Code Stroke in the Cath Lab

Thoughtful clinicians no longer doubt the efficacy of thrombolytic therapy for acute stroke, but its use outside of the Food and Drug Administration–approved indications remains controversial. One of the most difficult decisions for the stroke team arises upon a call to the cardiac cath lab or recovery area. First off, the onset time is usually vague, given that the patient was sedated and draped during the cardiac procedure. Second, large doses of anticoagulants and anti-platelet agents might have been needed during the procedure, which might increase the risk of hemorrhage after cerebral thrombolysis. Third, although the mechanism of stroke after cardiac catheterization is usually embolic, these patients typically have risk factors for other cerebrovascular etiologies, such as lacunes (deep white matter infarcts) and cerebral hemorrhages. The perfect storm of increased-but-uncertain risks, an unclear time course, and a (incorrectly) perceived need for extensive diagnostic testing can induce clinical paralysis in the responding neurology team. Against this background, the Khatri et al. (1) study in this issue of the Journal seems in stark contrast and leads to some useful insights that could help cardiologists and vascular neurologists prepare for these cases.

Calling upon leading stroke teams to contribute, the University of Cincinnati team (1) collected strokes after cardiac catheterizations. The statistical analysis and the interpretation of the results reflect a very high level of rigor. The authors (1) found that post-cardiac catheterization stroke patients seemed to benefit if they received thrombolysis, either intravenously or via an intra-arterial approach. Extensive neurovascular imaging, other than a computed tomography (CT) scan to evaluate for possible intracerebral hemorrhage, was avoided. The paucity of complications reassures us and lends credence to the idea that such strokes could and should be treated. Also, the benefits—measured as significant neurological improvement after 24 h—were seen in all grades of stroke severity, including moderate and severe. Thus, the idea of waiting and observing a stroke related to cardiac catheterization is just as inadvisable as it is in other situations. The lack of symptomatic intracerebral hemorrhages after thrombolysis reflects the small sample size but is reassuring.

The conclusions of Khatri et al. (1) must be tempered by some obvious limitations. First, the authors (1) collected patients retrospectively; systematic and prospective surveillance of the involved cath labs was not possible. To overcome this, they attempted to review all catheterization records with the International Classification of Diseases of the World Health Organization-9th Edition (ICD-9) codes that might be expected to identify strokes. Furthermore, they reviewed their stroke registries for any ICD-9 codes that might indicate a catheterization procedure. After this level of effort, it is unlikely they missed too many strokes. Second, a reporting bias favoring better outcomes cannot be excluded. Finally, the sample size is small, and a larger trial—while needed—is unlikely ever to be mounted.

These data reassure us that it makes sense to set up a Code Stroke protocol in every cath lab: time is brain, so the inevitable complication should be planned for. One hopes that more aggressive prevention strategies, including frequent neuro-checks while the patient is draped, will reduce the stroke incidence to 0, but the fact remains that catheterization-related strokes are inevitable. On the other end of the call, the stroke team should rehearse the steps needed for Code Stroke in the cath lab, including an expedited cerebral CT or magnetic resonance imaging scan to evaluate for possible intracerebral hemorrhage. Data do not justify recommending intra-arterial over intravenous therapy, but the judgment call should be left to the consulting stroke team; it makes sense to go with whatever procedure is most typical in the facility, intravenous or intra-arterial thrombolysis. The most important lesson from this article is that stroke remains the most treatable of neurological conditions, whether it occurs in the cath lab or not, and an expeditious use of the Code Stroke system is the fastest, safest, and best way to manage a patient with stroke during cardiac catheterization.

• American College of Cardiology Foundation