Acute ischemic stroke after cardiac catheterization

Abstract

: Intravenous thrombolysis is the preferred treatment for acute ischemic stroke; however, it remains unestablished in the area of cardiac catheterization. We report three patients with acute ischemic stroke after cardiac catheterization. After reversing the anticoagulant effect of unfractionated heparin with protamine, all of the patients were successfully off-label thrombolyzed with reduced doses of intravenous recombinant tissue plasminogen activator (0.6 mg/kg). This dose was preferred to reduce the risk of symptomatic cerebral or systemic bleeding. The sequential pathway of protamine recombinant tissue plasminogen activator at reduced doses may be safer for reducing intracranial or systemic bleeding events, whereas remaining efficacious for the treatment of acute ischemic stroke after cardiac catheterization.

Alteplase for Acute Ischemic Stroke after Heparin Reversal with Protamine: A Case Report and Review

“…8 The former, however, used low-dose alteplase (0.6 mg/kg). 7 It is notable that on initial neuroimaging our patient had no evidence of large-vessel occlusion by head and neck CTA and no perfusion abnormalities by brain CTP, suggesting small-vessel stroke that was later confirmed by brain MRI. The absence of an identified arterial occlusion by CTA before treatment suggests a lower risk of ICH after IV alteplase relative to a scenario of arterial occlusion identified by CTA before treatment.…”

Intravenous thrombolysis in acute ischemic stroke after antagonization of unfractionated heparin with protamine: case series and systematic review of literature

“…So far, the safety and efficacy of IVT after heparin antagonization with protamine has not been evaluated in large studies. In our case series and systematic review of the published cases of IVT in heparin-/protamine-treated AIS patients published from 2011 until the end of September 2021, 12,[31][32][33][34][35][36] the main findings were as follows.…”

“…Furthermore, no adverse events due to protamine were reported. In the systematic literature review, a total of 34 articles were identified and 7 articles including five case reports (Fontaine et al, 31 Bereczki et al, 32 Safouris et al, 33 Danoun et al, 34 and Warner et al 12 ) and two case series of three patients each (Guevara et al, 35 Ranasinghe et al 36 ) were retained (see Figure 1).…”

“…43 Except for one patient, all of our patients received a full-dose IVT (0.9 mg rtPA/kg body weight). Regarding the case reports and series, except for the case series by Guevara et al 35 and the case report of Warner et al, 12 dosage reduction to 0.6 mg rtPA/kg body weight with the aim to reduce the risk of sICH. 12,35,44 Overall, a noninferiority of effectiveness has been described in literature and a reduced IVT dosage can be used in a specific collective of patients but is not usually recommended.…”

“…Except for one patient, all of our patients received a full-dose IVT (0.9 mg rtPA/kg body weight). Regarding the case reports and series, except for the case series by Guevara et al 35 and the case report of Warner et al , 12 full dose of IVT has also been administered. The authors discussed the dosage reduction to 0.6 mg rtPA/kg body weight with the aim to reduce the risk of sICH.…”