Cerebral Hyperperfusion Syndrome After Carotid Revascularization and Acute Ischemic Stroke

  • Kathryn F. Kirchoff-Torres
  • Ekaterina Bakradze
Secondary Headache (M Robbins, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Secondary Headache


Purpose of Review

Cerebral hyperperfusion syndrome (CHS) is a rare but significant complication after carotid revascularization and is increasingly recognized after acute stroke treatments. In this review, we discuss the epidemiology and pathophysiology of CHS, clinical presentation including ipsilateral headache, seizures, and focal neurological deficits, and radiographic presentation. We propose preventive therapies with emphasis on acute stroke post-thrombectomy hyperperfusion.

Recent Findings

CHS was first described after carotid revascularization but is now also reported in patients with acute ischemic stroke. Proposed criteria involve a combination of new clinical symptoms, radiographic evidence of hyperperfusion, and/or presence of intracerebral hemorrhage occurring within 30 days after the carotid or intracranial vessel manipulation. Strongest risk factors include reduced cerebral vasoreactivity, contralateral stenosis of ≥ 70%, post-procedure hypertension, and recent ipsilateral stroke. Pathophysiology is incompletely understood but is likely due to increase in cerebral blood flow and impaired cerebral autoregulation, particularly in the areas of disrupted blood-brain barrier, as well as baroreceptor dysfunction during carotid surgery. Strict blood pressure control pre-, during, and post-procedure is recommended, depending on the recanalization status of the vessel. However, there is no randomized data regarding the goal blood pressure to prevent cerebral hyperperfusion syndrome.


With technical advances, carotid or intracranial vessel manipulation is increasingly common. CHS is a likely under-recognized and serious complication of carotid revascularization and intracranial thrombectomy. Awareness of and surveillance for CHS is important to reduce morbidity and mortality. Future research should focus on validation of proposed diagnostic criteria and determining optimal post-procedure hemodynamic management to prevent CHS.


Cerebral hyperperfusion Carotid endarterectomy Carotid artery stenting Acute stroke Intracerebral hemorrhage Thrombectomy 


Compliance with Ethical Standards

Conflict of Interest

Kathryn F. Kirchoff-Torres, and Ekaterina Bakradze declare no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance, •• Of major importance

