CATH MEET IISS Stroke, a rare complication in post PCI patient Presenter Praveen Gupta 4/02/2017 Pondicherry India 1
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CATH MEETIISS
Stroke, a rare complication in post PCI patient
Presenter Praveen Gupta
4/02/2017Pondicherry
India
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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
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Course after procedure
Immediately post PCI patient was complaiting of
Headache
Giddiness
Diplopia
Vomiting
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NCCT head
NCCT Head of the patient-No evidence of infact or any hemorrhage
JIPMER, Cardiology Department, 30/01/2017JIPMER, Radiology Department, 30/01/2017
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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
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MRI Brain
JIPMER, Cardiology Department, 02/2017JIPMER, Radiology Department, 02/2017
MRI brain (Plain)-No evidence of infact or any hemorrhage
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MRI Brain
MRI brain (Plain)-No evidence of infact or any hemorrhageJIPMER, Cardiology Department, 02/2017JIPMER, Radiology Department, 02/2017
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MRI Brain with diffusion weighted image
MRI brain (DW1)-Evidence of multiple embolic infact in the midbrain suggestive of posterior circulation stroke
JIPMER, Cardiology Department, 02/2017JIPMER, Radiology Department, 02/2017
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MRI Brain with Diffusion gaited image
MRI brain (DW1)-Evidence of multiple embolic infact in the midbrain suggestive of posterior circulation stroke
JIPMER, Cardiology Department, 02/2017JIPMER, Radiology Department, 02/2017
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MRI Cerebral angiography
MRI brain angiogrpahy-All four vessel were normal, no evidence of any thrombus or embolus or plaque
JIPMER, Cardiology Department, 02/2017JIPMER, Radiology Department, 02/2017
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MRI Cerebral angiography
MRI brain angiogrpahy-All four vessel were normal, no evidence of any thrombus or embolus or plaque
JIPMER, Cardiology Department, 02/2017JIPMER, Radiology Department, 02/2017
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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
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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%
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JIPMER Hospital dataTotal procedure
Approximately No of patient with stroke
PCI in 2014 409 0.73-1.63/yearPCI in 2015 673 0.74-2.69/yearPCI in 2016 540 0.59-2.16/yearCoroanry 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
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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
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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
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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
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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
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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
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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
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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
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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
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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.
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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
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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
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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
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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
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Reference 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.