Staged Carotid Artery Stenting for Prevention of Hyperperfusion-Induced Intracerebral Hemorrhage in Patients with Very High-Grade Carotid Stenosis and Poor Collateral Compensation

Objective: Hyperperfusion-induced intracerebral hemorrhage (HICH) is a relatively rare but potentially devastating event after carotid artery stenting (CAS). Staged angioplasty (SAP), a 2-stage form of CAS, has been shown to be effective for preventing cerebral hyperperfusion syndrome. The aim of our retrospective single-center study was to investigate the safety and efficacy of SAP to prevent HICH in patients with very severe carotid stenosis (90%-99%) and poor collateral compensation.

Methods: Between November 2011 and August 2018, 153 patients presented with severe symptomatic carotid artery stenosis ≥90%; 96 were scheduled to undergo regular CAS, and 57 were scheduled for SAP. High risk of HICH were identified based on severe stenosis degree (90%-99%) and poor collateral compensation, which were determined using digital subtraction angiography and qualitative computed tomography perfusion. Patients' clinical data, procedural details, and occurrence of HICH were compared between regular CAS and SAP groups.

Results: Of 57 patients scheduled for SAP, 3 were switched to regular CAS because of intraoperative dissection. The median interval between stages I and II was 8 days (IQR: 4-20 days). One patient who was switched to regular CAS experienced HICH. HICH occurred in 1 patient (1.75%; 1/57) in the SAP group and 12 patients (12.5%; 12/96) in the regular CAS group (odds ratio 0.117, 95% confidence interval 0.014-0.990, P = 0.049). Multivariate analysis showed that SAP was negatively related to cerebral hyperperfusion syndrome (odds ratio 0.117; 95% confidence interval 0.014-0.990; P = 0.049).

Conclusions: SAP is an effective treatment for avoiding HICH in patients with carotid preocclusive stenosis (90%-99%) and poor collateral compensation.