Catheterization and Cardiovascular Interventions 85:1033–1040 (2015)
Neuroimaging Patterns of Ischemic Stroke After Percutaneous Coronary Intervention Scott J. Hoffman,1 MD, Alan H. Yee,2 DO, Joshua P. Slusser,3 BS, Charanjit S. Rihal,1 MD, FSCAI, David R. Holmes Jr.,1 MD, FSCAI, Alejandro A. Rabinstein,2 MD, and Rajiv Gulati,1* MD, PhD, FSCAI Objectives: We sought to determine neuroimaging patterns, ischemic mechanisms, and functional outcomes of ischemic stroke related to percutaneous coronary intervention (PCI) over a 16-year period. Background: Stroke is a feared complication of PCI, associated with poor patient outcomes. The majority of strokes that occur after PCI are ischemic rather than hemorrhagic. However, mechanisms of cerebral ischemia in this setting are incompletely understood. Methods: We performed a retrospective single-center cohort study of patients with radiologically confirmed ischemic stroke occurring after PCI (PCI-stroke), between January 1, 1994 and December 31, 2009. Using brain imaging, infarctions were subclassified by radiological pattern and arterial territory as embolic, small subcortical, or hemodynamic. Modified Rankin Scale scores were used to assess functional outcome at 3 and 6 months. Results: Radiologically confirmed PCIstroke was identified in 35 patients. The majority of strokes (91%) revealed an embolic pattern, while the remaining strokes were small subcortical infarctions (9%). Watershed strokes with exclusive borderzone involvement, indicative of a hemodynamic mechanism, were not identified, despite the presence of periprocedural hypotension in 23% of patients. The middle cerebral artery (MCA) territory was affected most frequently (80%), and all patients suffering a complete MCA territorial infarction (14%) died in the hospital. Functional outcome among survivors of PCI-stroke was typically favorable in those who had single rather than multiple vascular territory involvement. Conclusions: The vast majority of radiologically confirmed ischemic strokes related to PCI are embolic. MCA territory strokes are most common and uniformly fatal when the entire MCA territory is affected. Functional outcomes in survivors of PCI-stroke are improved when only a single arterial territory is affected. VC 2014 Wiley Periodicals, Inc. Key words: percutaneous coronary intervention; PCI complications; stroke
INTRODUCTION
Stroke is a devastating complication of percutaneous coronary intervention (PCI) associated with substantial morbidity and mortality [1–4]. In a recent analysis of more than 24,000 PCI-related hospitalizations during the contemporary era of rising patient risk profiles and procedural complexity, we reported a 0.37% incidence of PCI-related stroke, which is associated with high rates of in-hospital death, reduced long-term survival, and severe functional limitation [4]. The majority of strokes that occur after PCI are ischemic [1–4]. Two primary mechanisms of PCI-related ischemic stroke (PCI-stroke) have been proposed: embolization of atheromatous debris from the aorta that can occur during catheter manipulation and hemodynamic insufficiency with or without an associated fixed stenosis of cervical or cerebral arteries [5–10]. C 2014 Wiley Periodicals, Inc. V
However, radiological infarction patterns have not been rigorously investigated to determine the mechanisms of ischemia. 1
Division of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota 2 Division of Neurology, Mayo Clinic, Rochester, Minnesota 3 Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota. Conflict of interest: Nothing to report. *Correspondence to: Rajiv Gulati, Division of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN 55905. E-mail: [email protected] Received 13 May 2014; Revision accepted 22 September 2014 DOI: 10.1002/ccd.25678 Published online 7 October 2014 in Wiley Online Library (wileyonlinelibrary.com)
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Historically, cerebral infarction patterns on neuroimaging have been used to elucidate mechanisms of strokes in numerous disease states. For example, thromboembolic strokes related to atrial fibrillation often affect intracranial arterial bed regions that supply the cerebral cortex and juxtacortical white matter, whereas infarctions related to hemodynamic insufficiency occur in borderzone (“watershed”) areas between major arterial territories, and small subcortical infarctions affect regions supplied by penetrating arteries [11–15]. Thus, stroke patterns are diverse and require a detailed interpretation of brain imaging to clarify the etiology of infarction. In this retrospective, single-center study, we evaluated radiological patterns of cerebral infarction to determine mechanisms of cerebrovascular ischemia in patients who experienced PCI-stroke. In addition, we examined long-term neurologic functional outcomes according to pattern of cerebral infarction after PCI. METHODS Patient Population