  1. 1.
    Yu S, Liebeskind DS, Dua S, Wilhalme H, Elashoff D, Qiao XJ, et al. Postischemic hyperperfusion on arterial spin labeled perfusion MRI is linked to hemorrhagic transformation in stroke. J Cereb Blood Flow Metab: Off J Int Soc Cereb Blood Flow Metab. 2015;35(4):630–7.CrossRefGoogle Scholar
  2. 2.
    Zhang Y, Kumar A, Tezel JB, Zhou Y. Imaging evidence for cerebral Hyperperfusion syndrome after intravenous tissue plasminogen activator for acute ischemic stroke. Case Rep Neurol Med. 2016;2016:8725494.PubMedPubMedCentralGoogle Scholar
  3. 3.
    Kim T, Oh CW, Bang JS, Kim JE, Cho WS. Moyamoya disease: treatment and outcomes. J Stroke. 2016;18(1):21–30.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Lin TW, Wang JN, Kan CD. Cerebral Hyperperfusion syndrome after surgical repair of congenital Supravalvular aortic stenosis. Ann Thorac Surg. 2015;100(3):e51–4.CrossRefPubMedGoogle Scholar
  5. 5.
    •• Farooq MU, Goshgarian C, Min J, Gorelick PB. Pathophysiology and management of reperfusion injury and hyperperfusion syndrome after carotid endarterectomy and carotid artery stenting. Exp Transl Stroke Med. 2016;8(1):7. Review of the pathophysiology, diagnosis and management of CHS. CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Moulakakis KG, Mylonas SN, Sfyroeras GS, Andrikopoulos V. Hyperperfusion syndrome after carotid revascularization. J Vasc Surg. 2009;49(4):1060–8.CrossRefPubMedGoogle Scholar
  7. 7.
    van Mook WN, Rennenberg RJ, Schurink GW, van Oostenbrugge RJ, Mess WH, Hofman PA, et al. Cerebral hyperperfusion syndrome. Lancet Neurol. 2005;4(12):877–88.CrossRefPubMedGoogle Scholar
  8. 8.
    • Wang GJ, Beck AW, DeMartino RR, Goodney PP, Rockman CB, Fairman RM. Insight into the cerebral hyperperfusion syndrome following carotid endarterectomy from the national Vascular Quality Initiative. J Vasc Surg. 2017;65(2):381–9.e2. Epidemiological study of the incidence, risk factors and sequelae of CHS in CEA patients. CrossRefPubMedGoogle Scholar
  9. 9.
    Spetzler RF, Wilson CB, Weinstein P, Mehdorn M, Townsend J, Normal TD. Perfusion pressure breakthrough theory. Clin Neurosurg. 1978;25:651–72.CrossRefPubMedGoogle Scholar
  10. 10.
    Sundt TM Jr, Sharbrough FW, Piepgras DG, Kearns TP, Messick JM Jr, O'Fallon WM. Correlation of cerebral blood flow and electroencephalographic changes during carotid endarterectomy: with results of surgery and hemodynamics of cerebral ischemia. Mayo Clin Proc. 1981;56(9):533–43.PubMedGoogle Scholar
  11. 11.
    •• Bouri S, Thapar A, Shalhoub J, Jayasooriya G, Fernando A, Franklin IJ, et al. Hypertension and the post-carotid endarterectomy cerebral hyperperfusion syndrome. Eur J Vasc Endovasc Surg: Off J Eur Soc Vasc Surg. 2011;41(2):229–37. Meta-analysis of post-CEA CHS with evidence based treatment recommendations. CrossRefGoogle Scholar
  12. 12.
    Headache Classification Committee of the International Headache S. The international classification of headache disorders, 3rd edition (beta version). Cephalalgia. 2013;33(9):629–808.CrossRefGoogle Scholar
  13. 13.
    Maas MB, Kwolek CJ, Hirsch JA, Jaff MR, Rordorf GA. Clinical risk predictors for cerebral hyperperfusion syndrome after carotid endarterectomy. J Neurol Neurosurg Psychiatry. 2013;84(5):569–72.CrossRefPubMedGoogle Scholar
  14. 14.
    Ho KJ, Madenci AL, Semel ME, McPhee JT, Nguyen LL, Ozaki CK, et al. Predictors and consequences of unplanned hospital readmission within 30 days of carotid endarterectomy. J Vasc Surg. 2014;60(1):77–84.CrossRefPubMedGoogle Scholar
  15. 15.
    McDonald RJ, Cloft HJ, Intracranial KDF. Hemorrhage is much more common after carotid stenting than after endarterectomy: evidence from the National Inpatient Sample. Stroke. 2011;42(10):2782–7.CrossRefPubMedGoogle Scholar
  16. 16.
    Park ST, Kim JK, Yoon KH, Park SO, Park SW, Kim JS, et al. Atherosclerotic carotid stenoses of apical versus body lesions in high-risk carotid stenting patients. AJNR Am J Neuroradiol. 2010;31(6):1106–12.CrossRefPubMedGoogle Scholar
