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Table 3 Key factors in the prevention and treatment of cerebral hyperperfusion syndrome [13, 9, 22, 23, 26, 32, 34, 38]

From: Pathophysiology and management of reperfusion injury and hyperperfusion syndrome after carotid endarterectomy and carotid artery stenting

Treatment modality Comment
Blood pressure control Strict control of blood pressure is recommended
Lower blood pressure even in normotensive patients
There are no definite guidelines about blood pressure parameters and management should be individualized
Avoid medications which have vasodilatory effect such as calcium channel blockers
Labetalol and clonidine are better options to treat elevated blood pressure in these patients
Timing of carotid surgery Carotid endarterectomy or stenting should be done within 2 weeks of transient ischemic attack or stroke
Patient is at risk of cerebral hyperperfusion syndrome if they underwent contralateral carotid endarterectomy in past 3 months
Type of anesthetic High doses of volatile halogenated hydrocarbon anesthetics may lead to cerebral hyperperfusion syndrome
Isoflurane is safer to use in these patients but can cause complications at higher doses
Nitrous oxide is also safe but should not be used with isoflurane
Propofol normalizes cerebral blood flow and is a safe option
Use of anti-epileptic medications Prophylactic use of an anti-epileptic drug is not recommended
If patient has lateralized epileptiform discharges or a clinically manifest seizure spell, an anti-epileptic drug may be administered
Use of hypertonic saline and mannitol The evidence about the use of hypertonic saline and mannitol is not strong but may be administered if the patient has cerebral edema
Corticosteroids and barbiturates are not indicated in most cases
Hyperventilation and sedation may be administered if the patient has cerebral edema