Hyperperfusion Syndrome After Neck Clipping of a Ruptured Aneurysm on a Dolichoectatic Middle Cerebral Artery

doi:10.1016/j.jstrokecerebrovasdis.2009.11.014

Journal of Stroke and Cerebrovascular Diseases

Volume 20, Issue 3, May–June 2011, Pages 260-263

https://doi.org/10.1016/j.jstrokecerebrovasdis.2009.11.014 Get rights and content

A 40-year-old female presented with sudden onset of severe headache and vomiting due to subarachnoid hemorrhage. Angiography demonstrated a saccular aneurysm on a dolichoectatic left middle cerebral artery (MCA) and delayed filling of the MCA. Magnetic resonance imaging showed a partially thrombosed giant aneurysm on the dolichoectatic MCA. An intentionally delayed operation was performed, during which the neck of the aneurysm was successfully clipped. The patient exhibited aphasia 48 hours after surgery. Single-photon emission computed tomography revealed hyperperfusion in the territory of the left MCA. The patient's blood pressure was maintained normotensively, and her symptoms gradually improved. She returned to work 1 month after surgery. The saccular aneurysm was formed on the dolichoectatic MCA, presumably due to an abnormal arterial wall and hemodynamic stress. The preoperative hypoperfusion might have been caused not only by the giant aneurysm, but also to some degree by the dolichoectatic MCA. After neck clipping, the increase in blood flow might have caused hyperperfusion.

Section snippets

Discussion

Intracranial arterial dolichoectasia (IADE) affects the distal vertebral arteries, basilar artery, or the distal ICA segments more frequently than other arteries.1, 2, 3, 4 Localization of dolichoectasia in the MCA or anterior cerebral artery seems to be rare, however.2, 3, 4 Abnormalities associated with IADE include arteriosclerosis, hypertension, diabetes mellitus, and defects or destruction of the internal elastic lamina.1, 2, 3 Several diseases have also been implicated, including

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Cited by (12)

Hyperperfusion after Clipping of Aneurysm: A Rare Entity
2018, Journal of Stroke and Cerebrovascular Diseases
Citation Excerpt :
The mechanisms underlying CHS involve dysregulation of the cerebral vascular system and hypertension in the setting of an acute and excessive increase of cerebral blood flow (CBF). The treatment strategies of CHS that focus on limiting the rise in CBF by regulating blood pressure and inhibiting vasodilation conflict with the therapeutic approaches for CVS.1-6 We report successful treatment of a case of CHS after clipping of a ruptured aneurysm.
Cerebral vasospasm is an uncontrollable and sometimes fatal complication occurring after subarachnoid hemorrhage. However, cerebral hyperperfusion syndrome is a rare complication after subarachnoid hemorrhage. Although plain computed tomography of cerebral hyperperfusion syndrome looks similar to cerebral infarction induced by cerebral vasospasm, they should be distinguished from each other because they require completely different treatments.
A 65-year-old man complained of severe headache and vomiting. A computed tomography scan of his head showed subarachnoid hemorrhage with acute hydrocephalus caused by intraventricular hematoma and aneurysm of the left middle cerebral artery. After endoscopic irrigation of the ventricular hematoma to decrease the intracranial pressure, we performed neck clipping for the ruptured aneurysm. We used a temporary clip to the proximal M1 segment twice for a total of 15 minutes. Five days after the clipping, a computed tomography scan of the patient's head showed a large low-density area in the left cerebral hemisphere. Although cerebral infarction caused by cerebral vasospasm was suspected, his perfusion computed tomography demonstrated a state of hyperperfusion corresponding to the low-density area. We started treatment to prevent vasodilation and excessive cerebral blood flow instead of treatment for cerebral vasospasm. After changing the treatment, the patient's symptoms gradually improved, and his perfusion computed tomography (8 days after surgery) showed no excessive increased blood flow.
We present a case of cerebral hyperperfusion syndrome and its successful treatment, distinct from that of cerebral vasospasm, after ruptured aneurysm clipping. In addition, we discuss the mechanism of this rare syndrome based on previous reports.
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2019, Neurosurgical Review
Factors influencing blood flow resistance from a large internal carotid artery aneurysm revealed by a computational fluid dynamics model
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Flow reversal bypass surgery: a treatment option for giant serpentine and dolichoectatic aneurysms—internal maxillary artery bypass with an interposed radial artery graft followed by parent artery occlusion
2017, Neurosurgical Review
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2016, American Journal of Neuroradiology
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Case ReportHyperperfusion Syndrome After Neck Clipping of a Ruptured Aneurysm on a Dolichoectatic Middle Cerebral Artery

Section snippets

Discussion

Ruptured saccular aneurysm of a dolichoectatic internal carotid artery in a patient with agenesis of the contralateral internal carotid artery: Case report

Neurol Med Chir (Tokyo)

Dolichoectasia of the middle cerebral artery: Case report

Neurol Med Chir (Tokyo)

Two cases of middle cerebral artery dolichoectasia: Usefulness of 3D-CT angiography

Jpn J Neurosurg (Tokyo)

Middle cerebral artery dolichoectasia in a young woman with a previous stroke

Eur J Neurol

Association of small-vessel disease with dilatative arteriopathy of the brain: Neuropathologic evidence

Stroke

Case Report
Hyperperfusion Syndrome After Neck Clipping of a Ruptured Aneurysm on a Dolichoectatic Middle Cerebral Artery