Cerebral hyperperfusion syndrome (CHS)

Created 04/11/2021, last revision 07/05/2023

  • 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)


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Clinical presentation

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

Diagnostic evaluation

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  • 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 IV. (to neutralize the effect of clopidogrel or other thienopyridines) [Qureshi, 2008]
  • if the 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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Cerebral hyperperfusion syndrome