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Abstract and Introdution
Abstract
Objectives: The purpose of this study was to systematically compare clinical outcomes of patients treated with thrombolysis with those without treatment in a multi-year, multicenter cohort of strokes after cardiac catheterization.
Background: Ischemic strokes after cardiac catheterization procedures, although uncommon, lead to the morbidity and mortality of thousands of patients each year. Despite the availability of Food and Drug Administration-approved thrombolytic therapy for acute ischemic stroke since 1996, thrombolysis remains unestablished in the setting of cardiac catheterization, owing to unique concerns regarding safety and efficacy.
Methods: Consecutive cases of ischemic stroke after cardiac catheterization were abstracted retrospectively and reviewed by clinicians at 7 major North American academic centers with acute stroke teams. Safety and efficacy outcome measures were pre-defined.
Results: A total of 66 cases of ischemic strokes after cardiac catheterization were identified over 3 to 4 years; 12 (18%) were treated with thrombolysis, consisting of 7 intravenous and 5 intra-arterial recombinant tissue plasminogen activator cases. Improvement in stroke symptoms, as measured by the primary efficacy measure of median change in National Institutes of Health Stroke Scale score from baseline to 24 h, was greater in treated versus nontreated cases (p < 0.001). Additional secondary measures of efficacy also showed better outcomes in the treated group. There were no significant differences in bleeding events, defined as symptomatic intracerebral hemorrhage, hemopericardium, or other systemic bleeding resulting in hemodynamic instability or blood tranfusions. Mortality rates were also similar.
Conclusions: Thrombolysis might improve early outcomes after post-catheterization strokes and seems safe in this context. Emergent cerebral revascularization should be a routine consideration.
Introduction
More than 2 million cardiac catheterization procedures are performed in the U.S. annually. Although strokes after cardiac catheterization (SCCs) are relatively rare, this high volume of cardiac catheterizations in the U.S. leads to thousands of SCCs each year. Rates of SCCs, including both ischemic and hemorrhagic subtypes, range widely from 0.07% to 7.0%. Large contemporary registries of exclusively diagnostic and invasive coronary procedures report rates from 0.07% to 0.38%, and smaller studies of other invasive studies report higher rates.
The majority of SCCs are likely ischemic infarcts, for which there is Food and Drug Administration-approved therapy. Intravenous thrombolytic therapy with recombinant tissue plasminogen activator (rt-PA) within 3 h of ischemic stroke symptom onset has been shown to be efficacious and cost-effective in the general stroke population. Unfortunately, this proven therapy is provided to only a small fraction of all ischemic strokes, primarily owing to delayed presentation to emergency departments. In addition, intra-arterial thrombolytic drugs and devices might be effective at later time windows. The SCCs typically occur in hospitalized patients under close observation and therefore offer the potential for early and rapid detection and treatment. However, there is debate about the safety and efficacy of thrombolysis in the peri- and post-cardiac catheterization setting.
No study has yet attempted to systematically collect data on all SCCs and characterize their treatment in either a single or multicenter cohort. Therefore, we designed a retrospective cohort study of consecutive SCCs managed at major academic stroke centers with organized stroke teams, and we compared outcomes of patients treated with thrombolysis to those without treatment. We hypothesized that intravenous and intra-arterial thrombolytic therapy for strokes in the cardiac catheterization setting would be relatively safe, with complication rates comparable to SCCs not receiving thrombolytic therapy, and patients treated with thrombolytic therapy would have better outcomes than those not treated with thrombolysis.
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