Incidence and etiology of intracerebral hemorrhage following carotid endarterectomy

Restricted access

✓ In a consecutive series of 1930 carotid endarterectomies there were eight cases of postoperative intracerebral hemorrhage. One of these patients was operated on 2 weeks following cerebral infarction and had severe uncontrollable hypertension after surgery. A second patient had an intraoperative embolus and bled while fully heparinized on the 3rd postoperative day. Only one patient in the series bled into an area of documented cerebral infarction. The remainder of the cases represented hemorrhage into essentially normal brain.

Seven of the eight patients with intracerebral hemorrhage had high-grade internal carotid artery stenosis preoperatively. Although several factors have contributed to the brain hemorrhages in this series of patients, postoperative cerebral hyperperfusion which often follows endarterectomy may have played an important role. Defective cerebrovascular autoregulation in chronically ischemic brain regions may predispose patients to intracerebral hemorrhage after removal of a high-grade stenosis of the internal carotid artery.

Article Information

Address reprint requests to: Robert A. Solomon, M.D., The Neurological Institute of New York, 710 West 168th Street, New York, New York 10032.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Representative preoperative angiograms. A: Case 1. Solid arrow points to the occlusion of the left internal carotid artery, and the open arrow shows a greater than 90% stenosis of the right carotid artery. B: Case 2. Arrows point to areas of greater than 90% stenosis of both carotid arteries.

  • View in gallery

    Gross autopsy specimens showing massive fresh intracerebral hematomas in Cases 1 (A) and 5 (B).

References

  • 1.

    Bernstein MFleming JFRDeck JHN: Cerebral hyperperfusion after carotid endarterectomy: a cause of cerebral hemorrhage. Neurosurgery 15:50561984Bernstein M Fleming JFR Deck JHN: Cerebral hyperperfusion after carotid endarterectomy: a cause of cerebral hemorrhage. Neurosurgery 15:50–56 1984

    • Search Google Scholar
    • Export Citation
  • 2.

    Bland JEChapman RDWylie EJ: Neurological complications of carotid artery surgery. Ann Surg 171:4594641970Bland JE Chapman RD Wylie EJ: Neurological complications of carotid artery surgery. Ann Surg 171:459–464 1970

    • Search Google Scholar
    • Export Citation
  • 3.

    Browne TRPoskanzer DC: Treatment of strokes (first of two parts). N Engl J Med 281:5946021969Browne TR Poskanzer DC: Treatment of strokes (first of two parts). N Engl J Med 281:594–602 1969

    • Search Google Scholar
    • Export Citation
  • 4.

    Bruetman MEFields WSCrawford ESet al: Cerebral hemorrhage in carotid artery surgery. Arch Neurol 9:4584671963Bruetman ME Fields WS Crawford ES et al: Cerebral hemorrhage in carotid artery surgery. Arch Neurol 9:458–467 1963

    • Search Google Scholar
    • Export Citation
  • 5.

    Caplan LRSkillman JOjemann Ret al: Intracerebral hemorrhage following carotid endarterectomy: a hypertensive complication? Stroke 9:4574601978Caplan LR Skillman J Ojemann R et al: Intracerebral hemorrhage following carotid endarterectomy: a hypertensive complication? Stroke 9:457–460 1978

    • Search Google Scholar
    • Export Citation
  • 6.

    Dolan JGMushlin AI: Hypertension, vascular headaches, and seizures after carotid endarterectomy. Case report and therapeutic considerations. Arch Intern Med 144:148914911984Dolan JG Mushlin AI: Hypertension vascular headaches and seizures after carotid endarterectomy. Case report and therapeutic considerations. Arch Intern Med 144:1489–1491 1984

    • Search Google Scholar
    • Export Citation
  • 7.

    Fisher MAdams RD: Observations on brain embolism with special reference to the mechanism of hemorrhagic infarction. J Neuropathol Exp Neurol 10:92941951Fisher M Adams RD: Observations on brain embolism with special reference to the mechanism of hemorrhagic infarction. J Neuropathol Exp Neurol 10:92–94 1951

    • Search Google Scholar
    • Export Citation
  • 8.

    Harvey JRasmussen T: Occlusion of the middle cerebral artery: an experimental study. Arch Neurol Psychiatry 66:20291951Harvey J Rasmussen T: Occlusion of the middle cerebral artery: an experimental study. Arch Neurol Psychiatry 66:20–29 1951

    • Search Google Scholar
    • Export Citation
  • 9.

    Heros RCScott RMKistler JPet al: Temporary neurological deterioration after extracranial-intracranial bypass. Neurosurgery 15:1781851984Heros RC Scott RM Kistler JP et al: Temporary neurological deterioration after extracranial-intracranial bypass. Neurosurgery 15:178–185 1984

    • Search Google Scholar
    • Export Citation
  • 10.

    Leviton ACaplan LSalzman E: Severe headache after carotid endarterectomy. Headache 15:2072101975Leviton A Caplan L Salzman E: Severe headache after carotid endarterectomy. Headache 15:207–210 1975

    • Search Google Scholar
    • Export Citation
  • 11.

