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Anna A. Penn, Don F. Schomer and Gary K. Steinberg

M ost complications following carotid endarterectomy are considered to be ischemic in nature, caused either by embolization or occlusion. However, postoperative neurological dysfunction may also be related to a syndrome of cerebral hyperperfusion. Hyperperfusion is a major increase (> 100%) in ipsilateral cerebral blood flow (CBF) well above the metabolic demands of the tissue after removal of a high-grade carotid stenosis. 13, 28 We report a patient with multiple risk factors for ipsilateral hyperperfusion who developed seizures after undergoing carotid

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Ahmed Mansour, Sherif Rashad, Kuniyasu Niizuma, Miki Fujimura and Teiji Tominaga

version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Niizuma. Statistical analysis: Mansour. Administrative/technical/material support: Niizuma, Tominaga. Study supervision: Niizuma, Tominaga. Supplemental Information Previous Presentations Part of this work was presented at BRAIN & BRAIN PET 2019, Yokohama, Japan, July 4–7, 2019. References 1 Ballesteros-Pomar M , Alonso-Argüeso G , Tejada-García J , Vaquero-Morillo F : [Cerebral hyperperfusion syndrome in carotid revascularisation surgery.] Rev Neurol

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Robert Macfarlane, Michael A. Moskowitz, Danos E. Sakas, Erol Tasdemiroglu, Enoch P. Wei and Hermes A. Kontos

will consider the major syndromes accompanied by cerebral hyperperfusion and will examine underlying metabolic and neurogenic mechanisms. Attention will focus on the importance of nerve pathways that innervate brain blood vessels from extrinsic sources and, in particular, the trigeminovascular system. Recently published data suggesting the importance of axon-like reflexes to the development of cortical hyperemia will be emphasized and potential therapeutic strategies discussed. Cerebral Hyperperfusion Syndromes Cessation of blood flow is not a prerequisite for

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Ryounoshin Hirooka, Kuniaki Ogasawara, Makoto Sasaki, Keiko Yamadate, Masakazu Kobayashi, Yasunori Suga, Kenji Yoshida, Yasunari Otawara, Takashi Inoue and Akira Ogawa

C erebral hyperperfusion after CEA is defined as a major increase in the ipsilateral CBF after surgical repair of carotid stenosis that is well beyond the metabolic demands of the brain tissue. 17 , 28 This condition is characterized by unilateral headache, face and eye pain, seizures, and focal symptoms related to cerebral edema or ICH. 2 , 17 , 27 , 28 Although the prognosis for patients with ICH is poor, the incidence is relatively low (0.4–1.8%). 6 , 16–19 , 22 , 27 Furthermore, the neurological deficits in those who develop cerebral hyperperfusion

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Kuniaki Ogasawara, Keiko Yamadate, Masakazu Kobayashi, Hidehiko Endo, Takeshi Fukuda, Kenji Yoshida, Kazunori Terasaki, Takashi Inoue and Akira Ogawa

C erebral hyperperfusion after CEA is defined as a major increase in ipsilateral CBF that is far greater than the metabolic demands of brain tissue following the surgical repair of CA stenosis. 39, 51 A rapid restoration of normal perfusion pressure following CEA may result in hyperperfusion in a region of the brain with impaired autoregulation due to chronic ischemia. This hypothesis is similar to the “normal perfusion pressure breakthrough” theory described by Spetzler, et al. 50 Cerebral hyperperfusion syndrome following CEA is a complication of cerebral

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Torben Schroeder, Henrik Sillesen, Ole Sørensen and Hans Christian Engell

tomography. Stroke 12: 454–459, 1981 4. Bernstein M , Fleming JFR , Deck JHN : Cerebral hyperperfusion after carotid endarterectomy: a cause of cerebral hemorrhage. Neurosurgery 15 : 50 – 56 , 1984 Bernstein M, Fleming JFR, Deck JHN: Cerebral hyperperfusion after carotid endarterectomy: a cause of cerebral hemorrhage. Neurosurgery 15: 50–56, 1984 5. Boysen G : Cerebral hemodynamics in carotid surgery. Acta Neurol Scand 49 ( Suppl 52 ): l – 84 , 1973 Boysen G: Cerebral hemodynamics in

