although cerebral hyperperfusion syndrome ( chs ) is well documented after carotid endarterectomy and carotid artery stenting , only a few cases have been described after intracranial stenting .
after the stenting versus aggressive medical therapy for intracranial arterial stenosis and vitesse stent ischemic therapy trials demonstrated the inferiority of intracranial stenting compared to aggressive medical treatment , this procedure has been largely abandoned .
cerebral hyperperfusion is defined as a > 100% increase in cerebral blood flow ( cbf ) compared to the baseline and it is generally associated with postprocedural hypertension .
chs has an estimated incidence of 0.4%2.7% after ce and usually presents with ipsilateral headache or migrainous phenomena , seizures , or intracerebral hemorrhage ( ich ) .
i would like to report an unusual case of chs following middle cerebral artery ( mca ) stenting .
a 71-year - old man presented to us with fluctuating motor aphasia of 3 h duration .
magnetic resonance imaging of the brain showed multiple acute infarcts in the left mca territory and he was started on antiplatelets and statins . by the next day morning , he had developed global aphasia and transient right - sided weakness . his blood pressure ( bp )
was 150/90 mm hg and he was taken up for a four - vessel digital subtraction angiography which showed a possible dissection with a thrombus in the distal left mca [ figure 1 ] .
after obtaining consent , a 4 mm  15 mm solitaire ab neurovascular modeling device ( ev3 , irvine , usa ) was placed across the lesion into the superior mca division with good recanalization .
postprocedure , the patient was sedated and ventilated , but had severe hypertension , exceeding 240/140 mm hg which was difficult to control even with multiple antihypertensives .
the next morning , a routine computed tomography ( ct ) brain ( 12 h later ) showed two discrete intracerebral hematomas ( ich ) in the left frontal and temporal areas [ figure 1 ] .
transcranial doppler ( tcd ) showed elevated mean flow velocities of > 130 cm / s in the left mca .
coagulation parameters were normal . on examination , now he had a dense right hemiplegia and global aphasia .
two weeks later , a repeat ct showed resolution of the ich and no fresh infarcts .
the patient had a residual wernicke 's aphasia and right hemiplegia at follow - up even 6 months later .
( a ) top left panel shows an irregularity in the left middle cerebral artery m1 segment , suggestive of dissection .
( c ) bottom panels ; computed tomography scan images showing left temporal and frontal intracerebral hematomas
risk factors for chs include age > 75 years , preexisting hypertension , high - grade stenosis with poor collateralization , decreased cerebrovascular reactivity , and increased peak flow velocities .
reperfusion of ischemic territories can also lead to  reperfusion injury ,  wherein oxidant production , complement activation , and increased microvascular permeability result in an impaired blood 
chs is a devastating complication because of the high morbidity and mortality of nearly 60%80% associated with this condition .
after cerebral revascularization , the advent of severe headache , seizures , or focal neurological deficits after cerebral revascularization should be presumed to signify chs unless proved otherwise .
tcd studies are helpful in monitoring elevated peak systolic velocities in the intracranial arteries as a marker of impending chs . in about 15% of patients ,
in such patients , near - infrared spectroscopy may be a useful option to monitor cbf .
all critical care physicians should be aware of this entity for better monitoring and prevention of this postprocedural complication in the icu .
 cerebral hyperperfusion syndrome ( chs ) is a rare complication following cerebral revascularization . 
 it presents with ipsilateral headache , seizures , and intracerebral hemorrhage . 
 it has mostly been described following extracranial carotid endarterectomy and stenting and it is very unusual after intracranial stenting . 
 a 71-year - old man with a stuttering stroke was taken up for a cerebral angiogram ( digital subtraction angiography ) , which showed a dissection of the distal left middle cerebral artery . 
 this was recanalized with a solitaire ab stent . 
 after 12 h , the patient developed a right hemiplegia and aphasia . 
 computed tomography brain showed two discrete intracerebral hematomas in the left hemisphere . 
 this is the first reported case of chs following intracranial stenting from india . 
Introduction
Case Report
Discussion
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