Acta Neurochirurgica

, Volume 159, Issue 11, pp 2089–2097 | Cite as

Intracerebral hemorrhage as a manifestation of cerebral hyperperfusion syndrome after carotid revascularization: systematic review and meta-analysis

  • Pedro Abreu
  • Jerina Nogueira
  • Filipe Brogueira Rodrigues
  • Ana Nascimento
  • Mariana Carvalho
  • Ana Marreiros
  • Hipólito Nzwalo
Review Article - Vascular



Intracerebral hemorrhage (ICH) in the context of cerebral hyperperfusion syndrome (CHS) is an uncommon but potentially lethal complication after carotid revascularization for carotid occlusive disease. Information about its incidence, risk factors and fatality is scarce. Therefore, we aimed to perform a systematic review and meta-analysis focusing on the incidence, risk factors and outcomes of ICH in the context of CHS after carotid revascularization.


We searched the PubMed and EBSCO hosts for all studies published in English about CHS in the context of carotid revascularization. Two reviewers independently assessed each study for eligibility based on predefined criteria. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and the PROSPERO register was made (register no. CRD42016033190), including the pre-specified protocol.


Forty-one studies involving 28,956 participants were deemed eligible and included in our analysis. The overall quality of the included studies was fair. The pooled frequency of ICH in the context of CHS was 38% (95% CI: 26% to 51%, I2 = 84%, 24 studies), and the pooled case fatality of ICH after CHS was 51% (95% CI: 32% to 71%, I2 = 77%, 17 studies). When comparing carotid angioplasty with stenting (CAS) with carotid endarterectomy (CEA), post-procedural ICH in the context of CHS was less frequent in CEA. ICH following CHS occurred less often in large series and was rare in asymptomatic patients. The most common risk factors were periprocedural hypertension and ipsilateral severe stenosis.


ICH as a manifestation of CHS is rare, more frequent after CAS and associated with poor prognosis. Periprocedural control of hypertension can reduce its occurrence.


Cerebral hyperperfusion syndrome Intracerebral hemorrhage Carotid endarterectomy Carotid angioplasty Carotid revascularization 


Compliance with ethical standards

Conflict of interest

FBR is supported by the CHDI Foundation and EHDN. All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

This article does not contain any studies with human participants performed by any of the authors.

Supplementary material

701_2017_3328_MOESM1_ESM.docx (20 kb)
ESM 1 (DOCX 19 kb)
701_2017_3328_MOESM2_ESM.docx (23 kb)
ESM 2 (DOCX 22 kb)


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Copyright information

© Springer-Verlag GmbH Austria 2017

Authors and Affiliations

  • Pedro Abreu
    • 1
  • Jerina Nogueira
    • 1
  • Filipe Brogueira Rodrigues
    • 2
    • 3
    • 4
  • Ana Nascimento
    • 5
  • Mariana Carvalho
    • 5
  • Ana Marreiros
    • 1
  • Hipólito Nzwalo
    • 1
  1. 1.Department of Biomedical Sciences and MedicineUniversity of AlgarveFaroPortugal
  2. 2.Clinical Pharmacology UnitInstituto de Medicina MolecularLisbonPortugal
  3. 3.Laboratory of Clinical Pharmacology and Therapeutics, Faculty of MedicineUniversity of LisbonLisbonPortugal
  4. 4.Huntington’s Disease Centre, Institute of NeurologyUniversity College LondonLondonUK
  5. 5.Department of NeurologyCentro Hospitalar do AlgarveFaroPortugal

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