  17. 17.
    Buczek J, Karlinski M, Kobayashi A, Bialek P, Czlonkowska A. Hyperperfusion syndrome after carotid endarterectomy and carotid stenting. Cerebrovasc Dis. 2013;35(6):531–7.CrossRefPubMedGoogle Scholar
  18. 18.
    Ziaja D, Biolik G, Kocelak P, Sznapka M, Janas P, Czajka A, et al. Neurological symptoms associated with cerebral hyperperfusion syndrome after CEA and CAS--one centre study. Eur Rev Med Pharmacol Sci. 2014;18(8):1176–80.PubMedGoogle Scholar
  19. 19.
    Galyfos G, Sianou A, Filis K. Cerebral hyperperfusion syndrome and intracranial hemorrhage after carotid endarterectomy or carotid stenting: a meta-analysis. J Neurol Sci. 2017;381:74–82.CrossRefPubMedGoogle Scholar
  20. 20.
    Ogasawara K, Sakai N, Kuroiwa T, Hosoda K, Iihara K, Toyoda K, et al. Intracranial hemorrhage associated with cerebral hyperperfusion syndrome following carotid endarterectomy and carotid artery stenting: retrospective review of 4494 patients. J Neurosurg. 2007;107(6):1130–6.CrossRefPubMedGoogle Scholar
  21. 21.
    Abou-Chebl A, Yadav JS, Reginelli JP, Bajzer C, Bhatt D, Krieger DW. Intracranial hemorrhage and hyperperfusion syndrome following carotid artery stenting: risk factors, prevention, and treatment. J Am Coll Cardiol. 2004;43(9):1596–601.CrossRefPubMedGoogle Scholar
  22. 22.
    Meng L, Gelb AW. Regulation of cerebral autoregulation by carbon dioxide. Anesthesiology. 2015;122(1):196–205.CrossRefPubMedGoogle Scholar
  23. 23.
    Waltz AG. Effect of blood pressure on blood flow in ischemic and in nonischemic cerebral cortex. The phenomena of autoregulation and luxury perfusion. Neurology. 1968;18(7):613–21.CrossRefPubMedGoogle Scholar
  24. 24.
    Naylor AR, Evans J, Thompson MM, London NJ, Abbott RJ, Cherryman G, et al. Seizures after carotid endarterectomy: hyperperfusion, dysautoregulation or hypertensive encephalopathy? Eur J Vasc Endovasc Surg. 2003;26(1):39–44.CrossRefPubMedGoogle Scholar
  25. 25.
    Bernstein M, Fleming JF, Deck JH. Cerebral hyperperfusion after carotid endarterectomy: a cause of cerebral hemorrhage. Neurosurgery. 1984;15(1):50-6.PubMedGoogle Scholar
  26. 26.
    Iwata T, Mori T, Miyazaki Y, Tanno Y, Kasakura S, Aoyagi Y. Global oxygen extraction fraction by blood sampling to anticipate cerebral hyperperfusion phenomenon after carotid artery stenting. Neurosurgery. 2014;75(5):546–51. discussion 51CrossRefPubMedGoogle Scholar
  27. 27.
    Ascher E, Markevich N, Schutzer RW, Kallakuri S, Jacob T, Hingorani AP. Cerebral hyperperfusion syndrome after carotid endarterectomy: predictive factors and hemodynamic changes. J Vasc Surg. 2003;37(4):769–77.CrossRefPubMedGoogle Scholar
  28. 28.
    Demirel S, Goossen K, Bruijnen H, Probst P, Bockler D. Systematic review and meta-analysis of postcarotid endarterectomy hypertension after eversion versus conventional carotid endarterectomy. J Vasc Surg. 2017;65(3):868–82.CrossRefPubMedGoogle Scholar
  29. 29.
    Tehindrazanarivelo AD, Lutz G, PetitJean C, Headache BMG. Following carotid endarterectomy: a prospective study. Cephalalgia: Int J headache. 1992;12(6):380–2.CrossRefGoogle Scholar
  30. 30.
    De Marinis M, Zaccaria A, Faraglia V, Fiorani P, Maira G, Agnoli A. Post-endarterectomy headache and the role of the oculosympathetic system. J Neurol Neurosurg Psychiatry. 1991;54(4):314–7.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Breen JCCL, DeWitt LD, Belkin M, Mackey WC, Donnell TP. Brain edema after carotid surgery. Neurology. 1996;46:175–81.CrossRefPubMedGoogle Scholar
  32. 32.
    Gunduz A, Goksan B, Kocer N, Karaali-Savrun F. Headache in carotid artery stenting and angiography. Headache. 2012;52(4):544–9.CrossRefPubMedGoogle Scholar
  33. 33.
    Suller Marti A, Bellosta Diago E, Velázquez Benito A, Tejero Juste C, Santos Lasaosa S. Headache after carotid artery stenting. Neurologia. 2017;S0213-4853(17):30149–74.
  34. 34.
    Evans RW, Mitsias PD. Headache at onset of acute cerebral ischemia. Headache. 2009;49(6):902–8.CrossRefPubMedGoogle Scholar
