Cortical non-aneurysmal subarachnoid hemorrhage post-carotid endarterectomy: a case report and literature review
© Thanabalasundaram et al.; licensee Springer. 2013
Received: 16 August 2013
Accepted: 15 October 2013
Published: 29 October 2013
Cerebral hyperperfusion syndrome is a well-recognized and potentially fatal complication of carotid revascularization. However, the occurrence of non-aneurysmal subarachnoid hemorrhage as a manifestation of cerebral hyperperfusion syndrome post-carotid endarterectomy is uncommon. We report a case of a patient who presented with headache following carotid endarterectomy for a critically occluded common carotid artery. This progressed to deteriorating consciousness and seizures. Investigations revealed a left cortical non-aneurysmal subarachnoid hemorrhage. Non-aneurysmal subarachnoid hemorrhage is a rare post-operative complication of carotid endarterectomy. Immediate management with aggressive blood pressure control is key to prevent permanent neurological deficits.
Cerebral hyperperfusion syndrome (CHS) after carotid revascularization procedures is an uncommon and potentially fatal complication. Pathophysiologically it is attributed to impaired autoregulatory mechanisms and results in disruption of cerebral hemodynamics with increased regional cerebral blood flow (Cardiol Rev 20:84–89, 2012; J Vasc Surg 49:1060–1068, 2009). The condition is characterized by throbbing ipsilateral frontotemporal or periorbital headache. Other symptoms include vomiting, confusion, macular edema, focal motor seizures with frequent secondary generalization, focal neurological deficits, and intraparenchymal or subarachnoid hemorrhage (SAH) (Lancet Neurol 4:877–888, 2005). The incidence of CHS varies from 0.2% to 18.9% after carotid endarterectomy (CEA), with a typical reported incidence of less than 3% in larger studies (Cardiol Rev 20:84–89, 2012; Neurosurg 107:1130–1136, 2007). Uncontrolled hypertension, an arterially isolated cerebral hemisphere, and contralateral carotid occlusion are the main risk factors (Lancet Neurol 4:877–888, 2005; J Neurol Neurosurg Psychiatry 83:543–550, 2012). We present a case of non-aneurysmal SAH after CEA, with focus on its presentation, risk factors, and management.
A 66-year old male presented with severe headache and tonic-clonic seizures on the 6th post-operative day after left CEA surgery at an outside facility. Past medical history included hypertension, hypercholesterolemia, bilateral carotid stenosis and smoking (40 pack-years). At time of left CEA the 99% occluded left carotid artery was revascularized without any apparent complications. Consequently, he was discharged on the 1st post-operative day with no neurological deficits on aspirin, statin and antihypertensives, though his blood pressure proved difficult to control. On the 6th post-operative day, he developed lethargy and drowsiness, followed by sudden onset of the worst headache of his life. Symptoms progressed rapidly to tonic-clonic movements with loss of consciousness. He was emergently intubated by paramedics, and taken to his local medical center. On admission, his blood pressure of 230/170 mmHg, was treated with nicardipine, and he was loaded with levetiracetam. Non-contrast head CT (NCCT) evinced SAH in the left Sylvian fissure, prompting referral to our center for further management.
Blood pressure control in the Neurosciences Intensive Care unit over the course of several days produced improvement and the patient was discharged to a rehabilitation hospital, able to walk, with mild confusion.
In this report, we describe a case of isolated left-sided SAH 6 days after ipsilateral CEA surgery. No evidence of intraparenchymal hemorrhage or other explanation for the SAH was found. SAH as a manifestation of CHS after CEA is an extremely rare complication; Ogasawara et al. report a 0% incidence of SAH in the CEA (n = 1596) subgroup of their retrospective review of 4494 patients (Ogasawara et al.2007), whereas McDonald et al. report it as being the least common form of CHS in 203 post-CEA patients (McDonald et al.2011). To our knowledge, there are only 2 previous cases that report this phenomenon (Bodenant et al.2010); (Dalton1992).
In 1992 SAH was described in a 62-year old Caucasian woman 5 days post-CEA surgery with no neurological deficits (Dalton1992). In 2010 a 74-year old male who presented with left-sided hemiplegia, left visual and sensory neglect, fluctuant altered consciousness and partial motor seizure 9 days following a right CEA was reported (Bodenant et al.2010). Neuroimaging confirmed a frontal SAH but was negative for aneurysms and vascular malformations. In contrast to our patient, that patient developed vasospasm in the middle cerebral artery. In both these cases, as in our patient, the likely source of the hemorrhage was rupture of small dilated, cortical vessels experiencing elevated flow and pressures following restoration of normal ICA flow.
Post-operative hypertension has been identified as one of the most important risk factors predisposing to CHS in post-CEA patients (Lieb et al.2012; Ogasawara et al.2007; van Mook et al.2005), and Bouri et al. report reduced odds for intracranial hemorrhage when systolic blood pressure is maintained at <140 – 160 mmHg post-operatively (Bouri et al.2011). Our patient was difficult to maintain normotensive in the post-operative period, and presented with blood pressures of 230/170 mmHg, which likely contributed to development of CHS and the subsequent SAH. A recent study reinforces the importance of treating hypertension to minimize neurological deficits (Wellman & Koide2013), supporting the strict blood pressure control the patient underwent.