Patients undergoing PCI at the Mayo Clinic in Rochester, Minnesota, are prospectively followed in a registry that includes demographic, clinical, angiographic, and procedural data. Immediate and in-hospital events are recorded, and each patient is surveyed by telephone using a standardized questionnaire at 6 months and 1 year, and then annually after the procedure. Ten percent of all records are randomly audited by the supervisor for data integrity. All adverse events are confirmed by reviewing the medical records of the patients followed at the institution and by contacting the patients’ physicians and reviewing the hospital records of patients followed elsewhere. In this study, all PCIs from January 1, 1994 to December 31, 2009 at this institution were eligible for analysis. For patients with multiple PCIs within a single hospitalization, only the first PCI was included. Patients who did not consent to use of their records for research were excluded, as per Minnesota state statute. There were 24, 728 PCI hospitalizations of 19,655 unique patients during this period. Four hundred ninety-two patients refused authorization of their records for research and were excluded, leaving 19,163 patients for analysis. These patients were divided into two groups for analysis: (1) those who suffered an inhospital ischemic stroke after PCI; and (2) those who did not. Medical records of all patients were reviewed to determine patterns of cerebral ischemia in patients suffering radiologically confirmed acute ischemic stroke directly attributed to PCI. Of the 19,163 patients considered for analysis, a total of 89 patients had an
acute cerebrovascular event after PCI. Patients in this group with hemorrhagic strokes (n ¼ 6) and transient ischemic attacks (TIAs; n ¼ 20) were excluded, because of lack of clear ischemic mechanism (hemorrhagic) or positive neuroimaging studies (TIAs) for analysis. Additionally, 3 patients were excluded due to intervening coronary artery bypass grafting performed prior to stroke and 25 patients were excluded due to insufficient imaging or clinical data. Imaging from 35 patients suffering radiologically confirmed PCI-stroke was analyzed. Of the 54 patients experiencing PCIrelated stroke who were excluded from the study, 10 of these had prior PCIs and were included in the control group, leaving 19,084 control patients. Clinical, procedural, and angiographic characteristics, as well as early and late clinical outcomes in relation to neuroimaging pattern, were assessed in PCI-stroke patients and controls. Definitions
Ischemic stroke was defined by the presence of a persistent neurological deficit of acute onset lasting >24 hr that was not attributable to intracerebral hemorrhage. Patients with resolution of neurological symptoms within 24 hr of onset were diagnosed with TIAs and were excluded. All patients were evaluated by a consultant neurologist at the time of the event and diagnosis was confirmed by clinical assessment. Additionally, all patients had either head computed tomography (CT), magnetic resonance imaging (MRI), or both performed as part of their evaluation. Causative extracranial ischemic stroke subtype categorization was based on previous classification schema [16]. Stroke distribution was classified according to major intracranial arterial territories outlined in published cerebrovascular maps [17–20]. Infarctions were categorized by radiological pattern, as well as arterial territory involved. Each intracranial large arterial-bed region [e.g., anterior cerebral artery (ACA), middle cerebral artery (MCA), posterior cerebral artery (PCA), and vertebrobasilar artery] was further subclassified into specific hemispheric areas. We used previously described and validated methods for categorizing imaging pattern/ischemic mechanism [21–29]. All images were reviewed by two consultant stroke neurologists and consensus agreement for categorization was obtained in every case. Embolic pattern was defined as an acute, wedge-shaped lesion based in the cortex, acute multiple brain infarctions on diffusion weighted imaging (DWI) sequence of MRI, or concurrent bilateral or multiterritorial acute infarctions. Small subcortical infarctions were defined by size < 10 mm on CT scan (or 3 was defined as a poor