In this ppt i am going to describe about one patient who develop acute stroke after PCI in our hospital. Also i am going to discuss how to diagnose, manage and treat such patient, risk factor associated with stroke after PCI.

1. CATH
MEET
IISS
Stroke, a rare
complication in post PCI
patient
Presenter
Praveen Gupta
4/02/2017
Pondicherry
India
1

2. History
 42 year old female
 known case of Diabetes mellitus since 3 years on OHA
 Acute onset retrosternal chest pain since 1 day
 ECG-NSR@60 beats/min, T wave inversion in lead 2,3,avF,V4-V6
 ECHO-Normal, LVEFF-60%
 ACS/Unstable angina
2

3. History
 CAG-SVD of LCX (80-90% stenosis)
 Transradial PCI to LCX with DES (Successful)
3

4. Course after procedure
 Immediately post PCI patient was complaiting of
 Headache
 Giddiness
 Diplopia
 Vomiting
4

5. NCCT head
5
NCCT Head of the patient-No evidence of infact or any hemorrhage
JIPMER, Cardiology Department, 30/01/2017
JIPMER, Radiology Department, 30/01/2017

6. Course during stay
 Neurology opinion taken
 During examination, right eye has CN III palsy in the form of
adduction and elevation limitation
 Rest of the motor and sensory system were normal
 ??Posterior circulation stroke
 Advised MRI brain with MRI angiography
6

7. MRI Brain
7
JIPMER, Cardiology Department, 02/2017
JIPMER, Radiology Department, 02/2017
MRI brain (Plain)-No evidence of infact or any hemorrhage

8. MRI Brain
8
MRI brain (Plain)-No evidence of infact or any hemorrhage
JIPMER, Cardiology Department, 02/2017
JIPMER, Radiology Department, 02/2017

9. MRI Brain with diffusion weighted image
9
MRI brain (DW1)-Evidence of multiple embolic infact in the
midbrain suggestive of posterior circulation stroke
JIPMER, Cardiology Department, 02/2017
JIPMER, Radiology Department, 02/2017

10. MRI Brain with Diffusion gaited image
10
MRI brain (DW1)-Evidence of multiple embolic infact in the
midbrain suggestive of posterior circulation stroke
JIPMER, Cardiology Department, 02/2017
JIPMER, Radiology Department, 02/2017

11. MRI Cerebral angiography
11
MRI brain angiogrpahy-All four vessel were normal, no evidence of
any thrombus or embolus or plaque
JIPMER, Cardiology Department, 02/2017
JIPMER, Radiology Department, 02/2017

12. MRI Cerebral angiography
12
MRI brain angiogrpahy-All four vessel were normal, no evidence of
any thrombus or embolus or plaque
JIPMER, Cardiology Department, 02/2017
JIPMER, Radiology Department, 02/2017

13. Final diagnosis
ACS/USA/CAD/S/P PCI to LCX/Posterior
circulation stroke
Repeat neurology referral taken and they have
advised continuation of dual antiplatelet
therapy
13

14. Introduction
 Stroke third-leading cause of death and the leading cause of disability
 Risk factors are similar to those for coronary disease
 Patients undergoing cardiac interventions for coronary disease have a
periprocedural risk for stroke
 Stroke during and after diagnostic cardiac catheterization from 0.11% to 0.4%
 Stroke during or after PCI 0.18-0.44%
 Incidence of cerebral hemorrhage specifically after PCI is 0.2-0.3%
 Asymptomatic cerebral infarction after cardiac catheterization has incidence of
15%
14

15. JIPMER Hospital data
15
Total procedure Approximately
No of patient
with stroke
PCI in 2014 409 0.73-1.63/year
PCI in 2015 673 0.74-2.69/year
PCI in 2016 540 0.59-2.16/year
Coroanry
Angio/Year
3000 4- 12/year
Total
hemorrhageic
stroke(over3 yr)
1622(Total PCI
done)
3.2-4.86/year
The no of stroke/hemorrhage was calculated by multiplying the
incidence of stroke/hemorrhage with no of procedure done per year

16. Introduction
 Patients who experience a stroke have an increased length of hospital stay and
moderate to severe disability post-discharge
 In-hospital mortality from 25-44%
 Rapid recognition of a stroke and immediate intervention improve outcomes
 Identifying patients at risk, and understanding symptoms and treatment is vital
 Cath lab team must be aware of hospital protocol should a PCI patient suffer a
stroke during or after their procedure
16

17. Risk factor for stroke after PCI
 Advanced age
 Female gender
 History of stroke
 Renal failure
 Diabetes mellitus
 Arterial hypertension
 Peripheral vascular disease
 Dyslipidemia
 Tobacco use
 Atrial fibrillation
 Previous myocardial infarction
 Congestive heart failure
 Left-sided valvular disease
 Poor left ventricular systolic function
 Prior coronary artery bypass graft
 No or irregular use of needed antiplatelet
medications
 PCI done under emergent conditions and
the use of an intra-aortic balloon pump
17

18. Stroke symptoms
 Stroke symptoms vary with the location of infarct or hemorrhage
 General population, 80-90% of embolic stroke affects anterior cerebral circulation
 Cardiac catheterization population >50% emboli affect vertebrobasilar circulation.
 20% of the cerebral blood flow traverses the posterior circulation and even very
small emboli in the can cause significant neuro deficits
 Symptoms of vertebrobasilar circulation disruption include facial paresthesias,
dysphagia, dysarthria, hoarseness, hemisensory extremity symptoms, motor
weakness, diplopia, and sudden sensorineural hearing loss
18

