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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 3  |  Issue : 3  |  Page : 125-128

On-table acute ischemic stroke during primary PCI-double intra-arterial thrombolysis in a young patient: Uncommon complication and “double-edged sword” management


Department of Cardiology, Yashoda Hospitals, Hyderabad, Telangana, India

Date of Submission29-Aug-2019
Date of Acceptance06-Nov-2019
Date of Web Publication29-Nov-2019

Correspondence Address:
Dr. Pankaj Jariwala
Department of Cardiology, Yashoda Hospitals, Somajiguda, Raj Bhavan Road, Hyderabad - 500 082, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/hm.hm_42_19

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  Abstract 

Stroke is an unusual but possibly devastating complication of cardiac catheterization. We report a case where a patient developed transient hemiplegia secondary to the embolization of a thrombus following thromboaspiration in the setting of acute myocardial infarction. The recent American College of Cardiology/European Society of Cardiology guidelines have classified the routine use of thromboaspiration as a Class III indication, but in some special circumstances with large thrombus burden, can be executed with a caution. Preprocedure identification of the high-risk patient should be performed along with measures to avoid ischemic stroke. If stroke happens, the instant evaluation and intervention of the patient could minimize cerebral damage. Every catheterization laboratory should develop a predefined protocol for the management of periprocedural stroke. We have discussed the management of periprocedural stroke with its review of literature.

Keywords: Acute cerebrovascular accident, acute myocardial infarction, cardioembolism, thrombolytic therapy


How to cite this article:
Jariwala P. On-table acute ischemic stroke during primary PCI-double intra-arterial thrombolysis in a young patient: Uncommon complication and “double-edged sword” management. Heart Mind 2019;3:125-8

How to cite this URL:
Jariwala P. On-table acute ischemic stroke during primary PCI-double intra-arterial thrombolysis in a young patient: Uncommon complication and “double-edged sword” management. Heart Mind [serial online] 2019 [cited 2022 Jul 3];3:125-8. Available from: http://www.heartmindjournal.org/text.asp?2019/3/3/125/272078


  Introduction Top


Periprocedural stroke is an iatrogenic complication with a reported incidence of 0.08%–0.40% in various case series. The development of cerebrovascular accident (CVA) after percutaneous coronary intervention (PCI) is usually associated with high rates of mortality and morbidity.[1],[2]


  Case Report Top


A 28-year-old male presented to the emergency room with complaints of chest pain for 2 h. Electrocardiogram showed anterior wall ST-segment elevation myocardial infarction (STEMI). The patient was shifted to the cardiac catheterization laboratory for primary percutaneous intervention (PCI). Coronary angiography (CAG) demonstrated a large occlusive thrombus in the proximal segment of the left anterior descending artery (LAD) [Figure 1]a with embolization into the distal segment of LAD (thrombolysis in myocardial infarction [TIMI] 0 flow). The patients' father did not give consent for the deployment of stent considering his younger age.
Figure 1: (A-D) Coronary angiography showing a large occlusive thrombus in the proximal left anterior descending artery with thrombolysis in myocardial infarction 0 flow (solid black arrow, Panel A). The repeated attempts of thromboaspiration (Panel B) embolized thrombus from the proximal segment (white arrow heads) into the distal segment of left anterior descending artery (solid white arrow, Panel C). Intracoronary thrombolysis using tenecteplase into the proximal and distal segments of the left anterior descending artery leads to thrombolysis in myocardial infarction III flow and dissolution of more than 90% thrombus (dashed white arrows, Panel D)

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Multiple runs of thromboaspiration were performed from the distal segment until the proximal segment of the LAD [Figure 1]b. However, despite thromboaspiration, flow into the LAD could not be established [Figure 1]c. The option of intracoronary thrombolysis using tenecteplase was discussed with the patient's father. After obtaining written informed consent, 5 mg of tenecteplase was injected through a thromboaspiration catheter into the embolized distal LAD thrombus and then 5 mg into the proximal LAD thrombus.

The patient had a bout of cough followed by sudden onset of loss of power to the left upper limb power (Grade 0) on the table in the catheterization laboratory.

