Shoskes Aaron, Mullaguri Naresh, Purohit Meghan, George Pravin, Newey Christopher Ryan
Cerebrovascular Center, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, USA.
Epilepsy Center, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, USA.
Neurohospitalist. 2021 Apr;11(2):165-169. doi: 10.1177/1941874420966850. Epub 2020 Oct 15.
The emergence of neurologic symptoms after carotid revascularization is not uncommon and typically caused by perioperative ischemic stroke or hyperperfusion. Postoperative vasculopathy, including reversible cerebral vasoconstriction syndrome (RCVS) is a rare complication of carotid intervention and may be an under-identified cause of neurologic deficit after revascularization. We report a case of reversible postoperative vasculopathy following carotid revascularization as well as its management.
A 74 year old right-handed woman presented to the emergency department with sudden onset left arm weakness and episodic shaking while hypotensive. Computed tomography angiography revealed total occlusion of her right internal carotid artery. Transcranial Doppler monitoring demonstrated active embolic events in her right middle cerebral artery raising concern for continued stump embolization. She underwent carotid revascularization with carotid endarterectomy, mechanical thrombectomy, and carotid angioplasty and initially did well postoperatively. On postoperative day 5, she developed a fixed right gaze and left hemiparesis. Computed tomography revealed new right frontal lobe and basal ganglia infarcts, and angiography showed new right internal carotid, middle cerebral, and anterior cerebral artery vasoconstriction consistent with postoperative vasculopathy. Despite treatment with pressure augmentation and vasodilator therapy, her symptoms persisted resulting in left hemiplegia at discharge.
This case highlights postoperative vasculopathy (including RCVS) as a rare potential complication after carotid revascularization that should be considered in a patient with persistent acute neurologic symptoms. Information regarding incidence and predisposing risk factors is limited. Multiple diagnostic and therapeutic modalities may be necessary in the recognition and treatment of postoperative vasculopathy.
颈动脉血运重建术后出现神经系统症状并不少见，通常由围手术期缺血性卒中或高灌注引起。术后血管病变，包括可逆性脑血管收缩综合征（RCVS）是颈动脉介入治疗的一种罕见并发症，可能是血运重建术后神经功能缺损的一个未被充分认识的原因。我们报告一例颈动脉血运重建术后可逆性术后血管病变及其治疗情况。
一名74岁右利手女性因突然出现左臂无力以及低血压时发作性震颤而就诊于急诊科。计算机断层血管造影显示其右侧颈内动脉完全闭塞。经颅多普勒监测显示右侧大脑中动脉有活动性栓塞事件，令人担心残端持续栓塞。她接受了颈动脉内膜切除术、机械取栓术和颈动脉血管成形术进行颈动脉血运重建，术后初期情况良好。术后第5天，她出现了固定性右凝视和左侧偏瘫。计算机断层扫描显示右侧额叶和基底节有新的梗死灶，血管造影显示右侧颈内动脉、大脑中动脉和大脑前动脉出现新的血管收缩，符合术后血管病变。尽管采用了升压和血管扩张剂治疗，她的症状仍持续存在，出院时导致左侧偏瘫。
本病例突出了术后血管病变（包括RCVS）作为颈动脉血运重建术后一种罕见的潜在并发症，对于有持续性急性神经症状的患者应予以考虑。关于发病率和易感危险因素的信息有限。在术后血管病变的识别和治疗中可能需要多种诊断和治疗方式。