outcome, indicating a moderate to severe residual neurologic deficit with a lack of functional independence, or death. Time to death was recorded if it occurred within the follow-up period. For baseline patient characteristics, prior history of cerebrovascular event was defined as a documented history of stroke or TIA that resulted in abnormalities in vision, speech, sensation, or motor function or a history of cerebrovascular (carotid) surgery. Severe renal dysfunction was defined as a creatinine of 3.0 mg/dl or a history of dialysis or renal transplant. Elevated cholesterol was defined as total serum cholesterol greater than or equal to 240 mg/dL. Myocardial infarction was diagnosed in the presence of at least 2 of 3 criteria: (1) typical chest pain for at least 20 min; (2) elevation of serum creatine kinase levels (or the myocardial band fraction) two times normal; and (3) a new Q-wave on the electrocardiogram. Cardiogenic shock was defined as a prolonged systolic arterial pressure 95 mm Hg, or systolic arterial pressure 110 mm Hg while on inotropes or with intraaortic balloon pumps support. The number of diseased coronary arteries was defined by the number of major arteries with at least 50% stenosis provided at least 1 of the major arteries had at least 70% stenosis. Patients with 50% stenosis in the left main coronary artery were considered to have twovessel disease if there was right dominance and threevessel disease if there was left dominance. Procedural success was defined as a reduction of residual luminal diameter stenosis to 20% without in-hospital death, Q-wave myocardial infarction, or need for emergency coronary artery bypass graft surgery. Statistical Analysis Continuous variables are summarized as mean 6 SD and categorical variables as frequency (percentage). Conditional logistic regression was used to compare clinical, angiographic, and procedural variables between PCI-stroke patients and the control population. Kaplan-
1035
Meier estimates and the log-rank test were used to assess differences in follow-up outcomes. P-values less than 0.05 were considered statistically significant. RESULTS Clinical, Angiographic, and Procedural Characteristics
Between 1994 and 2009, there were 89 patients who experienced PCI-related acute cerebrovascular events, including six hemorrhagic strokes (n ¼ 6), and 20 TIAs. Thirty-five patients who met strict inclusion criteria for this study experienced radiologically confirmed PCIstroke, and their clinical, angiographic, and procedural characteristics are summarized in Tables I and II. Compared to patients who underwent PCI and did not experience ischemic stroke, patients experiencing radiologically confirmed PCI-stroke were more likely to be older (age 73 6 11 years vs. 66 6 12 years, P ¼ 0.001), female (54% vs. 30%, P ¼ 0.002), have a history of hypertension (91% vs. 69%, P ¼ 0.004), cerebrovascular event (33% vs. 10%, P < 0.001), peripheral vascular disease (26% vs. 10%, P ¼ 0.003), or myocardial infarction within 7 days of PCI (66% vs. 36%, P < 0.001), have intracoronary thrombus (57% vs. 34%, P ¼0.008), have cardiogenic shock before the procedure (17% vs. 4%, P < 0.001), and be treated with an urgent or emergent intervention (83% vs. 64%, P < 0.001). Overall procedural success, defined as a reduction of residual luminal diameter stenosis to 20% without inhospital death, Q-wave myocardial infarction, or need for emergency coronary artery bypass graft surgery, was also lower in the PCI-stroke group than in the control group (63% vs. 89%, P < 0.001). A history of atrial fibrillation was more common in PCI-stroke patients than controls, but the difference was not statistically significant (20% vs. 11%, P ¼ 0.07), nor was the rate of ischemic stroke occurring in procedures that employed thrombectomy (6% vs. 3%, P ¼ 0.22) or a femoral vs. radial approach (0.18% vs. 0.37%, P ¼ 0.31). Cranial Imaging Characteristics Of the 35 patients suffering radiologically confirmed PCI-stroke, both head CT and MRI were performed in 24 patients, while 10 patients underwent CT alone, and one patient underwent MRI alone. The overwhelming majority of strokes (91%) demonstrated an embolic pattern of cerebral infarction on neuroimaging. The remaining strokes (9%) were small subcortical infarctions in the lenticulostriate territory. Figure 1 summarizes the frequency of single and multiple territory infarctions in patients suffering radiologically confirmed PCI-stroke. Multiple and bilateral strokes
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
