperperfusion syndrome.     

Technik der Karotis-PTA

Over the past 25 years carotid artery stenting (CAS) has emerged as an alternative to carotid endarterectomy (CEA). Most of all younger patients and symptomatic patients with contralateral carotid artery occlusion particularly benefit from CAS. To achieve an optimal result with CAS, patient selection and even more important, knowledge and experience of the interventionist is crucial. The periprocedural complication rate of CAS in large experienced centers is lower (2–3%) than those in randomized trials. Several different devices are now available which allow the procedure to be tailored according to patient anatomy and lesion complexity. Complications like hyperperfusion syndrome and intracerebral bleeding, rupture of side branches of the external or internal carotid artery as well as problems caused by slow flow can be widely avoided by adequate experience.     

颈动脉内膜切除术的术中经颅多普勒监测

颈动脉内膜切除术(carotid endarterectomy,CEA)可有效治疗有症状颈动脉狭窄,但围手术期卒中是CEA最重要的并发症.术中和术后产生的微栓子是造成围手术期卒中的最主要原因.另外,术中夹闭颈动脉所敛的低灌注、术后过度灌注综合征以及术后颈动脉再狭窄或闭塞,都是围手术期卒中的原因.作为一项尤创、实时的临测工具,经颅多普勒(transcranial Doppler,TCD)可广泛应用于CEA的术中监测,能发现围手术期各种血流变化和微栓子的产生,有效预测围手术期卒中的发生,降低围手术期卒中风险.     

Cerebrovascular resistance and blood flow velocity changes after carotid endarterectomy

BACKGROUND: To study the pattern of cerebral blood flow velocity and cerebral resistance changes after carotid endarterectomy. PATIENTS AND METHODS: In 81 patients (mean age +/- SD, 64 +/- 8 years) with unilateral carotid endarterectomy (CEA) the systolic, diastolic and mean blood velocities, and the pulsatility index (PI) were recorded in both middle cerebral arteries preoperatively and repetitively postoperatively with the use of transcranial Doppler ultrasound (TCD). RESULTS: In the middle cerebral artery ipsilateral to CEA mean blood velocity was increased 6 hours (64 +/- 25 cm/sec; p < 0.005) and 7 days (54 +/- 15 cm/sec; p < 0.05) after CEA and had returned to the preoperative level (49 +/- 11 cm/sec) after 3 months. Compared to preoperatively (0.86 +/- 22), the PI was significantly increased at 6 hours examination (1.03 +/- 23, p < 0.005), and remained increased thereafter. A pathologically increased mean blood velocity (> 83 cm/sec) 6 hours after CEA occurred in 11 patients, two of them developed a slight hyperperfusion syndrome. In the contralateral middle cerebral artery, only the diastolic blood velocity showed significant changes (preoperatively, 35 +/- 12 cm/sec; 3 months after CEA, 33 +/- 8 cm/sec; p < 0.05). CONCLUSIONS: Using TCD, hemodynamic changes occur predominantly in the middle cerebral arteries ipsilateral to CEA. Early postoperative TCD studies may be of help to identify patients at risk to develop a hyperperfusion syndrome.     

Cerebral hyperperfusion syndrome after carotid intervention: a review

Cerebral hyperperfusion syndrome (CHS) after carotid surgery, although rare, is a well-described phenomenon. Although originally described after carotid endarterectomy, it has now also been described after carotid artery stenting. It is classically described as an acute neurologic deficit occurring several days after a carotid procedure, associated with severe hypertension and preceded by a severe headache. CHS represents a spectrum of clinical symptoms ranging from severe unilateral headache, to seizures and focal neurologic defects, to intracerebral hemorrhage in its most severe form. The exact mechanism leading to CHS is unknown; however, it seems to be related to increased regional cerebral blood flow secondary to loss of cerebrovascular autoregulation. Given the significant morbidity associated with CHS, researchers have been trying to identify which patients are most at risk. This is a difficult task given the rarity of the disease and the multiple confounding factors in the patient population who undergo carotid intervention. The goal was to determine those patients most at risk preoperatively, so that they may be more closely monitored postoperatively to prevent the development of CHS and its associated morbidity. The purpose of this review was to summarize the data currently available in the literature on CHS, with emphasis on pathophysiology, risk factor assessment, diagnostic modalities, and disease management, to provide insight for future research to better elucidate how to reduce the morbidity and mortality caused by CHS.     

Assessment of flow changes in the circle of Willis after stenting for severe internal carotid artery stenosis.

