Treating hypoglycemia and hyperglycemia. (See "Initial assessment and management of acute stroke", section on 'Hypoglycemia' and "Initial assessment and management of acute stroke", section on 'Hyperglycemia'.) Evaluating and treating the source of any fever; for patients with acute stroke, we suggest maintaining normothermia for at least the first several days after an acute stroke. (See "Initial assessment and management of acute stroke", section on 'Fever'.) Preventing deep venous thrombosis and pulmonary embolism. (See "Prevention and treatment of venous thromboembolism in patients with acute stroke", section on 'Approach to VTE prevention'.) PROGNOSIS Stroke after cardiac catheterization is associated with a high in-hospital and 30-day mortality rate [10,15,17-19,21]. In the largest of these studies, the 30-day mortality rate after percutaneous coronary interventions was 19 percent for patients who experienced an ischemic stroke and 50 percent for those who had a hemorrhagic stroke, versus 2 percent in those without stroke [19]. Few data are available for long-term outcomes among survivors, but among 69 patients with stroke or transient ischemic attack who survived hospitalization in one report, transfers to inpatient rehabilitation, nursing home, or assisted living made up 31 percent of discharges [21]. The high morbidity and mortality associated with these strokes justifies aggressive treatment strategies. SOCIETY GUIDELINE LINKS Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Stroke in adults".) SUMMARY AND RECOMMENDATIONS Diagnostic and interventional cardiac catheterization may lead to either ischemic or hemorrhagic stroke. The overall incidence of clinically apparent stroke during or after cardiac catheterization is well under 1 percent in most studies, but may be higher with certain interventional procedures, particularly with aortic valvuloplasty. Stroke in this https://www.uptodate.com/contents/stroke-after-cardiac-catheterization/print 13/28 7/5/23, 12:07 PM Stroke after cardiac catheterization - UpToDate setting is associated with a high morbidity and mortality rate. (See 'Mechanisms' above and 'Incidence' above and 'Prognosis' above.) Most strokes related to cardiac catheterization present during the procedure or within the first 24 hours after the procedure. Frequent manifestations of ischemic stroke and intracerebral hemorrhage include visual disturbance, aphasia, dysarthria, hemiparesis, and altered mental status. (See 'Clinical presentation' above.) Important aspects of the management of any patient with periprocedural neurologic deterioration suggestive of stroke include stabilization of airway; breathing and circulation; stroke team activation; emergent brain imaging; determination of symptom onset time; and laboratory tests such as serum glucose and measures of hemostasis. (See 'Evaluation and diagnosis' above.) The differential diagnosis of acute stroke includes transient ischemic attack, seizure, migraine, encephalopathy, and other conditions such as hypoglycemia. An additional consideration in the periprocedural period is that of contrast-induced transient cortical blindness. (See 'Differential diagnosis' above.) For eligible patients with ischemic stroke who can be treated within 4.5 hours of stroke onset, and selected patients with unknown time of onset and favorable imaging, we suggest intravenous thrombolytic therapy ( table 2) (Grade 2C), followed by mechanical thrombectomy for select patients with large vessel occlusions. (See 'Treatment' above and 'Ischemic stroke' above.) Patients with acute ischemic stroke caused by a large artery occlusion who can be treated within 24 hours of the time they were last known to be at their neurologic baseline should be evaluated for mechanical thrombectomy ( algorithm 1). (See 'Ischemic stroke' above and "Mechanical thrombectomy for acute ischemic stroke".) For patients with hemorrhagic stroke (ie, intracerebral hemorrhage or subarachnoid hemorrhage), urgent management issues involve reversal of anticoagulation, blood pressure control, and treatment of elevated intracranial pressure. (See 'Hemorrhagic stroke' above.) Use of UpToDate is subject to the Terms of Use. REFERENCES https://www.uptodate.com/contents/stroke-after-cardiac-catheterization/print 14/28 7/5/23, 12:07 PM Stroke after cardiac catheterization - UpToDate 1. 