Cerebral Hyperperfusion Syndrome Risk Comparison between Transcarotid Artery Revascularization and Carotid Artery Stenting with Distal Embolic Protection

Background: Cerebral hyperperfusion syndrome (CHS) is a rare but serious complication after carotid artery revascularization. This study aims to determine the impact of carotid artery stenting (CAS) modality on the incidence, severity, and overall outcomes of CHS after carotid revascularization. Methods: Data from patients who underwent CAS with either distal embolic protection (CAS + DEP) or transcarotid artery revascularization (TCAR) were obtained from the Vascular Quality Initiative database through the years 2016-2023. Cases without embolic protection device and patients suffering from carotid dissection, trauma, or fibromuscular dysplasia were excluded from the study. Patients were stratified into asymptomatic and symptomatic carotid stenosis groups and then further reviewed based on the urgency of their revascularization. The primary outcome was the occurrence of CHS after revascularization. A subgroup analysis was then performed, evaluating postprocedural outcomes and severity of CHS. Lastly, patients with CHS were further analyzed according to the severity of their stroke on admission using the Results: In this analysis, a total of 69,480 (57.47% TCAR; 42.53% CAS + DEP) patients were included. Postprocedural CHS was lower in the TCAR cohort compared to the CAS + DEP cohort (0.53% vs. 1.1%, P < 0.001). On multivariate analysis, TCAR was associated with lower risk of CHS than CAS + DEP (P < 0.001). When considering only asymptomatic patients, revascularization modality did not significantly affect CHS occurrence (P - 0.610). However, in symptomatic patients, TCAR was associated with 2-fold lower risk of CHS (adjusted odds ratio (aOR): 0.52, 95% confidence interval (CI): 0.40-0.68, P < 0.001), in both elective (P - 0.003), and urgent/emergency cases (P < 0.001). Among patients who developed CHS, those undergoing TCAR had decreased in-hospital mortality (aOR: 0.51, 95% CI: 0.27-0.94, P - 0.031) and at 30 days (aOR: 0.46, 95% CI: 0.26-0.80, P - 0.006). TCAR patients with CHS also had a shorter length of hospitalization (aOR: 0.58, 95% CI: 0.36-0.92, P - 0.022) and suffered less frequently from severe CHS with seizures and intracranial hemorrhage (aOR: 0.51, 95% CI: 0.29-0.89, P - 0.019). Patients undergoing CAS + DEP who were admitted with severe stroke (Modified Conclusion: In patients with symptomatic carotid artery stenosis, TCAR is associated with a dergo TCAR express a milder form of CHS and have lower in-hospital and 30-day mortality than those treated with CAS + DEP.