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Cerebral Hyperperfusion Syndrome (CHS)


KEY FACTS

Terminology

  • Rare (1-3%) disorder most commonly occurring as complication of cerebral revascularization

    • Other etiologies less common

      • –

        Status epilepticus

      • –

        MELAS

  • Major increase in ipsilateral cerebral blood flow (CBF) well above normal metabolic demands

Imaging

  • Ipsilateral gyral swelling, sulcal effacement in post-carotid endarterectomy (CEA) patient

  • ↑ CBF, CBV on perfusion MR, perfusion CT

Top Differential Diagnoses

  • Acute cerebral ischemia-infarction

  • Status epilepticus

  • MELAS

  • Acute hypertensive encephalopathy, PRES

  • Hypercapnia

Pathology

  • Cerebral hyperperfusion syndrome (CHS) probably caused by maladaptive autoregulatory mechanisms, altered cerebral hemodynamics

    • Normal perfusion pressure breakthrough

    • Rapid restoration of normal perfusion following revascularization → hyperperfusion in previously underperfused brain

Clinical Issues

  • ~ 3% of post-CEA patients develop CHS

  • Classic: Triad of unilateral headache, neurologic deficit, & seizures

    • Variable cognitive impairment; ipsilateral face, eye pain

Diagnostic Checklist

  • Need to distinguish stroke/TIA from CHS

A 56-year-old man with > 70% stenosis of proximal left cervical ICA underwent carotid endarterectomy. A few hours after surgery, he became acutely confused and developed right-sided weakness; perfusion source image shows markedly increased vasculature in the left hemisphere
.

CT perfusion obtained in the same patient appears relatively normal, but cerebral blood flow on the left (as measured by circled regions of interest 2a, 2b) increased compared to the right side (1a, 1b).

Time to peak (TTP) in the same patient is even more striking. The abnormal side is not the right middle carotid artery distribution (green) but is the left side
(blue), where the TTP is markedly shortened.

Axial T2WI in the same patient shows gyral swelling, sulcal effacement, and hyperintensity in the left temporal and parietooccipital cortex/subcortical white matter
, basal ganglia
. DWI (not shown) was normal. This is a classic example of postcarotid endarterectomy hyperperfusion syndrome.

TERMINOLOGY

Abbreviations

  • Cerebral hyperperfusion syndrome (CHS)

Synonyms

  • Postcarotid endarterectomy hyperperfusion

  • Luxury perfusion

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