Fatal Intracerebral Hemorrhage Caused by Cerebral Hyperperfusion Following Carotid Endarterectomy: Case Report

We report the case of a 65-year-old man with intracerebral hemorrhage accompanying carotid endarterectomy. Preoperative angiography demonstrated very high-grade stenosis of the right internal carotid artery, with limited collateral flow. In the perioperative period, hypertension was well controlled. One clay after the operation, mild SAH and brain swelling was recognized in the right hemisphere on CT scan. On the third postoperative day, fatal intracerebral hemorrhage on the ipsilateral side of the CEA suddenly developed. Postoprative angiography showed wide patency of the right carotid artery without stenosis. Although a low dose of aspirin was medicated from the second postoperative day, it was considered that postoperative-hyperperfusion played the most important role. To determine the factors that predict the occurrence of hyperperfusion syndrome after CEA, we reviewed the literature and discussed the perioperative managements to avoid postoperative hyperperfusion syndrome in some tightly stenosed internal carotid arteries, we propose stepwise revascularization with a preliminary extra-intracranial bypass followed by a carotid endarterectomy.