Ischaemic stroke as a complication of cardiac catheterisation. Clinical and radiological characteristics, progression, and therapeutic implications.

INTRODUCTION: Ischaemic stroke is the most common neurological complication of cardiac catheterisation. This study aims to analyse the clinical and prognostic differences between post-catheterisation stroke code (SC) and all other in-hospital and prehospital SC. METHODS: We prospectively recorded SC activation at our centre between March 2011 and April 2016. Patients were grouped according to whether SC was activated post-catheterisation, in-hospital but not post-catheterisation, or before arrival at hospital; groups were compared in terms of clinical and radiological characteristics, therapeutic approach, functional status, and three-month mortality. RESULTS: The sample included 2224 patients, of whom 31 presented stroke post-catheterisation. Baseline National Institutes of Health Stroke Scale score was lower for post-catheterisation SC than for other in-hospital SC and pre-hospital SC (5, 10, and 7, respectively; P=.02), and SC was activated sooner (50, 100, and 125minutes, respectively; P<.001). Furthermore, post-catheterisation SC were more frequently due to transient ischaemic attack (38%, 8%, and 9%, respectively; P<.001) and less frequently to proximal artery occlusion (17.9%, 31.4%, and 39.2%, respectively; P=.023). The majority of patients with post-catheterisation strokes (89.7%) did not receive reperfusion therapy; 60% of the patients with proximal artery occlusion received endovascular treatment. The mortality rate was 12.95% for post-catheterisation strokes and 25% for all other in-hospital strokes. Although patients with post-catheterisation stroke had a better functional prognosis, the adjusted analysis showed that this effect was determined by their lower initial severity. CONCLUSIONS: Post-catheterisation stroke is initially less severe, and presents more often as transient ischaemic attack and less frequently as proximal artery occlusion. Most post-catheterisation strokes are not treated with reperfusion; in case of artery occlusion, mechanical thrombectomy is the preferred treatment.

[Clinical characteristics of patients with stroke code activation not identified by the emergency medical service]. / Características clínicas de los pacientes con activación de código ictus no identificados por el servicio de emergencias médicas.

AIMS: To determine the sensitivity of stroke detection by emergency medical services (EMS) and to analyse the clinical characteristics of unidentified patients with suspected stroke. PATIENTS AND METHODS: Prospective register of patients with suspected stroke in our area (850,000 inhabitants) from 2011 to 2017. The population that notified the EMS was selected. Of this population, patients with and without stroke code activation by the EMS were compared (EMS+ versus EMS-). Demographics, time to progression, clinical characteristics of the episode and reperfusion therapy administered were recorded. RESULTS: Of a total of 5,497 patients with suspected stroke, 2,087 alerted the EMS: 1,611 (77%) EMS+ and 476 (33%) EMS-. The EMS- patients presented lower scores on the National Institute of Health Stroke Scale (8 vs. 11) and a greater frequency of clinical features of the vertebrobasilar territory (14.1% vs. 8.7%) and partial hemispheric clinical features (23.5% vs. 18.4%), especially in the left hemisphere (78.1% vs. 48.4%). Reperfusion treatment was administered in 29% of EMS+ and 23% of EMS-. The time from symptom onset to treatment was 42 minutes longer in the EMS group (175 versus 133 minutes). CONCLUSIONS: The sensitivity of EMS to detect stroke patients in our series is 77%. We have identified clinical features associated with lack of sensitivity, such as vertebrobasilar territory symptoms or isolated language disorder.

TITLE: Características clínicas de los pacientes con activación de código ictus no identificados por el servicio de emergencias médicas.Objetivos. Determinar la sensibilidad de detección de ictus por parte de los servicios de emergencias médicas (SEM) y analizar las características clínicas de los pacientes con sospecha de ictus no identificados. Pacientes y métodos. Registro prospectivo de pacientes con sospecha de ictus de nuestra área (850.000 habitantes) desde 2011 hasta 2017. Se seleccionó a la población que avisó al SEM. De ésta, se compararon los pacientes con y sin activación de código ictus por parte del SEM (SEM+ frente a SEM-). Se registraron los datos demográficos, el tiempo de evolución, las características clínicas del episodio y el tratamiento de reperfusión administrado. Resultados. De un total de 5.497 pacientes con sospecha de ictus, 2.087 alertaron al SEM: 1.611 (77%) SEM+ y 476 (33%) SEM-. Los pacientes SEM- presentaron menor puntuación en la National Institute of Health Stroke Scale (8 frente a 11) y mayor frecuencia de clínica de territorio vertebrobasilar (14,1% frente a 8,7%) y de clínica hemisférica parcial (23,5% frente a 18,4%), especialmente del hemisferio izquierdo (78,1% frente a 48,4%). Se administró tratamiento de reperfusión en el 29% de los SEM+ y en el 23% de los SEM-. El tiempo desde el inicio de los síntomas hasta el tratamiento fue 42 minutos más largo en el grupo de pacientes SEM- (175 frente a 133 minutos). Conclusiones. La sensibilidad del SEM para detectar pacientes con ictus en nuestra serie es del 77%. Hemos identificado características clínicas asociadas a la falta de sensibilidad, como los síntomas de territorio vertebrobasilar o el trastorno de lenguaje aislado.

Ischaemic stroke as a complication of cardiac catheterisation. Clinical and radiological characteristics, progression, and therapeutic implications. / Ictus isquémico como complicación del cateterismo cardíaco. Características clínicas, radiológicas y evolutivas e implicaciones terapéuticas.

INTRODUCTION: Ischaemic stroke is the most common neurological complication of cardiac catheterisation. This study aims to analyse the clinical and prognostic differences between post-catheterisation stroke code (SC) and all other in-hospital and prehospital SC. METHODS: We prospectively recorded SC activation at our centre between March 2011 and April 2016. Patients were grouped according to whether SC was activated post-catheterisation, in-hospital but not post-catheterisation, or before arrival at hospital; groups were compared in terms of clinical and radiological characteristics, therapeutic approach, functional status, and three-month mortality. RESULTS: The sample included 2224 patients, of whom 31 presented stroke post-catheterisation. Baseline National Institutes of Health Stroke Scale score was lower for post-catheterisation SC than for other in-hospital SC and pre-hospital SC (5, 10, and 7, respectively; P=.02), and SC was activated sooner (50, 100, and 125minutes, respectively; P<.001). Furthermore, post-catheterisation SC were more frequently due to transient ischaemic attack (38%, 8%, and 9%, respectively; P<.001) and less frequently to proximal artery occlusion (17.9%, 31.4%, and 39.2%, respectively; P=.023). The majority of patients with post-catheterisation strokes (89.7%) did not receive reperfusion therapy; 60% of the patients with proximal artery occlusion received endovascular treatment. The mortality rate was 12.95% for post-catheterisation strokes and 25% for all other in-hospital strokes. Although patients with post-catheterisation stroke had a better functional prognosis, the adjusted analysis showed that this effect was determined by their lower initial severity. CONCLUSIONS: Post-catheterisation stroke is initially less severe, and presents more often as transient ischaemic attack and less frequently as proximal artery occlusion. Most post-catheterisation strokes are not treated with reperfusion; in case of artery occlusion, mechanical thrombectomy is the preferred treatment.