Cerebral Hyperperfusion

7/17/2019 Cerebral Hyperperfusion

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Carotid Artery Stenosis



CAS

Risk factors:

− Family Hx of atherosclerosis, Age > 75, High LL, Smoking, H!", #, $%esity,Sedentary lifestyle

Signs and Sx &arning signs of stroke

− Ama'rosis f'gax

− (eakness)n'm%ness of one side of the face)arms)legs

− Sl'rred s*eech, diffic'lty talking

− Loss of coordination

+hysical exam carotid %r'its

iagnostic -maging

− Carotid d'*lex .S, carotid angiogra*hy, #RA, C! scan, or C!A



CEA

-ndications for *roced're

+ro/en -ndications

− $ne or more !-As in the last 0 months and carotid stenosis 1723

− #ild stroke &ith carotid stenosis 1723

Acce*ta%le 4't "ot +ro/en -ndications

− !-As in the *ast 0 months and stenosis of 523 to 03

− +rogressi/e stroke and stenosis 1723

− #ild or moderate stroke in the *ast 0 months and stenosis of 523 to 03

− Carotid endarterectomy i*silateral to !-As and stenosis 1723, com%ined&ith re6'ired coronary %y*ass grafting















#RC Asym*tomatic Carotid S'rgery !rial

ACS!8

5 year risk of stroke 38

-mmediateC9A

n;502

eferredC9A

n;502

*

All *atients <= ;;=2 ?2=22;#en @=< ;2=5 ?2=222;

(omen <=2 7= 2=2@

Age ? 05 ;= =0< ?2=222;

Age 05B7 @=; =07 ?2=222;

02 B 23 S @=20 = ?2=222;

2 B 23 S <=@2 =50 ?2=222;



C9A

For sym*tomatic carotid artery stenosis of 72 to 3&ith no se/ere coBmor%idities:

− C9A ""! 0=<

For sym*tomatic stenosis of 52 to 03:− C9A ""! @@

ASA sho'ld %e started %efore s'rgery and contin'ed*osto*erati/ely



Com*lications of C9A

#-

Stroke

4leeding

Cer/ical hematoma

"er/e in'ry

-nfection

Carotid restenosis Cerebral hyperperfusion



Case

56y F.

− Sept 25th: amaurosis fugax

− Carotid stenosis of 90% hx of !"#

− $ooed for CEA in August &'C(ed home

− )eturned *ith hemip+egia and spee,h diffi,u+ties

− CEA done urgent+y

− &e-e+oped pounding heada,he seiures andS$/200



Cere%ral Hy*er*erf'sion Syndrome

Fail're of cere%ral a'toreg'lation *ost re/asc'larisation @=73of C9ADs8

− Com*ensation of CAS leads to chronic maximal dilation

− ilated /essels 'na%le to constrict after C9A

− Leads to edema and hemorrhage

− H!" is *rec'rsor to syndrome

Risk Factors:

− Stenosis >23 Stroke from CAS +resenting sym*toms

− H)A im*ro/ed &ith '*right *ost're se/ere, i*silateral, *o'nding8− "e'rological deficit hemi*legia, neglect, hemiano*ia, a*hasia8− SeiE're generaliEed or focal8− -CH 2=<B2=738− H)A normal after C9A 0@38 %'t mildBmoderate

x− S*asm, issection, stroke, hemorrhage−

SAH from *reBexisting ane'rysm



S+9C! Scan



#x

+rognosis de*ends on 4+ control

S4+ ?;52mmHg %e aggressi/e8

− - La%etalol, nitro*r'sside, nitroglycerine

Head C! R)$ stroke and hemorrhage

+henytoin for seiE're

)C ASA and antithrom%otics

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Cerebral Hyperperfusion