Review Article
Cerebral hyperperfusion syndrome and intracranial hemorrhage after carotid endarterectomy or carotid stenting: A meta-analysis

https://doi.org/10.1016/j.jns.2017.08.020Get rights and content

Highlights

  • CEA seems to be associated with a higher risk for CHS compared to CAS.

  • This association seems to be generated mainly from the older studies.

  • There seems to be no difference regarding ICH risk between the two methods.

  • ICH is associated with a significantly higher risk for death.

Abstract

Introduction

Cerebral hyperperfusion syndrome (CHS) and intracranial hemorrhage (ICH) after carotid revascularization have been associated with significant morbidity and mortality, although pooled data comparing these outcomes between open and endovascular treatment are lacking. Aim of this meta-analysis is to compare CHS and ICH risk between carotid endarterectomy (CEA) and carotid angioplasty with stenting (CAS).

Methods

A systematic literature review was conducted conforming to established criteria, in order to identify eligible articles published prior to February 2017. Eligible studies compared CHS and/or ICH between patients undergoing CEA and CAS. Other outcomes evaluated in this review included stroke and death due to ICH. Outcome risks are presented as odds ratios (OR) and 95% confidence intervals (CI).

Results

Overall, 6 studies (5 studies reporting on CHS and 4 studies reporting on ICH) included 236,537 procedures (218,144 CEA; 18,393 CAS) in total. CEA was associated with a higher risk for CHS compared to CAS (pooled OR = 1.432 [95% CI = 1.078–1901]; P = 0.015), although this difference was generated mainly from older studies (prior to 2012). However, no difference was found regarding ICH risk between the two methods (pooled OR = 0.544 [95% CI = 0.111–2.658]; P = 0.452). Regarding stroke incidence, no difference was found between the two methods as well, although this resulted mainly from studies with a higher volume of CAS procedures (pooled OR = 0.964 [95% CI = 0.741–1.252]; P = 0.833). Finally, death rate was significantly higher among patients with ICH compared to patients without ICH (pooled OR = 386.977 [95% CI = 246.746–606.906]; P < 0.0001). Pooled data were not adequate to calculate potential risk factors for CHS/ICH after CEA compared to CAS.

Conclusions

CEA seems to be associated with a higher risk for CHS compared to CAS, although this difference was generated mainly from older studies. However, there seems to be no difference regarding ICH risk between the two methods, with ICH being associated with a significantly higher risk for death.

Introduction

Cerebral hyperperfusion syndrome (CHS) has been described as a primary complication after carotid artery revascularization procedures by many authors [1], [2]. It seems to be associated with inadequate arterial blood pressure control and increased blood flow through the cerebral arteries postoperatively, leading to increased morbidity [3]. Although this phenomenon has been initially described after carotid endarterectomy (CEA) [4], many authors have evaluated its prevalence after carotid angioplasty and stenting (CAS) as well [5]. Main diagnostic criteria include typical neurologic symptoms such as seizures or headache as well as imaging criteria such as increased cerebral artery flow or exclusion of cerebral ischemia [6].

Furthermore, intracranial hemorrhage (ICH) has also been associated with CHS after carotid interventions [7]. Several risk factors have been found to predispose to ICH, including preoperative hypertension, bilateral carotid disease or contralateral carotid occlusion as well as impaired cerebrovascular reserve [7], [8]. Morbidity and mortality rates are high in such patients, either treated with open or endovascular repair, thus necessitating an offensive prevention strategy postoperatively [9].

However, data comparing postoperative CHS and ICH incidence between open and endovascular treatment of internal carotid artery (ICA) disease are limited, and no pooled data have been evaluated to date. Therefore, aim of this review is to collect and analyze all available comparative data, in order to produce useful conclusions for everyday clinical practice.

Section snippets

Data sources and search

We systematically searched Pubmed, Embase, Scopus and Cochrane Library (for the period January–February 2017) for studies published online prior to February 2017 comparing CEA and CAS as far as CHS and/or ICH rates are concerned. This review was conducted according to established methods for systematic reviews in cardiovascular medicine (PRISMA criteria) [10]. The following medical subject terms were utilized for the online search: ‘carotid endarterectomy’ or ‘carotid angioplasty ± stenting’ and

Results

In this meta-analysis, overall 236,537 procedures (218,144 CEA procedures and 18,393 CAS procedures) were included. Overall, 6 studies [12], [13], [14], [15], [16], [17] were included, out of which 5 studies [12], [13], [15], [16], [17] reported on CHS rate and 4 studies [12], [13], [14], [15] reported on ICH rate. The majority of the studies were retrospective, with only one study being a prospective observational study [15], and one study being a randomized trial [16]. However, no study was

Discussion

The present study confirmed that CEA is associated with a higher CHS risk compared to CAS although this result was observed mainly in the older studies. However, there seems to be no difference regarding the ICH risk, with ICH being strongly associated with a higher death risk postoperatively.

CEA was associated with a higher CHS risk in this review, although the included studies did not provide adequate data to conduct multi-regression analysis for potential risk factors. However, hypertension

Conclusions

CEA seems to be associated with a higher risk for CHS compared to CAS although this difference seems to be generated mainly from older studies. However, there seems to be no difference regarding ICH risk between the two methods, with ICH being associated with a significantly higher risk for death. Stroke risk was also found to be no different between the two methods in the included studies.

Declaration of conflict of interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Acknowledgments

There are no acknowledgments.

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