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Teaching NeuroImages : Altered Mental Status Following Carotid Revascularization

Teaching NeuroImages : Altered Mental Status Following Carotid Revascularization. Vivek Kalra , MD Balaji Rao , MD Ajay Malhotra , MD. Vignette. 69 year-old male presents with hypertensive crisis manifest by acute-onset confusion and elevated systolic pressures to the 160s

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Teaching NeuroImages : Altered Mental Status Following Carotid Revascularization

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  1. Teaching NeuroImages: Altered Mental Status Following Carotid Revascularization VivekKalra, MD BalajiRao, MD Ajay Malhotra, MD

  2. Vignette • 69 year-old male presents with hypertensive crisis manifest by acute-onset confusion and elevated systolic pressures to the 160s • He underwent carotid endarterectomyone day earlier for 75% proximal internal carotid artery stenosis • Stenosis was discovered after he developed right facial droop from multiple embolic infarcts in the left middle cerebral artery distribution two weeks earlier Kalra et al

  3. Imaging B C D A rCBV MTT rCBF Kalra et al

  4. Perfusion Imaging of Cerebral Hyperperfusion Syndrome Following Revascularization • Cerebral Hyperperfusion Syndrome (CHS) following revascularization may present as ipsilateral headache, focal seizure, and/or neurological deficit • CHS is caused by loss of autoregulation, hypertension, and ischemia-reperfusion injury resulting in increased regional blood flow and vascular congestion • Non-perfusion imaging may show intraparenchymal hemorrhage or edema • Perfusion imaging shows increased relative blood flow, increased relative blood volume, and decreased mean transit time • Labetalol and clonidine are used for aggressive blood pressure control until cerebral autoregulation is restored Kalra et al

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