19. Stroke symptoms
 Common neurological deficits noted in general during stroke in the cath
lab are motor weakness, aphasia, change in mental status and visual
disturbances, with the most common being motor or speech deficits
 Stroke symptoms can be camouflaged by or mimic the effects of sedation,
making difficult to identify stroke
 Seizures, hypoglycemia, and migraine can mimic stroke symptoms
19

20. Sources of infarcts
 Arise from various embolic sources
 The composition of the emboli also varies, from air to soft clot to calcified
atheroma, or multiple compositions such as atheroma with a fibrin clot around it
 Air emboli result from microbubbles injected with contrast or saline
 PCI use of a larger guide catheter, and more and stiffer-caliber catheters than
diagnostic catheterizations
 This raises the risk of trauma to the aorta and the dislodgement of aortic atheroma
during catheter manipulation
20

21. Sources of infarcts
 Thrombus formed within the catheter or catheter tip during the procedure can also become a
source of emboli.
 The transradial approach to catheterization is thought to lead to a higher number of solid
emboli due to mechanical forces near the apertures of the right vertebral and common carotid
arteries; plaques in those areas risk becoming dislodged and embolizing to the brain
 Transcranial Doppler (TCD) studies have shown multiple cerebral microemboli released
during cardiac catheterization
21

22. Sources of infarcts
 Recognition of the source and type of infarct will aid in determining which type of
immediate intervention will be most beneficial for the patient and in formulating
overall acute care treatment and secondary stroke prevention plans
 Brain has minimal oxygen reserves, cannot withstand ischemic situation
 Interventions are instituted as soon as possible after stroke symptoms evident
 In the case of the CCL, treatment should be initiated within 60 minutes of
symptom discovery
22

23. Response to stroke
 Once symptoms evident, the stroke team responders should be notified
 Assessment includes vital signs and basic neuro exam at least every 15 minutes,
and performing the National Institutes of Health Stroke Scale (NIHSS)
 The symptoms must be confirmed as the result of stroke, rather than other possible
neurological events, such as seizures or brain tumor
 Confirmation via CT or MRI
 CT most readily available
23

24. Response to stroke
 Procedure catheter can remain in place for the CT if there is a potential to use it for
an intra-arterial lytic intervention
 If the sheath in place, a cerebral angiogram can be performed
 An angiogram will better determine thrombus morphology, the location and degree
of the occlusion, and the status of collateral circulation, when compared to CT
 Sheath provide access for mechanical retrieval of the occluding material
 Selective intra-arterial treatment may be preferred if the patient has recently
received antiplatelets and anticoagulants which would increase the risk of bleeding.
24

25. Response to stroke
 If CT suggests infarct, t-PA inclusion/exclusion criteria list should be reviewed
 If meets criteria for intravenous t-PA, the drug should be started immediately
 t-PA dosage is weight-based at 0.9 mg/kg to a maximum of 90 mg
 It is given in two stages: 10% of the total dose is given through a dedicated IV line
over one minute, with the remaining 90% of the dose given over 60 minutes via IV
infusion pump
25

26. Treatment algorithm
26

27. Response to stroke
 Vital signs and neuro exams are performed every 15 minutes for two hours, every
half hour for six hours, then every hour for the next 16 hours.
 The patient should be admitted to an intensive care unit for close monitoring for
neurological changes and complications due to the t-PA
 Intra-arterial t-PA will be administered at a lesser dose
 If the patient is not a candidate for t-PA, mechanical extravasation of the embolus
or multimodal endovascular therapy may be considered
 Two critical complications that can occur with t-PA are intracranial or systemic
bleeding, and angioedema, both of which require immediate intervention
27

28. Response to stroke
 During or shortly after cardiac catheterization, retroperitoneal bleeding and groin
hematoma can also occur. If the sheath is in place during lysis, leaving it there for
several hours after t-PA infusion helps to minimize the risk of bleeding
 The risk of retroperitoneal blood loss from compressible access site is lower with
intra-arterial than with intravenous t-PA
 If the stroke is due to an intracranial hemorrhage, anticoagulation should be
reversed and a neurosurgeon consulted to determine if any surgical intervention is
indicated
 If cerebral embolism is due to air, 100% oxygen should be administered by face
mask and the patient considered for hyperbaric oxygen therapy
28

29. Treatment algorithm
29

30. Conclusion
 Stroke an uncommon but devastating complication of cardiac catheterization
 Pre-procedure identification of the high-risk patient
 Having patient well hydrated prior to the procedurre
 Using catheter techniques to minimize trauma
 Judicious use of ventriculography
 Initiating immediate patient assessment and intervention in case stroke event
30

31. Reference
31
 Thanks to department of Cardiology(JIPMER) for providing patient details and
Department of Radiology(JIPMER) for providing NCCT head/MRI brain images of
the patient
 Stroke and PCI: Best Practice in the Cardiac Cath Lab, Jan Yanko, Consultant ,Corazon,
Inc., Pittsburgh, Pennsylvania, Volume 20 - Issue 7 - July 2012,Cath Lab digest
 Hamon M, Baron JC, Viader F, Hamon M. Periprocedural stroke and cardiac
catheterization. Circulation. 2008 Aug 5;118(6):678-83
 Naik BI, Keeley EC, Gress DR, Zuo Z. Case scenario: A patient on dual antiplatelet
therapy with an intracranial hemorrhage after percutaneous coronary intervention. The
Journal of the American Society of Anesthesiologists. 2014 Sep 1;121(3):644-53.

32. 32