Retinal hemorrhage as an initial sign of hyperperfusion syndrome after carotid stenting

초록

A 62-year-old male was admitted with left side amaurosis fugax and temporary right hemiparesis. He had hypertension, diabetes mellitus, and 1-year history of cerebral infarction. His brain magnetic resonance image (MRI) and angiography (MRA) showed some old ischemic changes without any acute infarction and severe stenosis on left cervical internal carotid artery (ICA). As he had symptomatic carotid stenosis, he underwent digital subtraction cerebral angiography (DSA) for planning his treatment. There was severe stenosis (90%) on left cervical ICA. Carotid stenting was performed successfully without any procedure-related complication. The intracranial flow got better after the procedure. However, in the morning on the third day after the procedure, the patient complained blurred vision on his left eye. Then, he became lethargic and complained left temporoparietal headache. There was no intracranial hemorrhage on CT scan. Diffusion weighted MRI seemed to be not significant. However, perfusion weighted MRI showed rapid mean transit time (MTT) and increased cerebral blood volume (CBV) on left fronto-parietal area. Hyperperfusion syndrome was confirmed by patient’s symptoms, onset time, and radiological images. Ophthalmologic examination was performed to evaluate his blurred vision. Retinal hemorrhage on his left eye was confirmed by fundus photo. Left lower quadrant of Macula was involved by the retinal hemorrhage, which might be the cause of blurred vision. On 7th day after the procedure, follow-up angiography showed dense and larger left ophthalmic artery compared to the pre-stenting angiogram, suggesting the possible correlation between hyperperfusion syndrome and retinal hemorrhage. The patient discharged with minimal visual disturbance. This case might suggest that early ophthalmologic examination after carotid stenting, especially in patients with initial visual symptoms, would be helpful to predict hyperperfusion syndrome.