Transfemoral selective cerebral angiography of the right carotid artery revealed an embolization of a thrombus to the proximal segment of the middle cerebral artery (MCA) [Figure 2]a. Intra-arterial (IA) thrombolysis was advocated using tenecteplase 2.5 mg selectively into the MCA using “Cantata” Catheter (COOK, Medical LLC, Bloomington, IN, USA) that restored the flow into the MCA [Figure 2]b. The patient recovered Grade V power with complete relief of his chest pain.
Figure 2: (A and B) Cerebral angiography demonstrated embolization of thrombus into the middle cerebral artery territory (solid white arrow, Panel A). Intra-arterial cerebral thrombolysis using tenecteplase selectively into the middle cerebral artery using “Cantata” Catheter established the flow to middle cerebral artery territory (white circle and curved black arrow, Panel B)

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Final CAG showed 90% dissolution of the thrombus with TIMI 3 flow of the LAD [Figure 1]d. The postprocedure patient underwent a computed tomography (CT) scan brain, which did not show any infarct or bleed. The next-day magnetic resonance imaging (MRI) brain also did not show any intracranial bleed or cerebral infarction.

The patient was discharged uneventfully with optimal medical management. At 1-year follow-up, stress exercise test was negative for inducible ischemia.

The etiology of his myocardial infarction at a young age was secondary to hyperhomocysteinemia with deranged lifestyle as our patient was an employee of business process outsourcing on night shifts.


  Discussion Top


The prevalence of combined cerebrovascular complications is 0.27%–0.50% (1 in 300). The incidence of the periprocedural stroke after PCI is 0.18%–0.44%.[1],[2],[3],[4] A CVA was described as the beginning of a fresh neurological deficit during index hospitalization that happened at any time after PCI. If the deficit duration was <24 h, it was defined as a transient ischemic attack. It was described as a stroke if the deficit persisted for a longer period.[3]

Higher periprocedural risk of stroke is correlated with advanced age, female gender, history of previous stroke, renal failure, diabetes mellitus, hypertension, tobacco use, atrial fibrillation, previous myocardial infarction, left-sided valvular illness, poor left ventricular systolic function, congestive heart failure, prior coronary artery bypass graft, no or irregular use of the antiplatelet medications, PCI done under emergent conditions, and the use of an intra-aortic balloon pump.[5]

Neurological deficits in the form of motor weakness, aphasia, mental status changes, and visual disturbances are clinical presentation of the periprocedural stroke.[6] Some circumstances can resemble a stroke, such as seizures, hypoglycemia, and migraine. One should be able to differentiate them from a true periprocedural stroke.[7]

As compared to diagnostic catheterization, the PCI utilizes a bigger and stiffer guide catheter, which raises the likelihood of cerebral circulation embolism. Furthermore, there is a risk of trauma to the aorta and the dislodgement of aortic atheroma during catheter manipulation.[8] The thrombus can form within the catheter or catheter tip during the procedure. The source of the infarction must be identified. The structure of the emboli ranges from the air, soft clot, and calcified atheroma.[9]

Patients who experience a stroke during or after diagnostic cardiac catheterization or PCI increase the duration of hospital stay by about 4 days. They experience postdischarge moderate to serious disability. The inhospital mortality rate varies from 25% to 44%.[10]

Every catheterization laboratory should set up a rapid response system for stroke alert process. The assessment of the patient is done using vital signs, basic neuroexamination at least every 15 min, and the National Institutes of Health Stroke Scale.

The recommendation is to perform a quick cerebral angiography when the sheath is still in place. This can better define the thrombus morphology and the degree of occlusion. The patient should be subjected for the CT or MRI with sheath in situ to differentiate infarct from the hemorrhage.[10] Rapid administration of IA thrombolysis should be performed. If it can be rapidly diagnosed and acted upon, a short event-to-treatment time can be achieved.

