Staged Carotid Endarterectomy Following Percutaneous Transluminal Angioplasty for Hemodynamically Compromised Internal Carotid Artery Stenosis at High Risk of Hyperperfusion: A Case Report

Cerebral hyperperfusion syndrome (CHS) is a rare but potentially devastating complication after carotid revascularization in patients with severe carotid stenosis and impaired cerebral hemodynamics. We report a case of staged carotid endarterectomy (CEA) performed to reduce the risk of postoperative CHS. A 78-year-old woman underwent ophthalmologic evaluation for decreased vision in the left eye and was referred to our department because ocular ischemia related to ipsilateral carotid artery disease was suspected. Carotid ultrasonography demonstrated severe stenosis of the left internal carotid artery (ICA), with a peak systolic velocity of 353 cm/second and 87% stenosis by the area method, along with marked calcification and plaque ulceration. Digital subtraction angiography revealed near-occlusive left ICA stenosis with delayed antegrade flow, 99% stenosis by the North American Symptomatic Carotid Endarterectomy Trial (NASCET) method, occlusion of the left external carotid artery, and poor collateral circulation. Magnetic resonance angiography (MRA), arterial spin labeling (ASL), and N-isopropyl-p-[123I]-iodoamphetamine single-photon emission computed tomography (IMP-SPECT) demonstrated left hemispheric hemodynamic compromise. Because the patient was considered to be at increased risk for postoperative CHS and the lesion was heavily calcified, staged CEA consisting of percutaneous transluminal angioplasty (PTA) followed by delayed CEA was selected. After PTA, residual stenosis improved to 85% by the NASCET method and 83% by the area method, without new ischemic lesions. MRA, ASL, and IMP-SPECT showed improved left hemispheric perfusion. Seven days later, CEA was performed without CHS or major perioperative complications. The patient was discharged home 10 days after CEA with a modified Rankin Scale score of 0, and no restenosis or neurological complications had occurred at three years of follow-up. Staged CEA after PTA may be an individualized treatment option for selected patients with severe carotid stenosis, marked hemodynamic compromise, and lesion morphology that favors plaque removal over primary stenting.