Staged angioplasty for carotid artery stenosis to prevent postoperative hyperperfusion

Neurosurgery. 2009 Mar;64(3 Suppl):ons122-8; discussion ons128-9. doi: 10.1227/01.NEU.0000334046.41985.BB.


Objective: Hyperperfusion (HP) is a rare but potentially devastating complication after carotid revascularization. This report describes the clinical efficacy of staged angioplasty (SAP) for carotid artery stenosis to prevent HP after carotid revascularization.

Methods: Eighteen of 143 patients with high-grade internal carotid artery stenosis scheduled for angioplasty were considered at high risk of postprocedure HP based on their severely impaired cerebral blood flow (CBF) and cerebral vasoreactivity, which were determined using single-photon emission computed tomography with acetazolamide. Nine of the high-risk patients were treated with carotid artery stenting and the other 9 were treated with SAP, which consisted of balloon angioplasty with undersized balloon catheters (Stage 1) followed by carotid artery stenting 1 to 2 months later (Stage 2).

Results: In the regular carotid artery stenting group, 5 of 9 patients (56%) showed HP phenomenon on single-photon emission computed tomography just after stenting, and 1 patient (11%) developed status epilepticus owing to HP. In the SAP group, none of the 8 patients treated by SAP or the 1 patient who required stent placement during the first stage owing to a wall dissection developed postprocedure HP phenomenon or HP syndrome.

Conclusion: SAP decreased the HP phenomenon on single-photon emission computed tomography after performing these procedures in selected patients. Although additional intervention is needed, SAP is considered a relatively simple and effective method to avoid HP in patients at high risk of HP after carotid revascularization.

MeSH terms

  • Acetazolamide
  • Aged
  • Angioplasty, Balloon / methods*
  • Blood Pressure / physiology
  • Carotid Stenosis / surgery*
  • Cerebrovascular Disorders / diagnostic imaging
  • Cerebrovascular Disorders / prevention & control*
  • Diuretics
  • Female
  • Humans
  • Intraoperative Care
  • Iofetamine
  • Magnetic Resonance Imaging
  • Male
  • Middle Aged
  • Platelet Aggregation Inhibitors / therapeutic use
  • Postoperative Complications / prevention & control*
  • Radiopharmaceuticals
  • Stents
  • Technetium Tc 99m Exametazime
  • Tomography, Emission-Computed, Single-Photon
  • Treatment Outcome


  • Diuretics
  • Platelet Aggregation Inhibitors
  • Radiopharmaceuticals
  • Technetium Tc 99m Exametazime
  • Iofetamine
  • Acetazolamide