ADD-ONS

Cerebral hyperperfusion syndrome (CHS)

Created 25.09.2019 , last update 04.11.2021

  • Cerebral Hyperperfusion (reperfusion) Syndrome (CHS) can occur within hours to days after a revascularization procedure (carotid endarterectomy, carotid artery stenting, revascularization in moyamoya syndrome, severe aortic stenosis repair)
    • the peak incidence of CHS and hemorrhage after CEA is  5-7 days and 12-48 h after CAS   [Ogasawara, 2007]
    • longer delay (days to weeks) was reported as well
    • CHS following aortic stenosis surgery may lead to bilateral lesions
  • incidence 1-14% (usually approximately 7%) according to various authors
  • most patients with CHS have mild symptoms and signs
  • the cornerstone of prevention is strict perioperative BP correction (at least for 14-21 days)

Pathophysiology

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Clinical presentation

  • severe headaches 
    • worsening in the prone position
    • ipsilateral to the lesion side or diffuse
  • impaired consciousness
  • epileptic seizures (often focal)
  • focal neurologic deficits (usually in ICH)

Diagnostic evaluation

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Management

  • rigorous blood pressure correction (ideally <120/85 mmHg) – it also serves as a prevention
  • in case of seizure activity, administer AE drugs (PHE, VPA, LEV) → acute symptomatic seizures
  • antiedema therapy

Management of patients with hemorrhagic transformation/SAH/ICH

  • discontinue antiplatelet therapy, consider platelet concentrate infusion
  • administer SOLUMEDROL 25 mg i.v. (to neutralise the effect of clopidogrel or other thienopyridines) [Qureshi, 2008]
  • if CT scan indicates no progression in 24h,  patients with stent should be given aspirin,  postpone clopidogrel therapy for 5-7 days
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