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. 2. 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. 3. 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. 4. 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. 5. 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. 6. 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. 7. Wijman CA, Kase CS, Jacobs AK, Whitehead RE. Cerebral air embolism as a cause of stroke during cardiac catheterization. Neurology 1998; 51:318. 8. Jassal DS, Fast MD, McGinn G. Multifocal brain MRI hypointensities secondary to cardiac catheterization. Neurology 2000; 54:2023. 9. Brown DL, Topol EJ. Stroke complicating percutaneous coronary revascularization. Am J Cardiol 1993; 72:1207. 10. Segal AZ, Abernethy WB, Palacios IF, et al. Stroke as a complication of cardiac catheterization: risk factors and clinical features. Neurology 2001; 56:975. 11. 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. 12. 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. 13. Cho SM, Deshpande A, Pasupuleti V, et al. Radiographic and Clinical Brain Infarcts in Cardiac and Diagnostic Procedures: A Systematic Review and Meta-Analysis. Stroke 2017; 48:2753. 14. Dukkipati S, O'Neill WW, Harjai KJ, et al. Characteristics of cerebrovascular accidents after percutaneous coronary interventions. J Am Coll Cardiol 2004; 43:1161. https://www.uptodate.com/contents/stroke-after-cardiac-catheterization/print 15/28 7/5/23, 12:07 PM Stroke after cardiac catheterization - UpToDate 15. Fuchs S, Stabile E, Kinnaird TD, et al. Stroke complicating percutaneous coronary interventions: incidence, predictors, and prognostic implications. Circulation 2002; 106:86. 16. 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. 17. 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. 18. 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. 19. Myint PK, Kwok CS, Roffe C, et al. Determinants and Outcomes of Stroke Following Percutaneous Coronary Intervention by Indication. Stroke 2016; 47:1500. 20. Yamamoto K, Natsuaki M, Morimoto T, et al. Periprocedural Stroke After Coronary Revascularization (from the CREDO-Kyoto PCI/CABG Registry Cohort-3). Am J Cardiol 2021; 142:35. 21. Dukkipati S, O'Neill WW, Harjai KJ, et al. Characteristics of cerebrovascular accidents after percutaneous coronary interventions. J Am Coll Cardiol 2004; 43:1161. 22. Oh MS, Kwon JE, Kim KJ, et al. Subarachnoid hemorrhage mimicking leakage of contrast media after coronary angiography. Korean Circ J 2012; 42:197. 23. Akkerhuis KM, Deckers JW, Lincoff AM, et al. Risk of stroke associated with abciximab among patients undergoing percutaneous coronary intervention. JAMA 2001; 286:78. 24. 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. 25. Bladin CF, Bingham L, Grigg L, et al. Transcranial Doppler detection of microemboli during percutaneous transluminal coronary angioplasty. Stroke 1998; 29:2367. 26. Leclercq F, Kassnasrallah S, Cesari JB, et al. Transcranial Doppler detection of cerebral microemboli during left heart catheterization. Cerebrovasc Dis 2001; 12:59. 27. Dittrich R, Ringelstein EB. Occurrence and clinical impact of microembolic signals during or after cardiosurgical procedures. Stroke 2008; 39:503. 28. Hamon M, Baron JC, Viader F, Hamon M. Periprocedural stroke and cardiac catheterization. Circulation 2008; 118:678. 29. 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. https://www.uptodate.com/contents/stroke-after-cardiac-catheterization/print 16/28 7/5/23, 12:07 PM Stroke after cardiac catheterization - UpToDate 30. 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. 31. 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. 32. 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. 