    Loftus CMQuest DO: Current status of carotid endarterectomy for atheromatous disease. Neurosurgery 13:7187231983Loftus CM Quest DO: Current status of carotid endarterectomy for atheromatous disease. Neurosurgery 13:718–723 1983

    • Search Google Scholar
    • Export Citation
  • 12.

    Messert BBlack JA: Cluster headache, hemicrania, and other head pains: morbidity of carotid endarterectomy. Stroke 9:5595621978Messert B Black JA: Cluster headache hemicrania and other head pains: morbidity of carotid endarterectomy. Stroke 9:559–562 1978

    • Search Google Scholar
    • Export Citation
  • 13.

    Ojemann RGCrowell RMRoberson GHet al: Surgical treatment of extracranial carotid occlusive disease. Clin Neurosurg 22:2142631975Ojemann RG Crowell RM Roberson GH et al: Surgical treatment of extracranial carotid occlusive disease. Clin Neurosurg 22:214–263 1975

    • Search Google Scholar
    • Export Citation
  • 14.

    Satiani BVasko JSEvans WE: Hypertension following carotid endarterectomy. Surg Neurol 11:3573591979Satiani B Vasko JS Evans WE: Hypertension following carotid endarterectomy. Surg Neurol 11:357–359 1979

    • Search Google Scholar
    • Export Citation
  • 15.

    Schroeder THolstein PEEngell HC: Hyperperfusion following endarterectomy. Stroke 15:7581984 (Letter)Schroeder T Holstein PE Engell HC: Hyperperfusion following endarterectomy. Stroke 15:758 1984 (Letter)

    • Search Google Scholar
    • Export Citation
  • 16.

    Solomon RAMichelsen WJ: Defective cerebrovascular autoregulation in regions proximal to arteriovenous malformations of the brain: a case report and topic review. Neurosurgery 14:78821984Solomon RA Michelsen WJ: Defective cerebrovascular autoregulation in regions proximal to arteriovenous malformations of the brain: a case report and topic review. Neurosurgery 14:78–82 1984

    • Search Google Scholar
    • Export Citation
  • 17.

    Spetzler RFWilson CBWeinstein Pet al: Normal perfusion pressure breakthrough theory. Clin Neurosurg 25:6516721978Spetzler RF Wilson CB Weinstein P et al: Normal perfusion pressure breakthrough theory. Clin Neurosurg 25:651–672 1978

    • Search Google Scholar
    • Export Citation
  • 18.

    Sundt TM Jr: The ischemic tolerance of neural tissue and the need for monitoring and selective shunting during carotid endarterectomy. Stroke 14:93981983Sundt TM Jr: The ischemic tolerance of neural tissue and the need for monitoring and selective shunting during carotid endarterectomy. Stroke 14:93–98 1983

    • Search Google Scholar
    • Export Citation
  • 19.

    Sundt TM JrSandok BAWhisnant JP: Carotid endarterectomy. Complications and preoperative assessment of risk. Mayo Clin Proc 50:3013061975Sundt TM Jr Sandok BA Whisnant JP: Carotid endarterectomy. Complications and preoperative assessment of risk. Mayo Clin Proc 50:301–306 1975

    • Search Google Scholar
    • Export Citation
  • 20.

    Sundt TM JrSharbrough FWPiepgras DGet al: Correlation of cerebral blood flow and electroencephalographic changes during carotid endarterectomy, with results of surgery and hemodynamics of cerebral ischemia. Mayo Clin Proc 56:5335431981Sundt TM Jr Sharbrough FW Piepgras DG et al: Correlation of cerebral blood flow and electroencephalographic changes during carotid endarterectomy with results of surgery and hemodynamics of cerebral ischemia. Mayo Clin Proc 56:533–543 1981

    • Search Google Scholar
    • Export Citation
  • 21.

    Towne JBBernhard VM: The relationship of postoperative hypertension to complications following carotid endarterectomy. Surgery 88:5755801980Towne JB Bernhard VM: The relationship of postoperative hypertension to complications following carotid endarterectomy. Surgery 88:575–580 1980

    • Search Google Scholar
    • Export Citation
  • 22.

    Wylie EJHein MFAdams JE: Intracranial hemorrhage following surgical revascularization for treatment of acute strokes. J Neurosurg 21:2122151964Wylie EJ Hein MF Adams JE: Intracranial hemorrhage following surgical revascularization for treatment of acute strokes. J Neurosurg 21:212–215 1964

    • Search Google Scholar
    • Export Citation
  • 23.

    Youmans JRKindt GW: Influence of multiple vessel impairment on carotid blood flow in the monkey. J Neurosurg 29:1351381968Youmans JR Kindt GW: Influence of multiple vessel impairment on carotid blood flow in the monkey. J Neurosurg 29:135–138 1968

    • Search Google Scholar
    • Export Citation

TrendMD

Cited By

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 202 202 17
Full Text Views 165 127 1
PDF Downloads 101 83 0
EPUB Downloads 0 0 0

PubMed

Google Scholar