Elsevier

Neurochirurgie

Volume 68, Issue 3, April 2022, Pages 342-346
Neurochirurgie

Short clinical case
Massive non-aneurysmal subarachnoid hemorrhage after cervical carotid angioplasty and stenting: A case report and review of the literature

https://doi.org/10.1016/j.neuchi.2021.04.003Get rights and content

Abstract

Introduction

Carotid angioplasty and stenting (CAS) of the cervical segment is a safe and effective procedure for the treatment of carotid artery disease. In rare cases, this procedure causes intracranial hemorrhage (ICH), which is described most often as an ipsilateral intra-parenchymal hematoma. This ICH is the result of a cerebral hyperperfusion syndrome (CHS). Isolated subarachnoid hemorrhage may occur exceptionally, with only 9 cases that have been reported in the literature.

Observation

We reported a case of a 71-year-old man who presented a massive non-aneurysmal subarachnoid hemorrhage one hour after angioplasty and stenting of the cervical segment of the left internal carotid artery. Medical and surgical management included external ventricular drain placement. Rebleeding occurred two days later, worsening the patient's clinical condition. Finally, the patient died 2 weeks later.

Comments

This rare presentation of ICH following CAS allows us to discuss the risk factors, complications and management of CHS.

Introduction

Subarachnoid hemorrhage (SAH) is a rare but life-threatening complication following carotid angioplasty and stenting (CAS) [1]. The main determinant of this rare complication is based on cerebral hyperperfusion syndrome (CHS). CHS is a clinical syndrome following carotid revascularization. It is defined by the onset of headaches and, more rarely, neurological deficits and seizures [1]. In a few cases, CHS may induce intracranial hemorrhage (ICH), commonly described as an intraparenchymal hematoma ipsilateral to the procedure. Isolated SAH may exceptionally occur. After literature review, 9 cases of isolated SAH after CAS have been described in the literature, with heterogeneous clinical presentations, management and outcomes [2], [3], [4], [5], [6], [7], [8], [9]. Herein, we reported a rare case of severe SAH after left external CAS and we reviewed the literature on the clinical presentation, therapeutic strategy and risk factors related to this complication.

Section snippets

Case report

A 71-year-old man was referred for vascular surgery for restenosis of an asymptomatic cervical left internal carotid artery 2 years following a first CAS. A second surgical percutaneous angioplasty was decided due to very severe restenosis (80%). As past medical history, this patient had high blood pressure, dyslipidemia and medical treatment included clopidogrel for vascular disease. The patient had stopped smoking 3 years previously. The restenosis was detected by systematic follow-up

Literature review and Discussion

We conducted a literature search for published cases following the PRISMA guidelines for systematic reviews. A research line was created: (((carotid artery[MeSH Terms]AND (stenting)) OR (carotid artery stenting))) AND ((subarachnoid hemorrhage[MeSH Terms]) OR (intracranial hemorrhage[MeSH Terms])). Limit “English language” and “case report” was applied. Pubmed (Medline) was scanned from the beginning to December 1, 2020. Only articles reporting isolated subarachnoid hemorrhage after carotid

Conclusion

We report a very rare case of severe subarachnoid hemorrhage following carotid artery angioplasty. The risk factors for this life-threatening complication have been well described and are mainly postoperative hypertension, longstanding pre-existing hypertension, critical intracranial atherosclerotic stenosis > 90% and severe controlateral stenosis. In cases of severe SAH, the management is similar to aneurysmal SAH but the prognosis is poor with high mortality rate. Notwithstanding, carotid

Human and animal rights

The authors declare that the work described has not involved experimentation on humans or animals.

Informed consent and patient details

The authors declare that this report does not contain any personal information that could lead to the identification of the patient(s) and/or volunteers.

Disclosure of interest

The authors declare that they have no competing interest.

Funding

This work did not receive any grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author contributions

All authors attest that they meet the current International Committee of Medical Journal Editors (ICMJE) criteria for Authorship.

Acknowledgments

We are grateful to Nikki Sabourin-Gibbs, Rouen University Hospital, for her help in editing the manuscript.

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