33. B sing KA, Schulte-Sasse C, Fl chter 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. 34. Daly MJ, Boyle AJ, Morrison L, Hunter EK. Visual disturbance following cardiac catheterization. J Am Coll Cardiol 2013; 61:e5. 35. Kymionis GD, Tsilimbaris MK, Christodoulakis EB, Pallikaris IG. Late onset branch retinal artery occlusion following coronary angiography. Acta Ophthalmol Scand 2005; 83:122. 36. 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. 37. Dawson DM, Fischer EG. Neurologic complications of cardiac catheterization. Neurology 1977; 27:496. 38. De Marco F, Antonio Fernandez-Diaz J, Lef vre T, et al. Management of cerebrovascular accidents during cardiac catheterization: immediate cerebral angiography versus early neuroimaging strategy. Catheter Cardiovasc Interv 2007; 70:560. 39. Horwitz NH, Wener L. Temporary cortical blindness following angiography. J Neurosurg 1974; 40:583. 40. Zwicker JC, Sila CA. MRI findings in a case of transient cortical blindness after cardiac catheterization. Catheter Cardiovasc Interv 2002; 57:47. 41. 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. 42. 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. https://www.uptodate.com/contents/stroke-after-cardiac-catheterization/print 17/28 7/5/23, 12:07 PM Stroke after cardiac catheterization - UpToDate 43. Borghi C, Saia F, Marzocchi A, Branzi A. The conundrum of transient cortical blindness following coronary angiography. J Cardiovasc Med (Hagerstown) 2008; 9:1063. 44. Velden J, Milz P, Winkler F, et al. Nonionic contrast neurotoxicity after coronary angiography mimicking subarachnoid hemorrhage. Eur Neurol 2003; 49:249. 45. 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. 46. 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. 47. 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. 48. Kissela BM, Kothari RU, Tomsick TA, et al. Embolization of calcific thrombi after tissue plasminogen activator treatment. J Stroke Cerebrovasc Dis 2001; 10:135. 49. Khatri P, Kasner SE. Ischemic strokes after cardiac catheterization: opportune thrombolysis candidates? Arch Neurol 2006; 63:817. 50. Chan AW, Henderson MA. Immediate catheter-directed reperfusion for acute stroke occurring during diagnostic cardiac catheterization. Catheter Cardiovasc Interv 2006; 67:314. 51. 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. 52. 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. 53. Zaidat OO, Slivka AP, Mohammad Y, et al. Intra-arterial thrombolytic therapy in peri- coronary angiography ischemic stroke. Stroke 2005; 36:1089. 54. 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. 55. 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. https://www.uptodate.com/contents/stroke-after-cardiac-catheterization/print 18/28 7/5/23, 12:07 PM Stroke after cardiac catheterization - UpToDate 56. 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. 57. 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. 58. 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. 59. 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. Topic 14083 Version 20.0 https://www.uptodate.com/contents/stroke-after-cardiac-catheterization/print 19/28 7/5/23, 12:07 PM Stroke after cardiac catheterization - UpToDate GRAPHICS Cooperative cardiovascular project risk model for intracranial hemorrhage with thrombolytic therapy Risk Factors* Age 75 years Black race Female sex Prior history of stroke Systolic blood pressure 160 mmHg Weight 65 kg for women or 80 kg for men INR >4 or PT >24 Use of alteplase (versus other thrombolytic agent) Rate of intracranial hemorrhage, percent Risk score 0 or 1 0.69 2 1.02 3 1.63 4 2.49 5 4.11 Each risk factor is worth 1 point if present, 0 points if absent. Points are added to determine the risk score. INR: international normalized ratio; PT: prothrombin time. Data from 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. Graphic 62946 Version 6.0 https://www.uptodate.com/contents/stroke-after-cardiac-catheterization/print 20/28 7/5/23, 12:07 PM Stroke after cardiac catheterization - UpToDate Eligibility criteria for the treatment of