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Stroke after PCI PowerPoint Presentation

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Description : explaining stroke after PCI

Tags : stroke

Published on : Oct 02, 2020 | Views : 1869 | Downloads : 13

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Slide 1-

Stroke after PCI Packleton
Slide 2-

A 57-year-old lady presented to the ED after she had a near fainting episode. She was on a bus in a standing position when she felt unwell with cold sweats & giddiness. In ED she developed some vague central chest discomfort. A repeat 12-lead ECG showed mildly elevated STsegments(1 mm) in the inferior leads. PH: DM+
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She was sent to the cath Lab for Immediate PCI after she consented to the procedure.
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total occlusion of the proximal right coronary artery (pRCA) Primary PCI was done to the RCA lesion. It was then noted that the patient had developed Expressive aphasia & right hemiparesis. PCI results
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1.Symptoms and signs compatible with ??? haemorrhagic stroke Ischemic stroke 00:30
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haemorrhagic stroke: Gradual wrsening of neurologic deficits over minutes to hours and sings of elevated ICP. Ischemic stroke: Maximal deficit at onset or a fluctuating course
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2.What is/are the predictors of ischaemic stroke complications in this patient? 1)Female gender 2)DM 3)PCI after STEMI 4)All of them 00:30
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female gender, increasing age, Prevalent valvular heart disease, previous history of stroke, use of circulatory support devices, PCI in the setting of both NSTEMI and STEMI DM HTN RF(ischemic strok) Renal impairment. Longer procedure time HF Severity of CAD(ex 3VD) Greater contrast use Presence of coronary artery thrombus Use of IABP Interventions at bypass graft
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warfarin use and thrombolysis GPIIb/IIIa use haemodynamic instability such as cardiogenic shock increasing age(≥75) ACS Female sex SBP ≥160 Black race Low body weight prevalent valvular heart disease haemorrhagic stroke
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3.What is the first step? 1) Brain CT 2) R/O other reversible causes or differential diagnoses 00:30
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R/O other reversible causes or differential diagnoses. Hypoglycaemia, seizures, migraine attacks Encephalopathy not to forget the drugs & sedatives which may have been used during the procedure Reversible posterior leukoencephalopathy syndrom(contrast-induced transient cortical blindness)
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4.What is the second step after CVA diagnosis by history, Ph/ex and R/o other causes? (if the catheter sheath has not been removed) CT MRI cerebral angiography 00:30
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We recommend brain imaging to R/O hemorrhage as a standard approach In contrast,some experts have advocated immediate angiography followed by intra-arterial thrombolysis rather than obtaining a head CT or MRI. UpToDate
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5.Ischemic stroke being approved,what is the next step? if the catheter sheath has not been removed IV Thrombolytic therapy Observation Intra-arterial Thrombolytic therapy Thrombectomy 00:30
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If neurologic symptoms are recognized while the catheter sheath is still in place, the patient could receive IV rt-PA. If symptoms are first noted after the catheter sheath has been removed, the patient could be evaluated for catheter-based, endovascular treatment. braunwald
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tPA is safe and efficacious ,Initiated within 4.5 h of clearly defined symptom onset,followed by adjunctive endovascular therapy in selected patients with large vessel occlusions. For eligible patients with ischemic stroke caused by a large artery occlusion in the proximal anterior circulation,we recommend treatment with intra-arterial mechanical thrombectomy( within 6h) whether or not the patient received IV thrombolytic therapy with tPA. Ischemic stroke
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Intra-arterial tPa is a reasonable option in the 4.5 to 6h time window in pateints otherwise eligible for tPA( but not eligiblefor mechanical thrombectomy) Regardless of reperfuion therapy modality,it is imperative to minimize the time to treatment.
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6.What should we do? SBP=190 DBP=110 Initiate IV labetalol No anti-hypertensive agent is needed Initiate IV TNG 00:30
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Patient otherwise eligible for acute reperfusion therapy except that blood pressure is >185/110 mmHg Lowering MAP(15%) in One hours 1 Labetalol 10 to 20 mg intravenously over 1 to 2 min, may repeat one time; Other agents (Nicardipine, hydralazine, enalaprilat, etc) may be considered when appropriate If blood pressure is not maintained at or below 185/110 mmHg, do not administer rtPA candidates for acute reperfusion therapy
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Management to maintain BP at or below 180/105 mmHg during and after acute reperfusion therapy Monitor BP every 15 min for 2 hours from the start of rtPA therapy, then every 30 min for 6 hours, & then every hour for 16 hours.
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7.What shoud we do if patient receive heparin befor PCI? Check PTT and decide No check need
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7.What should we do if patient receive heparin before PCI? 1-Check PTT and decide 2-No check need 00:30
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A normal PTT should be documented prior to administration of intravenous tPA if heparin was administered within 48 hours. Protamine can be used to reverse the effect of heparin. For patients with a prolonged PTT, endovascular therapies with intra-arterial tPA and/or mechanical embolectomy are treatment options Single or dual antiplatelet therapy is not a contraindication to intravenous tPA.
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