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CORRESPONDENCE: LETTER TO THE EDITOR

The Timing of Thrombolysis for Strokes Complicating Cardiac Catheterization

^_* Institut Cardiovasculaire Paris Sud, 6 Avenue du Noyer Lambert, 91300 Massy, France (Email: federico.demarco{at}gmail.com).

In one of the largest single-center series of strokes complicating cardiac catheterization (2), we report how immediate on-table angiography was the key strategy to successful treatment in most patients. Four patients were treated with intra-arterial thrombolysis, 1 by mechanical reperfusion, and the last with prolonged intravenous infusion of abciximab. In the 2 patients in whom a neuroimaging strategy was adopted before intervention, inferior outcomes were observed. In particular, the only hemorrhagic transformation followed by death was observed in 1 of the 2 patients in whom a thrombolytic agent was administered more than 180 min after the event with the delay to allow brain magnetic resonance imaging.

Clearly with such small numbers, definitive demonstration of the superiority of immediate intervention over a neuroimaging strategy is not possible; however, we feel that "an expedited cerebral CT or magnetic resonance imaging scan to evaluate for possible intracerebral hemorrhage" as advocated by Lyden (3) may not be the best option in this setting. In strokes occurring in the general population, delay in thrombolysis is an important predictor of hemorrhagic transformation, and strokes complicating cardiac catheterization are unlikely to represent an exception to this rule. To this regard it is interesting to note that in the report by Khatri et al. (1) the median delay in intra-arterial lysis was 240 min, whereas only a 90-min delay occurred before intravenous therapy. It would be interesting to know in which group the 3 asymptomatic hemorrhages occurred.

We suggest that immediate on-table angiography might be a good time-saving and brain-saving point to include in the catheter laboratory Code Stroke protocol.

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1. Khatri P, Taylor RA, Palumbo V, et al. Treatment of Acute Stroke After Cardiac Catheterization (TASCC) Study Group The safety and efficacy of thrombolysis for strokes after cardiac catheterization J Am Coll Cardiol 2008;51:906-911.[Abstract/Free Full Text]
2. De Marco F, Fernandez-Diaz JA, Lefèvre T, et al. Management of cerebrovascular accidents during cardiac catheterization: immediate cerebral angiography versus early neuroimaging strategy Catheter Cardiovasc Interv 2007;70:560-568.[CrossRef][ISI][Medline]
3. Lyden PD. Code stroke in the cath lab J Am Coll Cardiol 2008;51:912.[Free Full Text]

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