acute ischemic stroke with intravenous thrombolysis (recombinant tissue plasminogen activator or tPA) Inclusion criteria Clinical diagnosis of ischemic stroke causing measurable neurologic deficit Onset of symptoms <4.5 hours before beginning treatment; if the exact time of stroke onset is not known, it is defined as the last time the patient was known to be normal or at neurologic baseline Age 18 years Exclusion criteria Patient history Ischemic stroke or severe head trauma in the previous three months Previous intracranial hemorrhage Intra-axial intracranial neoplasm Gastrointestinal malignancy Gastrointestinal hemorrhage in the previous 21 days Intracranial or intraspinal surgery within the prior three months Clinical Symptoms suggestive of subarachnoid hemorrhage Persistent blood pressure elevation (systolic 185 mmHg or diastolic 110 mmHg) Active internal bleeding Presentation consistent with infective endocarditis Stroke known or suspected to be associated with aortic arch dissection Acute bleeding diathesis, including but not limited to conditions defined under 'Hematologic' Hematologic 3 Platelet count <100,000/mm * Current anticoagulant use with an INR >1.7 or PT >15 seconds or aPTT >40 seconds* Therapeutic doses of low molecular weight heparin received within 24 hours (eg, to treat VTE and ACS); this exclusion does not apply to prophylactic doses (eg, to prevent VTE) Current use (ie, last dose within 48 hours in a patient with normal renal function) of a direct thrombin inhibitor or direct factor Xa inhibitor with evidence of anticoagulant effect by laboratory tests such as aPTT, INR, ECT, TT, or appropriate factor Xa activity assays Head CT Evidence of hemorrhage https://www.uptodate.com/contents/stroke-after-cardiac-catheterization/print 21/28 7/5/23, 12:07 PM Stroke after cardiac catheterization - UpToDate Extensive regions of obvious hypodensity consistent with irreversible injury Warnings Only minor and isolated neurologic signs or rapidly improving symptoms Serum glucose <50 mg/dL (<2.8 mmol/L) Serious trauma in the previous 14 days Major surgery in the previous 14 days History of gastrointestinal bleeding (remote) or genitourinary bleeding Seizure at the onset of stroke with postictal neurologic impairments Pregnancy** Arterial puncture at a noncompressible site in the previous seven days Large ( 10 mm), untreated, unruptured intracranial aneurysm Untreated intracranial vascular malformation Additional warnings for treatment from 3 to 4.5 hours from symptom onset Age >80 years Oral anticoagulant use regardless of INR Severe stroke (NIHSS score >25) Combination of both previous ischemic stroke and diabetes mellitus ACS: acute coronary syndrome; aPTT: activated partial thromboplastin time; ECT: ecarin clotting time; INR: international normalized ratio; PT: prothrombin time; NIHSS: National Institutes of Health Stroke Scale; tPA: intravenous alteplase; TT: thrombin time; VTE: venous thromboembolism. Although it is desirable to know the results of these tests, thrombolytic therapy should not be delayed while results are pending unless (1) there is clinical suspicion of a bleeding abnormality or thrombocytopenia, (2) the patient is currently on or has recently received anticoagulants (eg, heparin, warfarin, a direct thrombin inhibitor, or a direct factor Xa inhibitor), or (3) use of anticoagulants is not known. Otherwise, treatment with intravenous tPA can be started before availability of coagulation test results but should be discontinued if the INR, PT, or aPTT exceed the limits stated in the table, or 3 if platelet count is <100,000 mm . With careful consideration and weighting of risk-to-benefit, patients may receive intravenous alteplase despite one or more warnings. Patients who have a persistent neurologic deficit that is potentially disabling, despite improvement of any degree, should be treated with tPA in the absence of other contraindications. Any of the following should be considered disabling deficits: Complete hemianopia: 2 on NIHSS question 3, or Severe aphasia: 2 on NIHSS question 