  35. 35.
    Jamieson DG, Cheng NT, Headache SM. acute stroke. Curr Pain Headache Rep. 2014;18(9):444.CrossRefPubMedGoogle Scholar
  36. 36.
    Khan S, Amin FM, Holtmannspotter M, Hansen K, Florescu AM, Fakhril-Din Z, et al. Endovascular thrombectomy and post-procedural headache. J Headache Pain. 2017;18(1):10.CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Pennekamp CW, Immink RV, den Ruijter HM, Kappelle LJ, Ferrier CM, Bots ML, et al. Near-infrared spectroscopy can predict the onset of cerebral hyperperfusion syndrome after carotid endarterectomy. Cerebrovasc Dis. 2012;34(4):314–21.CrossRefPubMedGoogle Scholar
  38. 38.
    Newman JE, Ali M, Sharpe R, Bown MJ, Sayers RD, Changes NAR. In middle cerebral artery velocity after carotid endarterectomy do not identify patients at high-risk of suffering intracranial haemorrhage or stroke due to hyperperfusion syndrome. Eur J Vasc Endovasc Surg: Off J Eur Soc Vasc Surg. 2013;45(6):562–71.CrossRefGoogle Scholar
  39. 39.
    Karapanayiotides T, Meuli R, Devuyst G, Piechowski-Jozwiak B, Dewarrat A, Ruchat P, et al. Postcarotid endarterectomy hyperperfusion or reperfusion syndrome. Stroke. 2005;36(1):21–6.CrossRefPubMedGoogle Scholar
  40. 40.
    Terada Y, Hatano T, Nagai Y, Hayase M, Oda M, Nakamura T. Intraprocedural detection of cerebral hyperperfusion by flat detector computed tomography in the evaluation of cerebral blood volume during carotid artery stenting. A case report. Interv Neuroradiol. 2014;20(4):502–9.CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Okazaki S, Yamagami H, Yoshimoto T, Morita Y, Yamamoto H, Toyoda K, et al. Cerebral hyperperfusion on arterial spin labeling MRI after reperfusion therapy is related to hemorrhagic transformation. J Cereb Blood Flow Metab: Off J Int Soc Cereb Blood Flow Metab. 2017;37(9):3087–90.CrossRefGoogle Scholar
  42. 42.
    Warach S, Latour LL. Evidence of reperfusion injury, exacerbated by thrombolytic therapy, in human focal brain ischemia using a novel imaging marker of early blood-brain barrier disruption. Stroke. 2004;35(11 Suppl 1):2659–61.CrossRefPubMedGoogle Scholar
  43. 43.
    Cho AH, Cho YP, Lee DH, Kwon TW, Kwon SU, Suh DC, et al. Reperfusion injury on magnetic resonance imaging after carotid revascularization. Stroke. 2014;45(2):602–4.CrossRefPubMedGoogle Scholar
  44. 44.
    • Hosoda K. The significance of cerebral hemodynamics imaging in carotid endarterectomy: a brief review. Neurol Med Chir. 2015;55(10):782–8. Review of the use of preoperative cerebral vasoreactivity testing to predict CHS. CrossRefGoogle Scholar
  45. 45.
    • Oshida S, Ogasawara K, Saura H, Yoshida K, Fujiwara S, Kojima D, et al. Does preoperative measurement of cerebral blood flow with acetazolamide challenge in addition to preoperative measurement of cerebral blood flow at the resting state increase the predictive accuracy of development of cerebral hyperperfusion after carotid endarterectomy? Results from 500 cases with brain perfusion single-photon emission computed tomography study. Neurol Med Chir (Tokyo). 2015;55(2):141–8. Study of the use of preoperative cerebral vasoreactivity testing to predict CHS. CrossRefGoogle Scholar
  46. 46.
    Petersen NH, Ortega-Gutierrez S, Reccius A, Masurkar A, Huang A, Dynamic MRS. Cerebral autoregulation is transiently impaired for one week after large-vessel acute ischemic stroke. Cerebrovasc Dis. 2015;39(2):144–50.CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Yu S, Liebeskind DS, Dua S, Wilhalme H, Elashoff D, Qiao XJ, et al. Postischemic hyperperfusion on arterial spin labeled perfusion MRI is linked to hemorrhagic transformation in stroke. J Cereb Blood Flow Metab Off J Int Soc Cereb Blood Flow Metab. 2015;35(4):630–7.CrossRefGoogle Scholar
  48. 48.
    Meyers PM, Higashida RT, Phatouros CC, Malek AM, Lempert TE, Dowd CF, et al. Cerebral hyperperfusion syndrome after percutaneous transluminal stenting of the craniocervical arteries. Neurosurgery. 2000;47(2):335–43. discussion 43-5CrossRefPubMedGoogle Scholar