The neurologist should weigh the benefit/risk ratio of multiple available approaches and create a therapy plan. If needed, neuro-interventionalist assistance should be requested to conduct cerebral angiography and intravascular procedures.[11]

If the CT shows an infarction, the list of tissue plasminogen activator (t-PA) inclusion/exclusion criteria should be assessed. Also, one should decide on the mode of administration (intravenous vs. IA).[12] The rates of recanalization in the proximal MCA are higher with IA thrombolysis (70%) than intravenous thrombolysis (30%).[10]

The t-PA dose is weight-based with a maximum dose of 90 mg at 0.9 mg/kg/h – 10% of the total dose over 1 min, with 90% of the remaining dose over 60 min.[13],[14] Georgiadis et al. evaluated the safety of the IA thrombolysis using tenecteplase in acute ischemic stroke.[15] They compared IA thrombolysis using tenecteplase, alteplase, or reteplase and mechanical thrombectomy in 114 patients who were eligible patients with acute ischemic stroke. The dose of tenecteplase ranged from 1.5 to 10 mg depending on the angiographic result. IA t-PA is provided at a reduced dose not specified in any trial, but generally recommended to administer up to one-third of the calculated IA dose.[16]

Mechanical microembolism disruption, an adjunctive method along with IA thrombolysis, disruption of thrombus using laser energy, ultrasound devices or neurojet (an angiojet device used to remove the clot in the coronary circulation), and angioplasty with or without stenting, has tried, but no definitive guidelines are owing to the absence of big randomized controlled trials.[17]

In primary PCI for STEMI, Ge et al. reviewed the role of routine manual thromboaspiration. Thrombus aspiration in ST-elevation myocardial infarction in Scandinavia and routine aspiration thrombectomy trial with PCI versus PCI alone in patients with STEMI studies did not favor thromboaspiration for routine use. The authors recommended that thromboaspiration should be used when there is a large thrombus burden in special circumstances.[18] However, a word of caution should always be remembered that proper use of catheter, flushing techniques to be adopted, and interventional cardiologist should have experience to tackle the periprocedural stroke as a complication.

Tokushige et al. evaluated cerebrovascular disease (CVD) using MRI 48 h after CAG. Silent cerebral infarctions occurred in 9.8% of cases those who underwent CAG with prior history of coronary artery bypass grafting as they have associated advanced atherosclerosis.[19] Patients with advanced atherosclerosis such as advanced age >75 years, on hemodialysis, and prolonged procedure using complex devices are more prone to develop risk of CVD following cardiac procedures.

Most of the periprocedural strokes happen secondary to the embolization of atherosclerotic debris or clot formed over the catheters in the background of advanced atherosclerotic disease. Hence, we need to prepare patient with proper medical therapies such as high-dose statin therapy and antiplatelet therapy to reduce the exaggerated platelet aggregation.[20]

The detection of microembolization of thrombotic and plaque materials during cardiac procedures using transcranial Doppler (TCD) can be done. However, the long-term clinical implications of it are not known. Stygall et al. detected microembolization using TCD during in 17 cases of cardiac intervention in MCA occlusion. However, it is not recommended for routine use in clinical practice, as its relevance is not known.[21],[22]

As structural heart disease interventions such as transcatheter aortic valve replacements are emerging, the incidence of periprocedural strokes will also be on rise. The role of distal protection devices is not proven. The prevention of periprocedural stroke is a big challenge.

We need large randomized, prospective trials to identify risk factors, the definitive management in the form of medical and interventional procedures of the periprocedural strokes.


  Conclusion Top


Periprocedural stroke is an iatrogenic complication. High-risk cases involving cardiac intervention should have a standard neurological periprocedural examination to identify early-stage neurological deficits. If it can be treated and acted quickly, it will be possible to achieve a short time of event-to-treatment. In all hospitals providing cardiac catheterization facilities, a stroke protocol must be available and cardiologists must be familiar with the methods of diagnosis and management. It is also important to enable neurologists and stroke teams to get involved quickly and support collective decisions.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Werner N, Zeymer U. Stroke outcomes in patients undergoing percutaneous coronary intervention in clinical practice today. Interv Cardiol 2011;3:407-13.  Back to cited text no. 1
    
2.
Cale L, Constantino R. Strategies for decreasing vascular complications in diagnostic cardiac catheterization patients. Dimens Crit Care Nurs 2012;31:13-7.  Back to cited text no. 2
    
3.
Dukkipati S, O'Neill WW, Harjai KJ, Sanders WP, Deo D, Boura JA, et al. Characteristics of cerebrovascular accidents after percutaneous coronary interventions. J Am Coll Cardiol 2004;43:1161-7.  Back to cited text no. 3
    
4.
Khatri P, Taylor RA, Palumbo V, Rajajee V, Katz JM, Chalela JA, et al. The safety and efficacy of thrombolysis for strokes after cardiac catheterization. J Am Coll Cardiol 2008;51:906-11.  Back to cited text no. 4
    
