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. 2011;6(5):e19886.
doi: 10.1371/journal.pone.0019886. Epub 2011 May 20.

The role of perfusion computed tomography in the prediction of cerebral hyperperfusion syndrome

Affiliations

The role of perfusion computed tomography in the prediction of cerebral hyperperfusion syndrome

Chien Hung Chang et al. PLoS One. 2011.

Abstract

Background: Hyperperfusion syndrome (HPS) following carotid angioplasty with stenting (CAS) is associated with significant morbidity and mortality. At present, there are no reliable parameters to predict HPS. The aim of this study was to clarify whether perfusion computed tomography (CT) is a feasible and reliable tool in predicting HPS after CAS.

Methodology/principal findings: We performed a retrospective case-control study of 54 patients (11 HPS patients and 43 non-HPS) with unilateral severe stenosis of the carotid artery who underwent CAS. We compared the prevalence of vascular risk factors and perfusion CT parameters including regional cerebral blood volume (rCBV), regional cerebral blood flow (rCBF), and time to peak (TTP) within seven days prior to CAS. Demographic information, risk factors for atherosclerosis, and perfusion CT parameters were evaluated by multivariable logistic regression analysis. The rCBV index was calculated as [(ipsilateral rCBV - contralateral rCBV)/contralateral rCBV], and indices of rCBF and TTP were similarly calculated. We found that eleven patients had HPS, including five with intracranial hemorrhages (ICHs) of whom three died. After a comparison with non-HPS control subjects, independent predictors of HPS included the severity of ipsilateral carotid artery stenosis, 3-hour mean systolic blood pressure (3 h SBP) after CAS, pre-stenting rCBV index >0.15 and TTP index >0.22.

Conclusions/significance: The combination of severe ipsilateral carotid stenosis, 3 h SBP after CAS, rCBV index and TTP index provides a potential screening tool for predicting HPS in patients with unilateral carotid stenosis receiving CAS. In addition, adequate management of post-stenting blood pressure is the most important treatable factor in preventing HPS in these high risk patients.

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Conflict of interest statement

Competing Interests: Authors have no financial relationship to disclose and all authors understand that they must complete the Disclosure Statement.

Figures

Figure 1
Figure 1. A 68-year-old man with a right hemispheric ischemic stroke.
(A) Pre-stenting digital subtraction angiography reveals a 76% stenosis of the left internal carotid artery. A perfusion computed tomography (CT) study demonstrates a relatively decreased regional cerebral blood volume (rCBV) (B), decreased regional cerebral blood flow (rCBF) (C), and increased time to peak (TTP) (D) in the left hemisphere. The stenting procedure shows a 25% residual stenosis of the carotid artery (E). The rainbow on the right display reveals a range of rCBV from −2 to 60 ml/100 gm; rCBF from −2 to 100 ml/100 gm/min and TTP from −2 to 200 deciseconds. The patient suffered a sudden loss of consciousness two hours after stenting, and follow-up brain CT reveals a massive hematoma of the left basal ganglia, left frontal and temporal lobes with rupture into the ventricles (F).
Figure 2
Figure 2. rCBV (A) and TTP (B) in HPS and non-HPS patients.
From univariate discrimination analysis by receiver operating characteristic (ROC) curves, the threshold levels for the best discrimination of HPS and non-HPS are 1.15 and 1.22 for rCBV and TTP, respectively.

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