Hyperperfusion Syndrome after Carotid Stent-Supported Angioplasty in Patients with Autonomic Dysfunction
A 75-year-old male patient had presented with dysarthria and left-side weakness, which resolved within 24 h. He had a history of hypertension, diabetes mellitus. The MRI of the brain showed a few tiny foci of infarcts in the left subcortical watershed distribution (). The MRA showed a high-grade stenosis of the proximal left ICA with no stenosis of the right ICA. A carotid stenting procedure was carried out 4 days later post-presentation with patient already on aspirin and clopidogrel. Angiogram showed a critical stenosis at the left cervical ICA origin (). An anticholinergic drug (atropine) was administered before CSA and under full systemic heparinization, a catheter was placed in the left common carotid artery. A Transend EX SOFT TIP microcatheter (Boston Scientific Corporation, Global Park, Heredia, Costarica) with micro-guidewire were navigated past the stenosis; then an exchange wire was used to position a 6×40 mm Sterling Monorail angioplasty balloon (Boston Scientific Corporation, Maple Grove, MN, USA) across the stenosis and angioplasty was carried out (). An excellent result was achieved with the neurological baseline. His postoperative blood pressure was 144/91 mm Hg and maintained continuously at 160/90 mm Hg. After using antihypertensive agents, his blood pressure was kept normal range. Heparin was stopped and 24 hours later he developed headache. A CT scan was obtained, which showed multiple small subarachnoid hemorrhages within the right hemisphere. The MRI showed additionally blood in the left temporal lobes (). This was treated conservatively with temporary cessation of the antiplatelet agents and strict monitoring of the blood pressure.\nAssessment of the autonomic function test was performed. In cold pressor test, blood pressure increased by 63/29 mm Hg, showing a normal reaction. During the deep-breathing test, the difference between the maximal and minimal heart rate was 14 beats/min indicated abnormal function. The 30/15 ratio was calculated 1.02 as a borderline response. During Valsalva-maneuver testing, the Valsalva ratio for this patient was 1.19 and defined as an abnormal autonomic response ().