stroke a rare complication in post pci patient

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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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History

CAG-SVD of LCX (80-90% stenosis)

Transradial PCI to LCX with DES (Successful)

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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


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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


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MRI Cerebral angiography

MRI brain angiogrpahy-All four vessel were normal, no evidence of any thrombus or embolus or plaque


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MRI Cerebral angiography

MRI brain angiogrpahy-All four vessel were normal, no evidence of any thrombus or embolus or plaque


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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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Treatment algorithm

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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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Treatment algorithm

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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.

stroke a rare complication in post pci patient

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