A 65-year-old male is admitted to the ICU with confusion, headache, nausea, vomiting, and hypertension. He underwent right carotid endarterectomy 8 hours ago. The first set of vital signs obtained in the ICU showed blood pressure 171/94 mm Hg, heart rate 84 bpm, respiratory rate 22 per minute, and oxygen saturation 96% on room air.
Which of the following IS NOT recommended as treatment for his complication?
A. Hypertonic salineCorrect Answer: D
Cerebral hyperperfusion syndrome is relatively a rare following carotid endarterectomy or carotid stenting (incidence 0.74%-1.16%). The pathophysiology of hyperperfusion injury is not completely understood, but it is believed that impaired autoregulation due to baroreceptor dysfunction, hypertension, and increased blood flow to the ipsilateral hemisphere play a significant role. It is reversible if recognized early but can progress to unilateral cerebral edema or intracerebral hemorrhage, which significantly increases morbidity and mortality. Several imaging modalities are useful in the identification of cerebral hyperperfusion syndrome. Transcranial Doppler is noninvasive and provides real-time information. It will demonstrate increased flows when compared to preoperative values. CT or magnetic resonance imaging can detect areas of ischemia, edema, and intracerebral hemorrhage. Magnetic resonance perfusion study measures cerebral blood flow and may demonstrate interhemispheric differences in flow/ volume.
The mainstay of treatment is strict blood pressure control postoperatively (C). Hyperperfusion can be seen even in the setting of normotension in some patients. Medication selection is important as those with vasodilatory effects, which further increase cerebral blood flow, can worsen outcomes. Thus, antihypertensive agents that possess negative inotropic effects would be an appropriate first line therapy. There is no indication for prophylactic use of antiepileptic medications in cerebral hyperperfusion syndrome (D).
Although their benefit for treating cerebral hyperperfusion syndrome specifically is unclear, osmotic agents such as hypertonic saline and mannitol should be considered in the setting of symptomatic cerebral edema (A/B).
Cerebral hyperperfusion syndrome is an uncommon but potentially serious complication following carotid endarterectomy and stenting. Care should be taken to minimize precipitating factors such as uncontrolled hypertension.
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