A case of cerebral hemorrhage early after carotid stenting.

To the Editor: We read with interest the recent case report by McCabe et al,1 in which they describe a patient with fatal cerebral reperfusion hemorrhage after internal carotid artery (ICA) stenting. In their interesting discussion, the authors argue that this disastrous complication most likely occurred because cerebral perfusion pressure overwhelmed the vasoconstrictive capacity of the arteriolar circulation. Because a brain CT scan performed before carotid stenting disclosed diffuse patchy leukoaraiosis in the deep white matter, the authors suggest that leukoaraiosis could be a risk factor for reperfusion hemorrhage after carotid stenting. We provide an additional case report of reperfusion injury after carotid stenting that supports the main conclusion of McCabe and colleagues and provides some further understanding of this dreadful complication. On November, 10, 1999, a 43-year-old right handed man was admitted to our stroke unit, 2 days after a sudden onset of left-sided facial and brachial paresis. His past medical record was relevant for a history of hypertension since the age of 20, with no other atherosclerotic risk factors or past cerebrovascular events. On admission, his blood pressure was 150/80 mm Hg and his neurological exam was normal. A brain CT scan showed a 3.5-cm ischemic infarction in the right centrum ovale consistent with acute embolism. An old ischemic lacunar infarction 10 mm in size was also observed in the genu of the right internal capsule. Periventricular or brain stem leukoaraiosis and brain stem lacunar infarctions were absent. A Doppler ultrasound of the cervical vessels suggested >90% stenosis of the right ICA and normal findings on both vertebral arteries and left ICA. The following day a selective injection on the right common carotid artery disclosed 95% stenosis of the ICA, …