Stroke after cardiac catheterization
- Robert A Taylor, MD
Robert A Taylor, MD
- Stroke and Neurovascular Center of Central California
- Santa Barbara Cottage Hospital
- Pooja Khatri, MD, MSc
Pooja Khatri, MD, MSc
- Professor, Dept of Neurology and Rehabilitation Medicine
- University of Cincinnati
- Section Editors
- Scott E Kasner, MD
Scott E Kasner, MD
- Section Editor — Stroke
- Professor of Neurology
- University of Pennsylvania School of Medicine
- Donald Cutlip, MD
Donald Cutlip, MD
- Section Editor — Interventional Cardiology
- Professor of Medicine
- Harvard Medical School
- Beth Israel Deaconess Medical Center
Stroke resulting from cardiac catheterization is relatively common due to the high volume of cardiac procedures performed worldwide. This topic will review periprocedural stroke in the setting of cardiac catheterization, which includes diagnostic and interventional procedures. Other aspects of acute stroke are discussed elsewhere. (See "Initial assessment and management of acute stroke" and "Intravenous fibrinolytic (thrombolytic) therapy in acute ischemic stroke: Therapeutic use".)
Patients may experience either ischemic or hemorrhagic stroke in the setting of cardiac catheterization.
Ischemic stroke — In most cases, the mechanism of ischemic stroke is directly related to cardiac catheterization itself, which initially involves advancing catheters over wires into the aorta, generally using either transfemoral or transradial access. Catheter or wire manipulation may dislodge debris made up of thrombus, calcific material, or cholesterol particles from atherosclerotic plaques within the aortic arch and the proximal carotid and vertebral arteries [1-4]. In addition, fresh thrombus material may form at the catheter and guidewire tips. Most cases of ischemic stroke related to cardiac catheterization are caused by such thromboemboli. (See "Embolism from atherosclerotic plaque: Atheroembolism (cholesterol crystal embolism)".)
The mechanism of ischemic stroke is similar between diagnostic and interventional procedures. However, interventional catheters are on average larger than diagnostic catheters and the procedures are often longer and thus there may be a theoretical increase in risk.
Ultimately, one or more catheters end up in one of the cardiac chambers or in the coronaries arteries. Catheterization across a degenerated aortic valve may lead to thromboembolism and the risk of stroke may be particularly high in patients with significant valvular aortic stenosis (AS) who undergo retrograde catheterization of the aortic valve [5,6]. This was demonstrated in a study of 152 patients with AS (mean age 71 years) who were randomly assigned to cardiac catheterization with or without catheter passage through the valve . The following findings were noted:
- Keeley EC, Grines CL. Scraping of aortic debris by coronary guiding catheters: a prospective evaluation of 1,000 cases. J Am Coll Cardiol 1998; 32:1861.
- Qureshi AI, Luft AR, Sharma M, et al. Prevention and treatment of thromboembolic and ischemic complications associated with endovascular procedures: Part I--Pathophysiological and pharmacological features. Neurosurgery 2000; 46:1344.
- Werner N, Zahn R, Zeymer U. Stroke in patients undergoing coronary angiography and percutaneous coronary intervention: incidence, predictors, outcome and therapeutic options. Expert Rev Cardiovasc Ther 2012; 10:1297.
- Eggebrecht H, Oldenburg O, Dirsch O, et al. Potential embolization by atherosclerotic debris dislodged from aortic wall during cardiac catheterization:: histological and clinical findings in 7,621 patients. Catheter Cardiovasc Interv 2000; 49:389.
- Omran H, Schmidt H, Hackenbroch M, et al. Silent and apparent cerebral embolism after retrograde catheterisation of the aortic valve in valvular stenosis: a prospective, randomised study. Lancet 2003; 361:1241.
- Chambers J, Bach D, Dumesnil J, et al. Crossing the aortic valve in severe aortic stenosis: no longer acceptable? J Heart Valve Dis 2004; 13:344.
- Wijman CA, Kase CS, Jacobs AK, Whitehead RE. Cerebral air embolism as a cause of stroke during cardiac catheterization. Neurology 1998; 51:318.
- Jassal DS, Fast MD, McGinn G. Multifocal brain MRI hypointensities secondary to cardiac catheterization. Neurology 2000; 54:2023.
- Brown DL, Topol EJ. Stroke complicating percutaneous coronary revascularization. Am J Cardiol 1993; 72:1207.
- Segal AZ, Abernethy WB, Palacios IF, et al. Stroke as a complication of cardiac catheterization: risk factors and clinical features. Neurology 2001; 56:975.
- Ammann P, Brunner-La Rocca HP, Angehrn W, et al. Procedural complications following diagnostic coronary angiography are related to the operator's experience and the catheter size. Catheter Cardiovasc Interv 2003; 59:13.
- Korn-Lubetzki I, Farkash R, Pachino RM, et al. Incidence and risk factors of cerebrovascular events following cardiac catheterization. J Am Heart Assoc 2013; 2:e000413.
