Haemorrhagic complication following percutaneous transluminal angioplasty for carotid stenosis

Massive non-aneurysmal subarachnoid hemorrhage after cervical carotid angioplasty and stenting: a case report and review of the literature

INTRODUCTION

Carotid angioplasty and stenting (CAS) of the cervical segment is a safe and effective procedure for the treatment of carotid artery disease. In rare cases, this procedure causes intracranial hemorrhage (ICH), which is described most often as an ipsilateral intra-parenchymal hematoma. This ICH is the result of a cerebral hyperperfusion syndrome (CHS). Isolated subarachnoid hemorrhage may occur exceptionally, with only 9 cases that have been reported in the literature.

OBSERVATION

We reported a case of a 71-year-old man who presented a massive non-aneurysmal subarachnoid hemorrhage one hour after angioplasty and stenting of the cervical segment of the left internal carotid artery. Medical and surgical management included external ventricular drain placement. Rebleeding occurred two days later, worsening the patient's clinical condition. Finally, the patient died 2 weeks later.

COMMENTS

This rare presentation of ICH following CAS allows us to discuss the risk factors, complications and management of CHS.

Intracranial Hemorrhage After Carotid Angioplasty:A Pooled Analysis

PURPOSE

To use a pooled analysis of the literature to find the incidence of and characteristics common to intracranial hemorrhage (ICH) associated with carotid artery stenting (CAS).

METHODS

A search of the English-language literature (1996-2005) was performed in PubMed to find cases of CAS-associated ICH. Information was derived from the identified case studies in 5 categories and 19 aspects: (1) incidence of CAS-associated ICH; (2) demographic data (sex, age, symptom presentation, and presence of preexisting hypertension); (3) imaging data (side of lesion, degree of maximal stenosis, lesion location, status of the contralateral carotid artery, collateral circulation, and preprocedural imaging features); 4) procedure-related characteristics (antithrombotic medication, use of cerebral protection devices, residual stenosis, symptoms, interval from the procedure to ICH, type of ICH, and blood pressure changes); and (5) clinical outcome.

RESULTS

Fifty-four cases of CAS-associated ICH were reviewed: 51 cases from 36 published articles and our own 3 cases. The incidence of CAS-associated ICH was 0.63% (95% CI 0.38% to 0.97%) in studies consisting of >100 cases, which was significantly lower (p<0.0001) than that of case series consisting of <100 cases (2.69%, 95% CI 1.75% to 3.94%). Distinctive features included symptomatic lesions, severe stenosis (> or =90%), maximal stenosis in the internal carotid artery (ICA) distal to the bifurcation, and preexisting cerebral infarction.

CONCLUSION

The incidence of CAS-associated ICH was significantly lower in series consisting of >100 cases. More caution should be directed toward patients with symptomatic lesions, severe stenosis, maximal ICA stenosis distal to the carotid bifurcation, and preexisting cerebral infarction.

Hemorrhagic Complications after Endovascular Therapy for Atherosclerotic Intracranial Arterial Stenoses

OBJECTIVE:

Hemorrhagic complications were analyzed in 106 procedures of 99 patients treated with percutaneous transluminal angioplasty (PTA) or stenting for intracranial arterial stenoses.

METHODS:

Ninety-nine patients with intracranial arterial stenosis were treated with PTA or stenting 106 times from January 1995 to December 2003. Fifty-seven patients had intracranial internal carotid artery stenosis, 23 had middle cerebral artery stenosis, and 19 had vertebrobasilar stenosis. Evaluation of hemodynamic compromise via single-photon emission computed tomography was performed 50 times for 50 patients before the treatment.

RESULTS:

Four hemorrhagic complications occurred in 106 procedures. Two of these cases involved intracerebral hemorrhage after PTA or stenting in the treated vascular territory 30 minutes and 16 hours after the treatment, respectively. One case showed subarachnoid hemorrhage, which appeared 6 hours after treatment. Hemodynamic compromise was found on single-photon emission computed tomography in these three cases. The last case with a hemorrhagic complication was a hemorrhagic infarction after recanalization of stent thrombosis, which appeared 3 days after stenting. Hyperperfusion syndrome was strongly suggested as the cause of hemorrhage in the two cases associated with intracerebral hemorrhage.

CONCLUSION:

The rate of hemorrhagic complication directly related to the procedure of PTA or stenting was 3%, and hyperperfusion syndrome was suggested as the cause of hemorrhage in two cases (2%), from the perspective of clinical characteristics and single-photon emission computed tomographic findings.

Hyperperfusion syndrome after supraaortic vessel interventions and bypass surgery

Cerebral hyperperfusion and hemorrhage is a recognized complication of endarterectomy, aortocarotid bypass surgery or angioplasty and stenting of the carotid or vertebral artery. We performed 87 balloon angioplasty, stenting and bypass surgery of arteries supplying the brain over the last 15 years. We have found 6 cases of hyperperfusion syndrome in a total of 87 procedures. So the incidence of hyperperfusion was noted as 6.89%. Two cases occurred after two combined procedures in a single sitting. Hyperperfusion syndrome is a well-known complication of craniocervical revascularisation procedures. But with proper care, including strict post procedural control of blood pressure and staged procedure in case of multiples vessel stenosis, these complications can be largely avoided.