9, or Visual or sensory extinction: 1 on NIHSS question 11, or Any weakness limiting sustained effort against gravity: 2 on NIHSS question 5 or 6, or Any deficits that lead to a total NIHSS >5, or https://www.uptodate.com/contents/stroke-after-cardiac-catheterization/print 22/28 7/5/23, 12:07 PM Stroke after cardiac catheterization - UpToDate Any remaining deficit considered potentially disabling in the view of the patient and the treating practitioner using clinical judgment Patients may be treated with intravenous alteplase if glucose level is subsequently normalized. The potential risks of bleeding with alteplase from injuries related to the trauma should be weighed against the anticipated benefits of reduced stroke-related neurologic deficits. The increased risk of surgical site bleeding with alteplase should be weighed against the anticipated benefits of reduced stroke-related neurologic deficits. There is a low increased risk of new bleeding with alteplase in the setting of past gastrointestinal or genitourinary bleeding. However, alteplase administration within 21 days of gastrointestinal bleeding is not recommended. Alteplase is reasonable in patients with a seizure at stroke onset if evidence suggests that residual impairments are secondary to acute ischemic stroke and not to a postictal phenomenon. * Alteplase can be given in pregnancy when the anticipated benefits of treating moderate or severe stroke outweigh the anticipated increased risks of uterine bleeding. The safety and efficacy of administering alteplase is uncertain for these relative exclusions. Although these were exclusions in the trial showing benefit in the 3 to 4.5 hour window, intravenous alteplase appears to be safe and may be beneficial for patients with these criteria, including patients taking oral anticoagulants with an INR <1.7. Adapted from: 1. Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 2008; 359:1317. 2. Del Zoppo GJ, Saver JL, Jauch EC, et al. Expansion of the time window for treatment of acute ischemic stroke with intravenous tissue plasminogen activator. A science advisory from the American Heart Association/American Stroke Association. Stroke 2009; 40:2945. 3. Re-examining Acute Eligibility for Thrombolysis (TREAT) Task Force:, Levine SR, Khatri P, et al. Review, historical context, and clari cations of the NINDS rt-PA stroke trials exclusion criteria: Part 1: rapidly improving stroke symptoms. Stroke 2013; 44:2500. 4. Demaerschalk BM, Kleindorfer DO, Adeoye OM, et al. Scienti c rationale for the inclusion and exclusion criteria for intravenous alteplase in acute ischemic stroke: A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2016; 47:581. 5. Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2019; 50:e344. Graphic 71462 Version 26.0 https://www.uptodate.com/contents/stroke-after-cardiac-catheterization/print 23/28 7/5/23, 12:07 PM Stroke after cardiac catheterization - UpToDate Indications for mechanical thrombectomy to treat patients with acute ischemic IV: intravenous; tPA: tissue plasminogen activator (alteplase or tenecteplase); CTA: computed tomography an artery occlusion; MT: mechanical thrombectomy; ASPECTS: Alberta Stroke Program Early CT Score; NIHSS: Na tomography; MRI: magnetic resonance imaging; mRS: modified Rankin Scale; MCA: middle cerebral artery; IC recovery. Patients are not ordinarily eligible for IV tPA unless the time last known to be well is <4.5 hours. However, im that is diffusion positive and FLAIR negative) is an option at expert stroke centers to select patients with wake associated UpToDate topics for details. Usually assessed with MRA or CTA, less often with digital subtraction angiography. There is intracranial arterial occlusion of the distal ICA, middle cerebral (M1/M2), or anterior cerebral (A1/A2 MT may be a treatment option for patients with acute ischemic stroke caused by occlusion of the basilar ar stroke centers, but benefit is uncertain. [1] Based upon data from the Aurora study . Reference: https://www.uptodate.com/contents/stroke-after-cardiac-catheterization/print 