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TABLE I. Clinical Characteristics of Patients With PCI-Stroke Clinical characteristics Variable Age, yrs Male MI within 7 days prior Preprocedural shock Unstable angina Diabetes mellitus Hypertension History of atrial fibrillation Body mass index, kg/m2 History of cholesterol 240 mg/dl Prior PTCA Prior CABG Peripheral vascular disease History of cerebrovascular event Moderate-to-severe renal disease COPD Tumor/lymphoma/leukemia Metastatic cancer Cardiac arrest preprocedure
Imaging (þ) (N ¼ 35)
Controls (N ¼ 19,084)
Angiographic and procedural characteristics P Value
72.8 16 23 6 19 13 32 7 28.3 23
(10.8) (46%) (66%) (17%) (54%) (37%) (91%) (20%) (6.0) (77%)
66.3 13,379 6,726 793 10,770 4,543 12,606 2,007 29.4 12,625
(12.1) (70%) (36%) (4%) (56%) (24%) (69%) (11%) (5.6) (73%)
0.001 0.002
Neuroimaging Patterns of Ischemic Stroke After Percutaneous Coronary Intervention Scott J. Hoffman,1 MD, Alan H. Yee,2 DO, Joshua P. Slusser,3 BS, Charanjit S. Rihal,1 MD, FSCAI, David R. Holmes Jr.,1 MD, FSCAI, Alejandro A. Rabinstein,2 MD, and Rajiv Gulati,1* MD, PhD, FSCAI Objectives: We sought to determine neuroimaging patterns, ischemic mechanisms, and functional outcomes of ischemic stroke related to percutaneous coronary intervention (PCI) over a 16-year period. Background: Stroke is a feared complication of PCI, associated with poor patient outcomes. The majority of strokes that occur after PCI are ischemic rather than hemorrhagic. However, mechanisms of cerebral ischemia in this setting are incompletely understood. Methods: We performed a retrospective single-center cohort study of patients with radiologically confirmed ischemic stroke occurring after PCI (PCI-stroke), between January 1, 1994 and December 31, 2009. Using brain imaging, infarctions were subclassified by radiological pattern and arterial territory as embolic, small subcortical, or hemodynamic. Modified Rankin Scale scores were used to assess functional outcome at 3 and 6 months. Results: Radiologically confirmed PCIstroke was identified in 35 patients. The majority of strokes (91%) revealed an embolic pattern, while the remaining strokes were small subcortical infarctions (9%). Watershed strokes with exclusive borderzone involvement, indicative of a hemodynamic mechanism, were not identified, despite the presence of periprocedural hypotension in 23% of patients. The middle cerebral artery (MCA) territory was affected most frequently (80%), and all patients suffering a complete MCA territorial infarction (14%) died in the hospital. Functional outcome among survivors of PCI-stroke was typically favorable in those who had single rather than multiple vascular territory involvement. Conclusions: The vast majority of radiologically confirmed ischemic strokes related to PCI are embolic. MCA territory strokes are most common and uniformly fatal when the entire MCA territory is affected. Functional outcomes in survivors of PCI-stroke are improved when only a single arterial territory is affected. VC 2014 Wiley Periodicals, Inc. Key words: percutaneous coronary intervention; PCI complications; stroke
INTRODUCTION
Stroke is a devastating complication of percutaneous coronary intervention (PCI) associated with substantial morbidity and mortality [1–4]. In a recent analysis of more than 24,000 PCI-related hospitalizations during the contemporary era of rising patient risk profiles and procedural complexity, we reported a 0.37% incidence of PCI-related stroke, which is associated with high rates of in-hospital death, reduced long-term survival, and severe functional limitation [4]. The majority of strokes that occur after PCI are ischemic [1–4]. Two primary mechanisms of PCI-related ischemic stroke (PCI-stroke) have been proposed: embolization of atheromatous debris from the aorta that can occur during catheter manipulation and hemodynamic insufficiency with or without an associated fixed stenosis of cervical or cerebral arteries [5–10]. C 2014 Wiley Periodicals, Inc. V
However, radiological infarction patterns have not been rigorously investigated to determine the mechanisms of ischemia. 1
Division of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota 2 Division of Neurology, Mayo Clinic, Rochester, Minnesota 3 Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota. Conflict of interest: Nothing to report. *Correspondence to: Rajiv Gulati, Division of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN 55905. E-mail: [email protected] Received 13 May 2014; Revision accepted 22 September 2014 DOI: 10.1002/ccd.25678 Published online 7 October 2014 in Wiley Online Library (wileyonlinelibrary.com)
1034
Hoffman et al.
