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The following is a summary of “Cerebral Hyperperfusion Syndrome After Carotid Revascularization; Predictors and Complications,” published in the March 2025 issue of the Annals of Vascular Surgery by Abdelkarim et al.

Cerebral hyperperfusion syndrome (CHS) is a rare but potentially life-threatening complication following carotid artery revascularization, with varying incidence rates among carotid endarterectomy (CEA), transfemoral carotid artery stenting (TFCAS), and transcarotid artery revascularization (TCAR). Identifying the predictors and associated complications of CHS is critical for optimizing perioperative management and improving patient outcomes. This study leveraged a large-scale national database to evaluate the incidence, risk factors, and clinical consequences of CHS across different carotid revascularization techniques. 

A retrospective analysis was conducted on patients undergoing CEA, TFCAS, and TCAR for carotid artery stenosis in the Vascular Quality Initiative (VQI) database from 2020 to 2023. Multivariate logistic regression was performed to identify independent predictors of CHS, which were then used to develop a risk score calculator. Additionally, the study assessed the rates of stroke and mortality following CHS across the three revascularization techniques. The final cohort included 59,130 (53%) patients who underwent CEA, 14,064 (13%) who underwent TFCAS, and 37,565 (34%) who underwent TCAR. A total of 281 CHS cases (0.25%) were identified, with TFCAS showing the highest incidence (0.78%) compared to CEA (0.22%) and TCAR (0.15%) (p < 0.001). After adjusting for confounders, TFCAS was associated with a nearly three-fold higher risk of CHS compared to CEA ([aOR] = 2.87, 95% CI: 1.65–4.9; p < 0.001), whereas TCAR exhibited a risk profile similar to CEA. Additional independent predictors of CHS included uncontrolled hypertension, insulin-dependent diabetes, symptomatic status, history of prior carotid intervention, urgent procedures, and postoperative antihypertensive therapy. 

These variables were integrated into an interactive CHS risk calculator, which demonstrated strong predictive performance (C-statistic = 0.8). Among patients who developed CHS, those undergoing TFCAS faced a 70% increased risk of in-hospital stroke (aOR = 1.7, 95% CI: 1.4–2; p < 0.001) and a nearly three-fold higher risk of in-hospital mortality (aOR = 2.9, 95% CI: 2.3–3.8; p < 0.001) compared to other techniques. While TCAR and CEA were largely comparable in outcomes, TCAR carried a slightly higher risk of in-hospital stroke (aOR = 1.2, 95% CI: 1–1.3; p = 0.03). These findings emphasize the significant influence of revascularization type on CHS risk and associated complications, with TFCAS presenting the highest hazard. 

Furthermore, the strong correlation between uncontrolled hypertension and CHS highlights the need for stringent perioperative blood pressure management. The newly developed CHS prediction model may serve as a valuable tool for risk stratification and targeted postoperative surveillance. Future prospective studies should validate the clinical utility of this risk calculator and explore strategies to mitigate CHS risk in high-risk patient populations.

Source: annalsofvascularsurgery.com/article/S0890-5096(25)00087-1/abstract