Fatal Intracranial Hemorrhage Due to Cerebral Hyperperfusion Syndrome After Stenting of Both Internal Carotid Arteries

A 57-year-old male patient suffered a minor right-sided stroke due to high-grade atherosclerotic stenosis of the ipsilateral internal carotid artery (ICA). He also had high-grade radiogenic stenosis of the contralateral ICA. He chose to undergo bilateral carotid artery stenting in a single session. The procedure was performed under local anesthesia, and the patient was carefully monitored and maintained in a normotensive state throughout the procedure and for an hour immediately thereafter. While recovering at a different hospital, he experienced a hypertensive crisis which resulted in a generalized seizure and rapid neurologic deterioration due to cerebral hyperperfusion syndrome (CHS). Emergency cranial computed tomography performed 3 h after the deployment of the second ICA stent revealed both an intracerebral and subarachnoid hemorrhage. The patient died shortly thereafter. The factors leading to CHS relevant to this case are discussed together with a review of the demographics and pathophysiology as well as ways to predict and prevent this complication.