Prognostic Value of T2-FLAIR Hyperintense Vessel Sign for Cerebral Hyperperfusion Syndrome and Feasibility of Risk-Stratified Perioperative Management Following Carotid Artery Stenting.

Abstract

This study aimed to assess the prognostic performance of preoperative T2-FLAIR hyperintense vessel sign (HVS) grading for cerebral hyperperfusion syndrome (CHS) after carotid artery stenting (CAS), and to evaluate the clinical feasibility and safety of an HVS-guided risk-stratified perioperative management strategy. A single-center prospective cohort study was conducted on 128 consecutive patients with symptomatic carotid stenosis ≥70 who underwent elective CAS. All participants were categorized into three groups based on preoperative HVS grades: low-risk (HVS 0-1), intermediate-risk (HVS 2), and high-risk (HVS 3). Tailored interventions, including session-based staged angioplasty and tiered systolic blood pressure control, were implemented across all groups. The primary clinical endpoint was 30-day symptomatic CHS. Firth penalized logistic regression was applied for exploratory analysis of factors associated with CHS occurrence. The overall 30-day incidence of symptomatic CHS was 6.3%, with a stepwise rising risk across low-risk (0%), intermediate-risk (5.3%) and high-risk (24%) HVS subgroups (P<0.001). Exploratory regression analysis revealed that HVS grade ≥2 (OR=6.87, 95%CI: 2.91-16.23, P<0.001) and incomplete circle of Willis (OR=3.72, 95%CI: 1.58-8.76, P=0.003) were correlated with higher CHS odds. There were no intergroup differences in total procedural complications, and the CHS incidence of our cohort was numerically lower than that of a historical control group. Preoperative T2-FLAIR HVS grading serves as a reliable prognostic marker for stratifying CHS risk in patients receiving CAS. The HVS-guided risk-stratified perioperative management protocol is clinically feasible and safe. As a widely accessible imaging indicator, HVS has promising application value in routine clinical practice. Further large-scale multicenter studies are warranted to validate our findings.