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Table 3 Key factors in the prevention and treatment of cerebral hyperperfusion syndrome [1–3, 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