Cerebellar Hemorrhage after Angioplasty
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《新英格兰医药杂志》
To the Editor: A 57-year-old woman without hypertension or hypercholesterolemia who was receiving therapy with 75 mg of clopidogrel per day was admitted with transient dysarthria and diplopia. Initially, she had been treated with 100 mg of aspirin per day, but because of persistent transient ischemic attacks, that regimen had been changed to clopidogrel therapy. Duplex ultrasonography showed occlusion of the right vertebral artery and high-grade stenosis of the left vertebral artery, whereas both internal carotid arteries were normal. Angiography was performed with the intention to continue with dilation and stenting of the verified stenosis (Figure 1A). Three days before percutaneous transluminal angioplasty, additional antithrombotic treatment with 100 mg of aspirin per day was started. Percutaneous transluminal angioplasty and stenting of the left vertebral artery was performed, and control angiography confirmed complete restoration of the vessel lumen (Figure 1B). During the next two hours, the patient's condition was stable (blood pressure, between 120/80 and 160/90 mm Hg), and she was without neurologic deficit. Then, headache and emesis suddenly developed, and she lost consciousness. Urgent computed tomographic (CT) scanning revealed a cerebellar hemorrhage (Figure 1C). A second CT scan obtained three hours later showed compression of the brain stem and ventricular system. The patient did not regain consciousness, and she died 48 hours after the procedure.
Figure 1. Angiograms Obtained before and after Angioplasty and CT Scan Obtained after Angioplasty.
In Panel A, a lateral angiogram of the left vertebral artery shows a high-grade (atherosclerotic) stenosis proximal to the origin of the posterior inferior cerebellar artery and delayed filling of the basilar artery and its branches, with reduced perfusion of the brain stem and the cerebellar parenchyma. Angiography did not reveal an aneurysm or vascular malformation, and magnetic resonance imaging did not show signs of ischemic or hemorrhagic infarction. In Panel B, a control angiogram obtained after percutaneous transluminal angioplasty shows complete restoration of the vessel lumen, with markedly improved filling of the basilar artery and its branches. In Panel C, a CT scan obtained two hours after percutaneous transluminal angioplasty reveals a large cerebellar hemorrhage with secondary extension into the fourth ventricle and subarachnoid space.
Intracranial hemorrhage due to reperfusion is an uncommon event after carotid endarterectomy or percutaneous transluminal angioplasty1 that is performed to treat carotid stenosis. Since percutaneous transluminal angioplasty is also increasingly being used for symptomatic vertebrobasilar disease,2 the potential occurrence of this complication should be taken into consideration. Although in the case of our patient there was no objective documentation of hyperperfusion, we believe that the fatal cerebellar hemorrhage was most likely the sequela of the hyperperfusion syndrome. In support of this notion, two cases of substantially increased blood flow after percutaneous transluminal angioplasty of a vertebral artery have been reported.3,4 One of these cases involved an occlusion of one vertebral artery, and the other a high-grade stenosis of the other vertebral artery. Since magnetic resonance imaging before stenting had ruled out pathologic processes in our case, it is unlikely that the intracerebellar hemorrhage was a spontaneous episode that resulted from the aggressive antiplatelet therapy.
Our case emphasizes that spontaneous cerebellar hemorrhage due to reperfusion can occur after percutaneous transluminal angioplasty of the vertebrobasilar vasculature. Meticulous periprocedural monitoring of symptoms and cardiorespiratory functions is mandatory.
Axel Riecker, M.D.
Ulrike Ernemann, M.D.
Andreas Kastrup, M.D.
University of Tübingen
72076 Tübingen, Germany
axel.riecker@web.de
References
McCabe DJ, Brown MM, Clifton A. Fatal cerebral reperfusion hemorrhage after carotid stenting. Stroke 1999;30:2483-2486.
Stenting of Symptomatic Atherosclerotic Lesions in the Vertebral or Intracranial Arteries (SSYLVIA): study results. Stroke 2004;35:1388-1392.
Meyers PM, Higashida RT, Phatouros CC, et al. Cerebral hyperperfusion syndrome after percutaneous transluminal stenting of the craniocervical arteries. Neurosurgery 2000;47:335-345.
Bando K, Satoh K, Matsubara S, Nakatani M, Nagahiro S. Hyperperfusion phenomenon after percutaneous transluminal angioplasty for atherosclerotic stenosis of the intracranial vertebral artery: case report. J Neurosurg 2001;94:826-830.
Figure 1. Angiograms Obtained before and after Angioplasty and CT Scan Obtained after Angioplasty.
In Panel A, a lateral angiogram of the left vertebral artery shows a high-grade (atherosclerotic) stenosis proximal to the origin of the posterior inferior cerebellar artery and delayed filling of the basilar artery and its branches, with reduced perfusion of the brain stem and the cerebellar parenchyma. Angiography did not reveal an aneurysm or vascular malformation, and magnetic resonance imaging did not show signs of ischemic or hemorrhagic infarction. In Panel B, a control angiogram obtained after percutaneous transluminal angioplasty shows complete restoration of the vessel lumen, with markedly improved filling of the basilar artery and its branches. In Panel C, a CT scan obtained two hours after percutaneous transluminal angioplasty reveals a large cerebellar hemorrhage with secondary extension into the fourth ventricle and subarachnoid space.
Intracranial hemorrhage due to reperfusion is an uncommon event after carotid endarterectomy or percutaneous transluminal angioplasty1 that is performed to treat carotid stenosis. Since percutaneous transluminal angioplasty is also increasingly being used for symptomatic vertebrobasilar disease,2 the potential occurrence of this complication should be taken into consideration. Although in the case of our patient there was no objective documentation of hyperperfusion, we believe that the fatal cerebellar hemorrhage was most likely the sequela of the hyperperfusion syndrome. In support of this notion, two cases of substantially increased blood flow after percutaneous transluminal angioplasty of a vertebral artery have been reported.3,4 One of these cases involved an occlusion of one vertebral artery, and the other a high-grade stenosis of the other vertebral artery. Since magnetic resonance imaging before stenting had ruled out pathologic processes in our case, it is unlikely that the intracerebellar hemorrhage was a spontaneous episode that resulted from the aggressive antiplatelet therapy.
Our case emphasizes that spontaneous cerebellar hemorrhage due to reperfusion can occur after percutaneous transluminal angioplasty of the vertebrobasilar vasculature. Meticulous periprocedural monitoring of symptoms and cardiorespiratory functions is mandatory.
Axel Riecker, M.D.
Ulrike Ernemann, M.D.
Andreas Kastrup, M.D.
University of Tübingen
72076 Tübingen, Germany
axel.riecker@web.de
References
McCabe DJ, Brown MM, Clifton A. Fatal cerebral reperfusion hemorrhage after carotid stenting. Stroke 1999;30:2483-2486.
Stenting of Symptomatic Atherosclerotic Lesions in the Vertebral or Intracranial Arteries (SSYLVIA): study results. Stroke 2004;35:1388-1392.
Meyers PM, Higashida RT, Phatouros CC, et al. Cerebral hyperperfusion syndrome after percutaneous transluminal stenting of the craniocervical arteries. Neurosurgery 2000;47:335-345.
Bando K, Satoh K, Matsubara S, Nakatani M, Nagahiro S. Hyperperfusion phenomenon after percutaneous transluminal angioplasty for atherosclerotic stenosis of the intracranial vertebral artery: case report. J Neurosurg 2001;94:826-830.