We thank Drs. De Marco, Routledge, and Lefèvre for their interest in our work (1). They raise the important question of whether to take the time to do an imaging study before administering cerebral reperfusion therapy in the setting of stroke after cardiac catheterization. They have proposed immediate acute stroke treatment, transitioning directly from cardiovascular to cerebral angiography for intra-arterial therapy, for strokes after cardiac catheterization on the table. However, the limited reports on this topic are likely subject to a publication bias toward favorable clinical outcomes.

Even if an embolism is identified on an immediate cerebral angiogram, the possibility of an acute hemorrhagic infarction remains a concern, particularly in the setting of antithrombotics and anticoagulants. Studies discriminating stroke subtypes have reported hemorrhagic strokes in 24% (2) and 46.5% (3) of cases.

While we agree that, in most circumstances, the added delay of magnetic resonance imaging (MRI) is not warranted, a computed tomography (CT) scan can and should be accomplished in no longer than 15 min. Typically, this time could be used for concurrent stroke team evaluation and participation.

Among our 12 recombinant tissue plasminogen activator cases, 1 was treated without acute imaging, 1 received MRI, and 10 received CT scans. Among the 54 cases not treated acutely, 6 received MRI and 48 received CT scans.

The 3 asymptomatic intracranial hemorrhages reported in our study occurred with intra-arterial thrombolysis initiation at 54, 265, and 305 min. While longer times to treatment initiation may be associated with higher rates of symptomatic hemorrhage, the relationship of time and asymptomatic hemorrhage has not been established (4). In fact, mild radiological subtypes of intracranial hemorrhage may actually mark early reperfusion and good clinical outcome, compared with cases without hemorrhage (5). Nevertheless, we agree that time to treatment is a critical determinant of good clinical outcome after stroke.

In summary, we favor an immediate CT scan of the head before stroke reperfusion therapy in the setting of stroke after cardiac catheterization. It should result in minimal loss of time if concurrent with stroke team activation and evaluation and will provide important diagnostic and therapeutic information.