5.
Lin CF, Chu KC, Wang YM. Acute ischemic stroke after percutaneous cardiac intervention in an elderly patient. Int J Gerontol 2010;4:43-6.  Back to cited text no. 5
    
6.
Hamon M, Baron JC, Viader F, Hamon M. Periprocedural stroke and cardiac catheterization. Circulation 2008;118:678-83.  Back to cited text no. 6
    
7.
Demaerschalk BM, Yip TR. Economic benefit of increasing utilization of intravenous tissue plasminogen activator for acute ischemic stroke in the United States. Stroke 2005;36:2500-3.  Back to cited text no. 7
    
8.
Keeley EC, Grines CL. Scraping of aortic debris by coronary guiding catheters: A prospective evaluation of 1,000 cases. J Am Coll Cardiol 1998;32:1861-5.  Back to cited text no. 8
    
9.
He LJ, Zhang JW, Yang Q, Cao SJ, Yang SW, Nie B, et al. The incidence and risk factors of acute asymptomatic brain infarcts after percutaneous coronary intervention in patients with acute myocardial infarction. Int J Gerontol 2014;8:70-3.  Back to cited text no. 9
    
10.
Sankaranarayanan R, Msairi A, Davis GK. Stroke complicating cardiac catheterization – A preventable and treatable complication. J Invasive Cardiol 2007;19:40-5.  Back to cited text no. 10
    
11.
McPherson TP, Dighe K, Charania J, Sridhar K. Cardiac Catheterization and Periprocedural Stroke. CCC; 2012. Available from: http://www.pulsus.com/ccc2010/abs/546.htm. [Last accessed on 2019 Aug].  Back to cited text no. 11
    
12.
DeMarco F, Antonio Fernandez-Diaz J, Lefevre T, Balcells J, Araya M, Routledge H, et al. Management of CVA during cardiac catheterization: cerebral angiography versus early neuroimaging techniques and strategies. Catheter Cardiovasc Interv 2007;70:5.  Back to cited text no. 12
    
13.
Adams HP, Adams RJ, Brott T, del Zoppo GJ, Furlan A, Goldstein LB, et al. Guidelines for the early management of patients with ischemic stroke: A scientific statement from the Stroke Council of the American Stroke Association. Stroke [Internet]. 2003;34:1056-83.  Back to cited text no. 13
    
14.
15.
Georgiadis AL, Memon MZ, Shah QA, Vazquez G, Tariq NA, Suri MF, et al. Intra-arterial tenecteplase for treatment of acute ischemic stroke: Feasibility and comparative outcomes. J Neuroimaging 2012;22:249-54.  Back to cited text no. 15
    
16.
Aleu A, Hussain MV, Lin R, Gupta R, Jankowitz BT, Vora NA, et al. Endovascular therapy for cardiac catheterization associated strokes. J Neuroimaging 2011;21:247-50.  Back to cited text no. 16
    
17.
Lateef F. Case of stroke during cardiac catheterization: It's not common, but it is a double whammy! J Acute Dis 2016;5:255-7.  Back to cited text no. 17
    
18.
Ge J, Schäfer A, Ertl G, Nordbeck P. Thrombus aspiration for ST-segment-elevation myocardial infarction in modern era: Still an issue of debate? Circ Cardiovasc Interv 2017;10. pii: e005739.  Back to cited text no. 18
    
19.
Tokushige A, Miyata M, Sonoda T, Kosedo I, Kanda D, Takumi T, et al. Prospective study on the incidence of cerebrovascular disease after coronary angiography. J Atheroscler Thromb 2018;25:224-32.  Back to cited text no. 19
    
20.
Tanaka A, Node K. Prediction of stroke after cardiac catheterization: No reason, no stroke. J Atheroscler Thromb 2018;25:221-3.  Back to cited text no. 20
    
21.
Stygall J, Kong R, Walker JM, Hardman SM, Harrison MJ, Newman SP, et al. Cerebral microembolism detected by transcranial Doppler during cardiac procedures. Stroke 2000;31:2508-10.  Back to cited text no. 21
    
22.
AETNA. Clinical Policy Bulletin: Trans-Cranial Doppler Ultrasonography; 2015. p. 1-17.  Back to cited text no. 22
    


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