- Dukkipati S, O'Neill WW, Harjai KJ, et al. Characteristics of cerebrovascular accidents after percutaneous coronary interventions. J Am Coll Cardiol 2004; 43:1161.
- Fuchs S, Stabile E, Kinnaird TD, et al. Stroke complicating percutaneous coronary interventions: incidence, predictors, and prognostic implications. Circulation 2002; 106:86.
- Palmerini T, Biondi-Zoccai G, Reggiani LB, et al. Risk of stroke with coronary artery bypass graft surgery compared with percutaneous coronary intervention. J Am Coll Cardiol 2012; 60:798.
- Werner N, Bauer T, Hochadel M, et al. Incidence and clinical impact of stroke complicating percutaneous coronary intervention: results of the Euro heart survey percutaneous coronary interventions registry. Circ Cardiovasc Interv 2013; 6:362.
- Kwok CS, Kontopantelis E, Myint PK, et al. Stroke following percutaneous coronary intervention: type-specific incidence, outcomes and determinants seen by the British Cardiovascular Intervention Society 2007-12. Eur Heart J 2015; 36:1618.
- Myint PK, Kwok CS, Roffe C, et al. Determinants and Outcomes of Stroke Following Percutaneous Coronary Intervention by Indication. Stroke 2016; 47:1500.
- Dukkipati S, O'Neill WW, Harjai KJ, et al. Characteristics of cerebrovascular accidents after percutaneous coronary interventions. Am J Cardiol 2004; 43:1161.
- Oh MS, Kwon JE, Kim KJ, et al. Subarachnoid hemorrhage mimicking leakage of contrast media after coronary angiography. Korean Circ J 2012; 42:197.
- Akkerhuis KM, Deckers JW, Lincoff AM, et al. Risk of stroke associated with abciximab among patients undergoing percutaneous coronary intervention. JAMA 2001; 286:78.
- Büsing KA, Schulte-Sasse C, Flüchter S, et al. Cerebral infarction: incidence and risk factors after diagnostic and interventional cardiac catheterization--prospective evaluation at diffusion-weighted MR imaging. Radiology 2005; 235:177.
- Lund C, Nes RB, Ugelstad TP, et al. Cerebral emboli during left heart catheterization may cause acute brain injury. Eur Heart J 2005; 26:1269.
- Hamon M, Lipiecki J, Carrié D, et al. Silent cerebral infarcts after cardiac catheterization: a randomized comparison of radial and femoral approaches. Am Heart J 2012; 164:449.
- Hamon M, Gomes S, Oppenheim C, et al. Cerebral microembolism during cardiac catheterization and risk of acute brain injury: a prospective diffusion-weighted magnetic resonance imaging study. Stroke 2006; 37:2035.
- Hamon M, Gomes S, Clergeau MR, et al. Risk of acute brain injury related to cerebral microembolism during cardiac catheterization performed by right upper limb arterial access. Stroke 2007; 38:2176.
- Bladin CF, Bingham L, Grigg L, et al. Transcranial Doppler detection of microemboli during percutaneous transluminal coronary angioplasty. Stroke 1998; 29:2367.
- Leclercq F, Kassnasrallah S, Cesari JB, et al. Transcranial Doppler detection of cerebral microemboli during left heart catheterization. Cerebrovasc Dis 2001; 12:59.
- Dittrich R, Ringelstein EB. Occurrence and clinical impact of microembolic signals during or after cardiosurgical procedures. Stroke 2008; 39:503.
- Hamon M, Baron JC, Viader F, Hamon M. Periprocedural stroke and cardiac catheterization. Circulation 2008; 118:678.
- Lazar JM, Uretsky BF, Denys BG, et al. Predisposing risk factors and natural history of acute neurologic complications of left-sided cardiac catheterization. Am J Cardiol 1995; 75:1056.
- Batchelor WB, Anstrom KJ, Muhlbaier LH, et al. Contemporary outcome trends in the elderly undergoing percutaneous coronary interventions: results in 7,472 octogenarians. National Cardiovascular Network Collaboration. J Am Coll Cardiol 2000; 36:723.
- Meine TJ, Harrison JK. Should we cross the valve: the risk of retrograde catheterization of the left ventricle in patients with aortic stenosis. Am Heart J 2004; 148:41.
- Brass LM, Lichtman JH, Wang Y, et al. Intracranial hemorrhage associated with thrombolytic therapy for elderly patients with acute myocardial infarction: results from the Cooperative Cardiovascular Project. Stroke 2000; 31:1802.
- Daly MJ, Boyle AJ, Morrison L, Hunter EK. Visual disturbance following cardiac catheterization. J Am Coll Cardiol 2013; 61:e5.
- Kymionis GD, Tsilimbaris MK, Christodoulakis EB, Pallikaris IG. Late onset branch retinal artery occlusion following coronary angiography. Acta Ophthalmol Scand 2005; 83:122.
- Serry R, Tsimikas S, Imbesi SG, Mahmud E. Treatment of ischemic stroke complicating cardiac catheterization with systemic thrombolytic therapy. Catheter Cardiovasc Interv 2005; 66:364.
