Abstract
Objective: We report a rare case of subarachnoid hemorrhage (SAH) following carotid artery stenting (CAS) with cerebral hyperperfusion (CHP). We also present a review of the relevant literature.
Case presentation: A 71-year-old man with a history of myocardial infarction and hypertension experienced sudden-onset right hemiparesis. He was taking antiplatelet and antihypertensive medications. Diffusion-weighted (DW) magnetic resonance imaging of the head showed fresh infarctions in the left middle cerebral artery (MCA) territory. Cervical computed tomography (CT) angiography indicated a severe stenosis (NASCET 95%) in the left carotid artery. The patient underwent left CAS using the Carotid Wallstent (Boston Scientific, Mountain View, CA). The procedure was uneventful; no change in regional cerebral oxygen saturation (rSO2) was noted. We did not perform post-dilatation for fear of CHP, despite the minimum diameter of 31 mm and residual stenosis (NASCET 45%). However, 6 hours after CAS, elevated rSO2 (left, 70%; right, 65%) and decreased blood pressure (80/40 mmHg) were noted. The patient experienced a mild headache and vomiting, but had an alert level of consciousness. A follow-up head CT at 24 hours after CAS indicated a mild SAH in the left MCA territory. N-isopropyl-[123I]-p-iodoamphetamine single photon emission computed tomography indicated CHP in the left MCA territory. DW imaging showed new high intensity lesions in the left MCA territory. He suffered a cerebral infarction as a result of in-stent occlusion 9 days after CAS.
Conclusion: Thus, mild SAH after CAS may occur more frequently than is expected. Further evidence is required to establish the optimal therapeutic approach for SAH after CAS.
