Stepwise revascularization preventing hyperperfusion syndrome after carotid endarterectomy: A case report

A 61-year-old man presented with repeated transient ischemic attacks (TIAs) associated with weakness of the right extremities and aphasia. MRI and MRA revealed severe stenosis of the left internal carotid artery (ICA) without cerebral ischemic changes. Carotid endarterectomy was chosen for revascularization of the symptomatic left ICA stenosis due to the presence of a bulky fragile plaque. Single photon emission computed tomography (SPECT) showed left total hemispheric hypoperfusion with steal phenomenon, which suggested the possibility of hyperperfusion syndrome (HPS) occurring after CEA. To alleviate the severely hemodynamically compromised state and to prevent HPS after CEA, we performed a low flow bypass (left superficial temporal artery-middle cerebral artery anastomosis : STA-MCA anastomosis) in advance. The left CEA was then performed three weeks after confirmation of improved cerebral hemodynamics with postoperative SPECT. The patient did not experience any symptoms of HPS or cerebral ischemia, and resumed his previous activities without recurrence of TIAs. Stepwise revascularization may attenuate the risk of HPS in severely hemodynamically compromised patients. However, the indications should be strictly limited because multidisciplinary revascularization may increase the complication rate because of the compounding of risk from each treatment.