- Dawson DM, Fischer EG. Neurologic complications of cardiac catheterization. Neurology 1977; 27:496.
- De Marco F, Antonio Fernandez-Diaz J, Lefèvre T, et al. Management of cerebrovascular accidents during cardiac catheterization: immediate cerebral angiography versus early neuroimaging strategy. Catheter Cardiovasc Interv 2007; 70:560.
- Horwitz NH, Wener L. Temporary cortical blindness following angiography. J Neurosurg 1974; 40:583.
- Zwicker JC, Sila CA. MRI findings in a case of transient cortical blindness after cardiac catheterization. Catheter Cardiovasc Interv 2002; 57:47.
- Vranckx P, Ysewijn T, Wilms G, et al. Acute posterior cerebral circulation syndrome accompanied by serious cardiac rhythm disturbances: a rare but reversible complication following bypass graft angiography. Catheter Cardiovasc Interv 1999; 48:397.
- Saigal G, Bhatia R, Bhatia S, Wakhloo AK. MR findings of cortical blindness following cerebral angiography: is this entity related to posterior reversible leukoencephalopathy? AJNR Am J Neuroradiol 2004; 25:252.
- Borghi C, Saia F, Marzocchi A, Branzi A. The conundrum of transient cortical blindness following coronary angiography. J Cardiovasc Med (Hagerstown) 2008; 9:1063.
- Velden J, Milz P, Winkler F, et al. Nonionic contrast neurotoxicity after coronary angiography mimicking subarachnoid hemorrhage. Eur Neurol 2003; 49:249.
- Korn-Lubetzki I, Rosenmann D, Steiner-Birmanns B. Reaction to intravenous contrast media mimicking intracerebral hemorrhage after percutaneous coronary intervention. Med Sci Monit 2008; 14:CS142.
- Papaconstantinou D, Georgalas I, Diagourtas A, et al. Cortical blindness due to bilateral embolism: a rare complication of cardiac catheterisation. Clin Exp Optom 2010; 93:366.
- Khatri P, Taylor RA, Palumbo V, et al. The safety and efficacy of thrombolysis for strokes after cardiac catheterization. J Am Coll Cardiol 2008; 51:906.
- Kissela BM, Kothari RU, Tomsick TA, et al. Embolization of calcific thrombi after tissue plasminogen activator treatment. J Stroke Cerebrovasc Dis 2001; 10:135.
- Khatri P, Kasner SE. Ischemic strokes after cardiac catheterization: opportune thrombolysis candidates? Arch Neurol 2006; 63:817.
- Chan AW, Henderson MA. Immediate catheter-directed reperfusion for acute stroke occurring during diagnostic cardiac catheterization. Catheter Cardiovasc Interv 2006; 67:314.
- Horowitz M, Jovin T, Levy E, Anderson W. Emergent basilar artery and bilateral posterior cerebral artery angioplasty, urokinase thrombolysis, and stenting for acute basilar artery occlusion secondary to diagnostic cardiac catheterization: case presentation. J Neuroimaging 2005; 15:315.
- Presbitero P, Gasparini GL, Pagnotta P. Images in cardiovascular medicine. Intra-arterial thrombolysis for left middle cerebral artery embolic stroke during coronary angiography. Circulation 2006; 113:e64.
- Zaidat OO, Slivka AP, Mohammad Y, et al. Intra-arterial thrombolytic therapy in peri-coronary angiography ischemic stroke. Stroke 2005; 36:1089.
- Arnold M, Fischer U, Schroth G, et al. Intra-arterial thrombolysis of acute iatrogenic intracranial arterial occlusion attributable to neuroendovascular procedures or coronary angiography. Stroke 2008; 39:1491.
- Harb SC, Thomas G, Saliba WI, et al. Characteristics, treatment, and outcomes of periprocedural cerebrovascular accidents during electrophysiologic procedures. J Interv Card Electrophysiol 2013; 37:41.
- Furlan A, Higashida R, Wechsler L, et al. Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial. Prolyse in Acute Cerebral Thromboembolism. JAMA 1999; 282:2003.
- Nogueira RG, Smith WS, MERCI and Multi MERCI Writing Committee. Safety and efficacy of endovascular thrombectomy in patients with abnormal hemostasis: pooled analysis of the MERCI and multi MERCI trials. Stroke 2009; 40:516.
- Deshmukh VR, Fiorella DJ, Albuquerque FC, et al. Intra-arterial thrombolysis for acute ischemic stroke: preliminary experience with platelet glycoprotein IIb/IIIa inhibitors as adjunctive therapy. Neurosurgery 2005; 56:46.
- Straub S, Junghans U, Jovanovic V, et al. Systemic thrombolysis with recombinant tissue plasminogen activator and tirofiban in acute middle cerebral artery occlusion. Stroke 2004; 35:705.
- Pancioli AM, Adeoye O, Schmit PA, et al. Combined approach to lysis utilizing eptifibatide and recombinant tissue plasminogen activator in acute ischemic stroke-enhanced regimen stroke trial. Stroke 2013; 44:2381.