Effectiveness of staged angioplasty for avoidance of cerebral hyperperfusion syndrome after carotid revascularization

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Cerebral hyperperfusion syndrome (CHS) is a serious complication after carotid artery stenting (CAS). Staged angioplasty (SAP)—i.e., angioplasty followed by delayed CAS—has been reported as a potential CHS-avoiding procedure. The purpose of this study was to clarify the effectiveness of SAP in avoiding CHS after carotid revascularization for patients at high risk for this complication.


The authors retrospectively studied cases involving patients at high risk for CHS from 44 Japanese centers who were scheduled for SAP, regular CAS, angioplasty, or staged procedures other than SAP between October 2007 and March 2014. They investigated the rate of CHS in the population scheduled for SAP or regular CAS, and for safety analysis, the composite rate of transient ischemic attack (TIA) and ischemic stroke in the population eventually receiving SAP or regular CAS.


Data from a total of 525 patients (532 lesions, mean age 72.5 ± 7.5 years, 74 women ) were analyzed. Scheduled procedures included SAP for 113 lesions and regular CAS for 419 lesions. The rate of CHS was lower in the SAP group than in the regular CAS group (4.4% vs 10.5%, p = 0.047). Multivariate analysis showed that SAP was negatively related to CHS (OR 0.315; 95% CI 0.120–0.828). In the population eventually receiving SAP (102 lesions) or regular CAS (428 lesions), the composite rate of TIA and ischemic stroke was comparable between the SAP group and the regular CAS group (9.8% vs 9.3%).


SAP may be an effective and safe carotid revascularization procedure to avoid CHS.

ABBREVIATIONS AI = asymmetry index; CAS = carotid artery stenting; CBF = cerebral blood flow; CEA = carotid endarterectomy; CHS = cerebral hyperperfusion syndrome; CI = confidence interval; CVR = cerebrovascular reactivity; HPP = hyperperfusion phenomenon; ICH = intracranial hemorrhage; IQR = interquartile range; JASTNEC = Japanese Society for Treatment at Neck in Cerebrovascular Disease; JSNET = Japanese Society for Neuroendovascular Therapy; MCA = middle cerebral artery; MLD = minimum lumen diameter; mRS = modified Rankin Scale; OR = odds ratio; ROI = region of interest; SAP = staged angioplasty; SPECT = single-photon emission computed tomography; TIA = transient ischemic attack.

Article Information

Correspondence Kenji Sugiu: Okayama University Graduate School of Medicine, Okayama, Japan. ksugiu@md.okayama-u.ac.jp.

INCLUDE WHEN CITING Published online January 18, 2019; DOI: 10.3171/2018.8.JNS18887.

Disclosures Dr. Matsumaru reports receiving honoraria from Medtronic. Dr. Ogasawara reports receiving research funds from Bristol-Myers Squibb and Nihon Medi-Physics. Dr. Oishi reports receiving honoraria from Covidien and Medtronic and research funds from Medtronic and Medikit. Dr. Sakai reports receiving honoraria from Otsuka Pharmaceutical, Stryker, and Johnson & Johnson and research funds from Terumo. Dr. Yamagami reports receiving honoraria from Stryker Japan, Bayer, and Daiichi Sankyo and research funds from Bristol-Myers Squibb. Dr. Yoshimura reports receiving honoraria from Medtronic, Stryker, Bristol-Myers Squibb, Boehringer Ingelheim, Otsuka Pharmaceutical, Mitsubishi Tanabe Pharma, Bayer, Sanofi, Daiichi Sankyo, and Pfizer and research funds from Terumo, Takeda Pharmaceutical, and Bristol-Myers Squibb.

© AANS, except where prohibited by US copyright law.





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