An isolated cerebral hemisphere, whose perfusion is dependent solely upon the ipsilateral carotid artery, is also a risk factor for CHS (Moulakakis et al.2009; Moulakakis et al.2012). While our patient did not have an incomplete Circle of Willis, he had bilateral carotid stenosis, and his CTA showed severe right ICA narrowing, which has been associated with an increased likelihood of developing CHS (Pyysalo et al.2011), likely through disruption of auto-regulatory mechanisms. However, on the other hand, a recent paper earlier this year has found that the degree of contralateral stenosis was not significant in the development in cerebral hyper-perfusion. These results indicate that further research has to be done in the field of contralateral stenosis (Maas et al.2013).
The risk of significant vasospasm developing from a cortical SAH in this clinical context is minimal, and was not a significant management concern in this case. If concern is higher, due to a significant hemorrhagic component in the basal cisterns, consideration may be given to the use of nimodipine, and longer inpatient monitoring, with cerebrospinal fluid drainage as indicated. Anticonvulsants (used to treat his presumed seizures at onset) are important to ensure adequate seizure control because the spikes in systolic blood pressure during seizure activity can further worsen the established CHS (Connolly et al.2012).
This case demonstrates the importance of aggressively controlling hypertension in patients after their CEA surgery. The presence of one or more risk factors for CHS demands particular vigilance and outpatient blood pressure monitoring on discharge. The case also highlights a rare presentation of CHS. Appropriate aggressive management of this complication through blood pressure reduction, seizure control and antispasmodic therapy (if indicated) decrease the risk of mortality and neurological deficits (Pyysalo et al.2011).
Informed consent was obtained from the patient for the publication of this report and any accompanying images.
- Bodenant M, Leys D, Lucas C: Isolated subarachnoidal hemorrhage following carotid endarterectomy. Case Rep Neurol 2010, 2(2):80-84. 10.1159/000315865View ArticleGoogle Scholar
- Bouri S, Thapar A, Shalhoub J, Jayasooriya G, Fernando A, Franklin I, Davies A: Hypertension and the post-carotid endarterectomy cerebral hyperperfusion syndrome. Eur J Vasc Endovasc Surg 2011, 41: 229-237. 10.1016/j.ejvs.2010.10.016View ArticleGoogle Scholar
- Connolly E, Rabinstein A, Carhuapoma J, Derdeyn C, Dion J, Higashida R, et al.: Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American heart association/American stroke association. Stroke 2012, 43(6):1711-1737. 10.1161/STR.0b013e3182587839View ArticleGoogle Scholar
- Dalton M: Subarachnoid hemorrhage after carotid endarterectomy. J Vasc Surg 1992, 16(5):799. 10.1016/0741-5214(92)90242-ZView ArticleGoogle Scholar
- Lieb M, Shah U, Hines G: Cerebral hyperperfusion syndrome after carotid intervention: a review. Cardiol Rev 2012, 20: 84-89.Google Scholar
- Maas MB, Kwolek CJ, Hirsch JA, Jaff MR, Rordorf GA: Clinical risk predictors for cerebral hyperperfusion syndrome after carotid endarterectomy. J Neurol Neurosurg Psychiatry 2013, 84: 569-572. doi:10.1136/jnnp-2012-303659 10.1136/jnnp-2012-303659View ArticleGoogle Scholar
- McDonald R, Cloft H, Kallmes D: Intracranial hemorrhage is much more common after carotid stenting than after endarterectomy: evidence from the national inpatient sample. Stroke 2011, 42: 2782-2787. 10.1161/STROKEAHA.111.618769View ArticleGoogle Scholar
- Moulakakis K, Mylonas S, Sfyroeras G, Andrikopoulos V: Hyperperfusion syndrome after carotid revascularization. J Vasc Surg 2009, 49: 1060-1068. 10.1016/j.jvs.2008.11.026View ArticleGoogle Scholar
- Ogasawara K, Sakai N, Kuroiwa T, Hosoda K, Iihara K, Toyoda K, et al.: Intracranial hemorrhage associated with cerebral hyperperfusion syndrome following carotid endarterectomy and carotid artery stenting: retrospective review of 4494 patients. J Neurosurg 2007, 107: 1130-1136. 10.3171/JNS-07/12/1130View ArticleGoogle Scholar
- Pyysalo L, Niskakangas T, Keski-Nisula L, Kähärä V, Öhman J: Long term outcome after subarachnoid haemorrhage of unknown aetiology. J Neurol Neurosurg Pyschiatry 2011, 82(11):1264-1266. 10.1136/jnnp.2010.239335View ArticleGoogle Scholar
- van Mook W, Rennenberg R, Schurink G, van Oostenbrugge R, Mess W, Hofman P, de Leeuw P: Cerebral hyperperfusion syndrome. Lancet Neurol 2005, 4: 877-888. 10.1016/S1474-4422(05)70251-9View ArticleGoogle Scholar
- Wellman G, Koide M: Impact of subarachnoid hemorrhage on parenchymal arteriolar function. Acta Neurochir Suppl 2013, 115: 173-177.Google Scholar
- Wu T, Anderson N, Pa B: Neurological complications of carotid revascularization. J Neurol Neurosurg Psychiatry 2012, 83: 543-550. 10.1136/jnnp-2011-301162View ArticleGoogle Scholar
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