  49. 49.
    Liu AY, Do HM, Albers GW, Lopez JR, Steinberg GK, Marks MP. Hyperperfusion syndrome with hemorrhage after angioplasty for middle cerebral artery stenosis. AJNR Am J Neuroradiol. 2001;22(8):1597–601.PubMedGoogle Scholar
  50. 50.
    Rezende MT, Spelle L, Mounayer C, Piotin M, Abud DG, Hyperperfusion MJ. Syndrome after stenting for intracranial vertebral stenosis. Stroke. 2006;37(1):e12–4.CrossRefPubMedGoogle Scholar
  51. 51.
    Zhang R, Zhou G, Xu G, Liu X. Posterior circulation hyperperfusion syndrome after bilateral vertebral artery intracranial stenting. Ann Vasc Surg. 2009;23(5):686.e1–5.Google Scholar
  52. 52.
    Maramattom BV. Cerebral hyperperfusion syndrome after intracranial stenting of the middle cerebral artery. Indian J Crit Care Med. 2016;20(10):620–1.CrossRefPubMedPubMedCentralGoogle Scholar
  53. 53.
    Medel R, Crowley RW, Dumont AS. Hyperperfusion syndrome following endovascular cerebral revascularization. Neurosurg Focus. 2009;26(3):E4.CrossRefPubMedGoogle Scholar
  54. 54.
    Backhaus R, Boy S, Fuchs K, Ulrich B, Schuierer G, Schlachetzki F. Hyperperfusion syndrome after MCA embolectomy - a rare complication? Am J Case Rep. 2013;14:513–7.CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    Vollman AT, Bruno CA Jr, Dumeer S, Malone H, Meyers PM. Angiographic warning of hemorrhagic transformation after stent retriever thrombectomy procedure. J Neurointerv Surg. 2014;6(1):e6.CrossRefPubMedGoogle Scholar
  56. 56.
    de Havenon A, Bennett A, Stoddard GJ, Smith G, Chung L, O'Donnell S, et al. Determinants of the impact of blood pressure variability on neurological outcome after acute ischaemic stroke. BMJ. 2017;2(1):1–6.Google Scholar
  57. 57.
    Martins AI, Sargento-Freitas J, Silva F, Jesus-Ribeiro J, Correia I, Gomes JP, et al. Recanalization modulates association between blood pressure and functional outcome in acute ischemic stroke. Stroke. 2016;47(6):1571–6.CrossRefPubMedGoogle Scholar
  58. 58.
    Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2018;49:e46–e110.CrossRefPubMedGoogle Scholar
  59. 59.
    • Goyal N, Tsivgoulis G, Pandhi A, Chang JJ, Dillard K, Ishfaq MF, et al. Blood pressure levels post mechanical thrombectomy and outcomes in large vessel occlusion strokes. Neurology. 2017;89(6):540–7. Study of post-mechanical thrombectomy blood pressure effect on outcome. CrossRefPubMedGoogle Scholar
  60. 60.
    Abou-Chebl A, Reginelli J, Bajzer CT, Yadav JS. Intensive treatment of hypertension decreases the risk of hyperperfusion and intracerebral hemorrhage following carotid artery stenting. Catheter Cardiovasc Interv: Off J Soc Card Angiogr Interv. 2007;69(5):690–6.CrossRefGoogle Scholar
  61. 61.
    Ogasawara K, Inoue T, Kobayashi M, Endo H, Fukuda T, Ogawa A. Pretreatment with the free radical scavenger edaravone prevents cerebral hyperperfusion after carotid endarterectomy. Neurosurgery. 2004;55(5):1060–7.CrossRefPubMedGoogle Scholar
  62. 62.
    Schechter MA, Shortell CK, Scarborough JE. Regional versus general anesthesia for carotid endarterectomy: the American College of Surgeons National Surgical Quality Improvement Program perspective. Surgery. 2012;152(3):309–14.CrossRefPubMedGoogle Scholar
  63. 63.
    Lewis SC, Warlow CP, Bodenham AR, Colam B, Rothwell PM, Torgerson D, et al. General anaesthesia versus local anaesthesia for carotid surgery (GALA): a multicentre, randomised controlled trial. Lancet (Lond, Engl). 2008;372(9656):2132–42.CrossRefGoogle Scholar
  64. 64.
    Leslie-Mazwi T, Chen M, Yi J, Starke RM, Hussain MS, Meyers PM, et al. Post-thrombectomy management of the ELVO patient: guidelines from the society of NeuroInterventional surgery. J Neurointerv Surg. 2017;9:1258–66.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Kathryn F. Kirchoff-Torres
    • 1
  • Ekaterina Bakradze
    • 1
  1. 1.Department of Neurology, Montefiore Medical Center, Stern Stroke CenterAlbert Einstein College of MedicineBronxUSA

Personalised recommendations