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Kuniaki Ogasawara, Nobuyuki Sakai, Terumasa Kuroiwa, Kohkichi Hosoda, Koji Iihara, Kazunori Toyoda, Chiaki Sakai, Izumi Nagata, Akira Ogawa and Japanese Society for Treatment at Neck in Cerebrovascular Disease Study Group

M ost complications following CEA are ischemic in nature due to either embolization or inadequate cerebral protection in patients with a poor collateral supply. 13 However, postoperative neurological dysfunction can also be related to cerebral hyperperfusion, which is defined as a major increase in ipsilateral CBF well above the metabolic demands of the brain tissue following the repair of carotid artery stenosis. 33 , 48 Risk factors for this syndrome include long-standing hypertension, high-grade stenosis, poor collateral blood flow, and contralateral

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Lukas Andereggen, Sepideh Amin-Hanjani, Marwan El-Koussy, Rajeev K. Verma, Kenya Yuki, Daniel Schoeni, Kety Hsieh, Jan Gralla, Gerhard Schroth, Juergen Beck, Andreas Raabe, Marcel Arnold, Michael Reinert and Robert H. Andres

cerebral hyperperfusion syndrome . PLoS One 6 : e19886 , 2011 10.1371/journal.pone.0019886 21625479 12 Cohen DJ , Stolker JM , Wang K , Magnuson EA , Clark WM , Demaerschalk BM , : Health-related quality of life after carotid stenting versus carotid endarterectomy: results from CREST (Carotid Revascularization Endarterectomy Versus Stenting Trial) . J Am Coll Cardiol 58 : 1557 – 1565 , 2011 21958882 10.1016/j.jacc.2011.05.054 13 Coutts SB , Hill MD , Hu WY : Hyperperfusion syndrome: toward a stricter definition . Neurosurgery 53

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Mikito Hayakawa, Kenji Sugiu, Shinichi Yoshimura, Tomohito Hishikawa, Hiroshi Yamagami, Mayumi Fukuda-Doi, Nobuyuki Sakai, Koji Iihara, Kuniaki Ogasawara, Hidenori Oishi, Yasushi Ito and Yuji Matsumaru

of Cerebral Hyperperfusion Syndrome (STOP CHS) Study Group: Co-Principal Investigators Kenji Sugiu, MD, PhD (Department of Neurological Surgery, Okayama University Graduate School of Medicine, Okayama), and Shinichi Yoshimura, MD, PhD (Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya) Vice-Principal Investigators Hidenori Oishi, MD, PhD (Department of Neurosurgery/Neuroendovascular Therapy, Juntendo University Faculty of Medicine, Tokyo), Yasushi Ito MD, PhD (Department of Neurosurgery, Brain Research Institute, Niigata University, Niigata), and

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Jianjian Zhang, Sirui Li, Miki Fujimura, Tsz Yeung Lau, Xiaolin Wu, Miao Hu, Hanpei Zheng, Haibo Xu, Wenyuan Zhao, Xiang Li and Jincao Chen

) Trial. 7 , 10 , 20 , 23 However, one of the common issues with direct bypass surgery is cerebral hyperperfusion (CHP), which can cause severe complications, such as transient neurological deficits (TNDs) and intracranial hemorrhage. 2 , 3 , 14 , 16 , 27 , 28 The occurrence of postoperative CHP is still not fully understood and is difficult to accurately predict through diagnosis prior to surgery. Direct cerebral bypass surgery can be viewed as a “battle” between the extracranial and intracranial circulation due to blood flow competition between the donor and