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Case 2

History:

50 year old patient status post endarterectomy presents with change in mental status, headache and seizures

Findings:

The FLAIR sequences show abnormal hyperintensity signal in the subcortical areas of the right frontal and parietal lobes with mild patchy enhancement and no corresponding restriction on the diffusion sequences.

Diagnosis:

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Discussion:

Cerebral hyperperfusion syndrome (CHS) is believed to occur following restoration of blood flow to a brain with impaired autoregulation due to chronic hypoperfusion.  If not treated properly it can result in severe brain oedema, intracerebral or subarachnoid haemorrhage, and death.

Patients who are thought to be at risk are those with uncontrolled hypertension, severe carotid artery stenosis, contralateral occlusion, and poor collateral capacity of the circle of Willis. It is thought that these patients have chronic hyperfusion of ipsilateral vascular territories and loss of normal adaptive autoregulatory responses.

Presenting clinical signs are: ipsilateral headache, hypertension, seizures, and focal neurological deficits, which can occur few hours to few days post procedural. Management requires aggressive blood pressure control to prevent stroke and intracerebral hemorrhage.

Typical MRI findings are subcortical area of signal alteration on the long TR sequences without corresponding DWI abnormality, indicating vasculogenic edema rather than cytotoxic edema.

References:

  • Scozzafava J, Hussain MS, Yeo T, Jeerakathil T, Brindley PG. Case report: Aggressive blood pressure management for carotid endarterectomy hyperperfusion syndrome. Can J Anaesth. 2006 Aug;53(8):764-8.
  • Karaipanayiotides T, Mueli R, Devuyst G, et al. Postcarotid EndarterectomyHyperperfusion or Reperfusion Syndrome. Stroke 36:21-26, 2005.
  • Araki CT, lBabikian Vl., Cantelmo NL, et al: Cerebrovascularhemodynamic changes associated with carotid endarterectomy. JVasc Surg 1.3:854-9; discussion 859-60, 1991.
  • Karapanayiotides T. Mtieli R. Devuyst G, et al: Postcarotid endarterectomy hyperperfusion or reperfusion syndrome. Stroke 36:21-26, 2005.