Cerebral hyperperfusion syndrome: A rare postoperative complication of carotid endarterectomy

摘要

Acute neurological deficits are common presentations to the emergency department. Cerebral hyperperfusion syndrome, a rare phenomenon which can occur within one month following carotid surgical revascularization, may be challenging for the emergency physician to diagnose in the setting of an acute neurological presentation. Carotid arterial disease contributes 15-20% of ischemic cerebrovascular accidents and surgical revascularization is the commonest intervention for preventing stroke in patients with significant carotid disease. However if the patient remains hypertensive postoperatively in the setting of sudden carotid reperfusion following revascularization, they are prone to cerebral hyperperfusion syndrome. Caused by increased, unregulated cerebral blood flow, cerebral hyperperfusion syndrome can result in cerebral edema and intracranial hemorrhage which may manifest in symptoms ranging from headaches, myoclonus, hemiparesis, seizures, reduced consciousness and potentially result in death. The most important facets in management of cerebral hyperperfusion syndrome in the emergency department is early recognition, prompt management and monitoring of hypertension (up to 81% of patients have severe hypertension at onset of neurological symptoms) and early imaging. We report a case of cerebral hyperperfusion syndrome in a woman who had ongoing severe hypertension following carotid endarterectomy. Five days following surgery and after discharge, she presented to the emergency department with worsening right upper limb myoclonus, tremor, weakness and hypertonia. Initially treated with anticonvulstants without resolution of symptoms, prompt imaging and management of hypertension in the emergency department resulted in the correct diagnosis and complete resolution of symptoms without any permanent neurological deficits.