24/28 7/5/23, 12:07 PM Stroke after cardiac catheterization - UpToDate 1. Albers GW, Lansberg MG, Brown S, et al. Assessment of Optimal Patient Selection for Endovascular Thrombectomy Beyond 6 Hou Neurol 2021; 78:1064. Graphic 117086 Version 3.0 https://www.uptodate.com/contents/stroke-after-cardiac-catheterization/print 25/28 7/5/23, 12:07 PM Stroke after cardiac catheterization - UpToDate Options to treat hypertension before and during reperfusion therapy for acu te ischemic stroke Patient otherwise eligible for acute reperfusion therapy except that blood pressure is >185/110 mmHg* Labetalol 10 to 20 mg intravenously over 1 to 2 minutes, may repeat one time; or Nicardipine 5 mg/hour intravenously, titrate up by 2.5 mg/hour every 5 to 15 minutes, maximum 15 mg/hour; when desired blood pressure reached, adjust to maintain proper blood pressure limits; or Clevidipine 1 to 2 mg/hour intravenously, titrate by doubling the dose every 2 to 5 minutes, maximum 21 mg/hour, until desired blood pressure reached ; or Other agents (hydralazine, enalaprilat, etc) may also be considered If blood pressure is not maintained at or below 185/110 mmHg, do not administer alteplase Management to maintain blood pressure at or below 180/105 mmHg during and after acute reperfusion therapy* Monitor blood pressure every 15 minutes for 2 hours from the start of rtPA therapy, then every 30 minutes for 6 hours, and then every hour for 16 hours If systolic blood pressure is >180 to 230 mmHg or diastolic is >105 to 120 mmHg: Labetalol 10 mg intravenously followed by continuous infusion 2 to 8 mg/min; or Nicardipine 5 mg/hour intravenously, titrate up to desired effect by 2.5 mg/hour every 5 to 15 minutes, maximum 15 mg/hour; or Clevidipine 1 to 2 mg/hour intravenously, titrate by doubling the dose every 2 to 5 minutes, maximum 21 mg/hour, until desired blood pressure reached If blood pressure is not controlled or diastolic blood pressure >140 mmHg, consider intravenous sodium nitroprusside Different treatment options may be appropriate in patients who have comorbid conditions that may benefit from acute reductions in blood pressure, such as acute coronary event, acute heart failure, aortic dissection, or preeclampsia/eclampsia. Clevidipine has been included as part of the 2018 guidelines for the early management of patients with acute ischemic stroke [1] . Reference: 1. Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2018; 49:e46. Adapted with permission. Stroke. 2013: 44:870-947. Copyright 2013 American Heart Association, Inc. https://www.uptodate.com/contents/stroke-after-cardiac-catheterization/print 26/28 7/5/23, 12:07 PM Stroke after cardiac catheterization - UpToDate Graphic 50725 Version 15.0 https://www.uptodate.com/contents/stroke-after-cardiac-catheterization/print 27/28 7/5/23, 12:07 PM Stroke after cardiac catheterization - UpToDate Contributor Disclosures Robert A Taylor, MD Consultant/Advisory Boards: Boston Scientific [Non-valvular atrial fibrillation]. All of the relevant financial relationships listed have been mitigated. Pooja Khatri, MD, MSc Grant/Research/Clinical Trial Support: Bayer [Stroke]; Cerenovus [Stroke]. All of the relevant financial relationships listed have been mitigated. Scott E Kasner, MD Grant/Research/Clinical Trial Support: Bayer [Stroke]; Bristol Meyers Squibb [Stroke]; Medtronic [Stroke]; WL Gore and Associates [Stroke]. Consultant/Advisory Boards: Abbvie [Stroke]; AstraZeneca [Stroke]; BMS [Stroke]; Diamedica [Stroke]; Medtronic [Stroke]. All of the relevant financial relationships listed have been mitigated. Donald Cutlip, MD Consultant/Advisory Boards: MedAlliance [Drug-eluting balloon]. Other Financial Interest: Baim Institute for Clinical Research [Clinical research]. All of the relevant financial relationships listed have been mitigated. John F Dashe, MD, PhD No relevant financial relationship(s) with ineligible companies to disclose. Nisha Parikh, MD, MPH No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www.uptodate.com/contents/stroke-after-cardiac-catheterization/print 28/28