PURPOSE: To assess flow velocities in the cerebral arteries after carotid artery stenting (CAS) in patients with unilateral versus bilateral lesions and analyze velocities in patients with neurological complications after CAS. METHODS: Ninety-two patients (68 men; mean age 63.2 +/- 8.4 years, range 44-82) with internal carotid artery (ICA) stenoses were divided according to unilateral (group I, n = 72) or bilateral (group II, n = 20) disease. Fifty age- and gender-matched patients without lesions in the extra- or intracranial arteries served as a control group. Transcranial color-coded Doppler ultrasound was performed prior to and within 24 hours after CAS in the test groups; systolic velocities were assessed ipsilateral (i) and contralateral (c) to the CAS site in the middle cerebral artery (MCA) and anterior cerebral artery (ACA). RESULTS: Collateral flow via the anterior communicating artery (ACoA) was found in all group-II patients and 90% of group-I patients. After CAS, collateral flow through the ACoA ceased, and the velocity increased by 26% in the iMCA in group I compared to controls (p < 0.001). In group II, iMCA flow increased by 30% (p < 0.001) and flow via the ACoA (p < 0.001) increased, resulting in normalization of cMCA velocities (p = 0.928). In 89 (96.7%) subjects, CAS was uncomplicated. Hyperperfusion syndrome occurred in 2 (2.2%) patients, both with bilateral ICA stenoses; 1 (1.1%) transient ischemic attack was seen in a patient with unilateral disease. In the patients with hyperperfusion syndrome, the MCA velocities were 2.7- and 7.4-fold higher, respectively, versus before CAS and 2-fold higher than in controls. CONCLUSION: Uncomplicated CAS results in an iMCA velocity increase >25% compared to controls. MCA velocities in hyperperfusion syndrome were greatly increased versus before CAS and in controls.     

Postendarterectomy Cerebral Hyperperfusion Syndrome: The Etiological Significance of “Cerebral Reserve”

Postoperative cerebral hyperperfusion syndrome (CHS) in patients undergoing carotid intervention is thought to be related to the absence of cerebral reserve. Although hyperperfusion syndrome is rare, severe postoperative headache is common and is considered to be a prodromal sign. Cerebral reserve is measured by studying the response of cerebral vessels to a vasodilator such as hypercarbia. We produced hypercarbia by holding respiration for 60 seconds during carotid endarterectomy. We attempted to evaluate the relationship between intraoperatively evaluated cerebral reserve and the development of postoperative headache which was severe enough to require the patient to take an over the counter analgesic (e.g., ibuprofen, acetaminophen, aspirin). Internal carotid artery flow 1 (F1), Pco ₂, and blood pressure 1 (BP1) were recorded before and after (F2, Pco ₂, and BP2) 60 seconds of apnea. An increase in flow of > 20% was considered indicative of adequate cerebral reserve. Patients were evaluated before discharge and with follow-up calls at 2 to 5 days postdischarge. Fisher exact test was used to evaluate categorical predictors. Unpaired t test was used to compare continuous variables. Results were considered significant when p < 0.05. A total of 30 nonconsecutive patients were evaluated prospectively. Of the 30 patients, 4 (Group I) developed severe postoperative headache; 26 did not (Group II). Demographics were similar in both the groups. Three patients in Group I and 16 patients in Group II had > 20% increase in flow (p = 0.6315). Pco ₂ rose in both groups and BP2 was unchanged from BP1 in both groups. Lack of cerebral reserve does not appear to be related to the development of severe postoperative headache.     

Brain injury secondary to carotid intervention.

Causes of brain injury during endovascular carotid intervention are protean. Mechanisms of injury include embolic and hemodynamic events, acute carotid occlusions occurring through a variety of means, and the relatively rare contrast-induced encephalopathy. Embolic injury may result from micro- and macroembolization and most commonly causes ischemic stroke when sufficiently severe. Hemodynamic injury may proceed from hemodynamic depression and hypoperfusion (which may result in watershed infarction) or the hyperperfusion syndrome, which may, if severe, result in hemorrhagic stroke. Embolic and dynamic causes of stroke may either occur intraprocedurally or at a variable time after stent placement and may be co-related. Impaired clearance of emboli due to relative hypoperfusion may exacerbate their clinical relevance. Other causes of stroke include acute carotid occlusions, which most commonly occur procedurally due to flow-limiting spasm, acute dissection, and, if a filter-type cerebral protection device has been used, filter occlusion due to a large trapped embolic load. These scenarios may result in stroke if not recognized and dealt with appropriately. Acute stent thrombosis may occur within 24 hours of the procedure as a result of adverse hemodynamic factors or suboptimal patient response to procedural heparin and antiplatelet agents, or it may occur after the procedure, again perhaps as a result of suboptimal response to antiaggregate drugs.