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