Aphasia 1 Week After Carotid Endarterectomy

An 83-year-old man with a history of arterial hypertension and dyslipidemia, presented to a neurologist with a tremor of the right hand. Magnetic resonance imaging of the brain was performed, which did not show major abnormalities (Figure A and C). A routine carotid ultrasound revealed an occluded right internal carotid artery (ICA) and high-grade stenosis (u003e75%) of the left ICA. An uncomplicated carotid endarterectomy (CEA) of the left ICA was performed, and the patient was discharged 2 days later.Figure. White matter changes associated with cerebral hyperperfusion syndrome. Corresponding fluid-attenuated inversion recovery images before ( A and C ) and several days after the clinical presentation with cerebral hyperperfusion syndrome ( B and D ) revealing extensive white matter changes in the left hemisphere with cortical sparing.Eight days post CEA, he was admitted at our hospital with sudden onset of aphasia and confusion. On neurological examination, severe aphasia and a mild right-sided hemiparesis were documented; in addition, his blood pressure was elevated (213/75 mm Hg). Computed tomography (CT) of the brain was normal and a CT angiography showed a patent left ICA. He subsequently developed fever (38.6°C) for which a lumbar puncture was performed. Analysis of the cerebrospinal fluid was unremarkable. Shortly after admission, he experienced an epileptic seizure and treatment with levetiracetam was initiated. The diagnosis of a cerebral hyperperfusion syndrome (CHS) was considered …