Historically, cerebral infarction patterns on neuroimaging have been used to elucidate mechanisms of strokes in numerous disease states. For example, thromboembolic strokes related to atrial fibrillation often affect intracranial arterial bed regions that supply the cerebral cortex and juxtacortical white matter, whereas infarctions related to hemodynamic insufficiency occur in borderzone (“watershed”) areas between major arterial territories, and small subcortical infarctions affect regions supplied by penetrating arteries [11–15]. Thus, stroke patterns are diverse and require a detailed interpretation of brain imaging to clarify the etiology of infarction. In this retrospective, single-center study, we evaluated radiological patterns of cerebral infarction to determine mechanisms of cerebrovascular ischemia in patients who experienced PCI-stroke. In addition, we examined long-term neurologic functional outcomes according to pattern of cerebral infarction after PCI. METHODS Patient Population
Patients undergoing PCI at the Mayo Clinic in Rochester, Minnesota, are prospectively followed in a registry that includes demographic, clinical, angiographic, and procedural data. Immediate and in-hospital events are recorded, and each patient is surveyed by telephone using a standardized questionnaire at 6 months and 1 year, and then annually after the procedure. Ten percent of all records are randomly audited by the supervisor for data integrity. All adverse events are confirmed by reviewing the medical records of the patients followed at the institution and by contacting the patients’ physicians and reviewing the hospital records of patients followed elsewhere. In this study, all PCIs from January 1, 1994 to December 31, 2009 at this institution were eligible for analysis. For patients with multiple PCIs within a single hospitalization, only the first PCI was included. Patients who did not consent to use of their records for research were excluded, as per Minnesota state statute. There were 24, 728 PCI hospitalizations of 19,655 unique patients during this period. Four hundred ninety-two patients refused authorization of their records for research and were excluded, leaving 19,163 patients for analysis. These patients were divided into two groups for analysis: (1) those who suffered an inhospital ischemic stroke after PCI; and (2) those who did not. Medical records of all patients were reviewed to determine patterns of cerebral ischemia in patients suffering radiologically confirmed acute ischemic stroke directly attributed to PCI. Of the 19,163 patients considered for analysis, a total of 89 patients had an
acute cerebrovascular event after PCI. Patients in this group with hemorrhagic strokes (n ¼ 6) and transient ischemic attacks (TIAs; n ¼ 20) were excluded, because of lack of clear ischemic mechanism (hemorrhagic) or positive neuroimaging studies (TIAs) for analysis. Additionally, 3 patients were excluded due to intervening coronary artery bypass grafting performed prior to stroke and 25 patients were excluded due to insufficient imaging or clinical data. Imaging from 35 patients suffering radiologically confirmed PCI-stroke was analyzed. Of the 54 patients experiencing PCIrelated stroke who were excluded from the study, 10 of these had prior PCIs and were included in the control group, leaving 19,084 control patients. Clinical, procedural, and angiographic characteristics, as well as early and late clinical outcomes in relation to neuroimaging pattern, were assessed in PCI-stroke patients and controls. Definitions
Ischemic stroke was defined by the presence of a persistent neurological deficit of acute onset lasting >24 hr that was not attributable to intracerebral hemorrhage. Patients with resolution of neurological symptoms within 24 hr of onset were diagnosed with TIAs and were excluded. All patients were evaluated by a consultant neurologist at the time of the event and diagnosis was confirmed by clinical assessment. Additionally, all patients had either head computed tomography (CT), magnetic resonance imaging (MRI), or both performed as part of their evaluation. Causative extracranial ischemic stroke subtype categorization was based on previous classification schema [16]. Stroke distribution was classified according to major intracranial arterial territories outlined in published cerebrovascular maps [17–20]. Infarctions were categorized by radiological pattern, as well as arterial territory involved. Each intracranial large arterial-bed region [e.g., anterior cerebral artery (ACA), middle cerebral artery (MCA), posterior cerebral artery (PCA), and vertebrobasilar artery] was further subclassified into specific hemispheric areas. We used previously described and validated methods for categorizing imaging pattern/ischemic mechanism [21–29]. All images were reviewed by two consultant stroke neurologists and consensus agreement for categorization was obtained in every case. Embolic pattern was defined as an acute, wedge-shaped lesion based in the cortex, acute multiple brain infarctions on diffusion weighted imaging (DWI) sequence of MRI, or concurrent bilateral or multiterritorial acute infarctions. Small subcortical infarctions were defined by size < 10 mm on CT scan (or 3 was defined as a poor outcome, indicating a moderate to severe residual neurologic deficit with a lack of functional independence, or death. Time to death was recorded if it occurred within the follow-up period. For baseline patient characteristics, prior history of cerebrovascular event was defined as a documented history of stroke or TIA that resulted in abnormalities in vision, speech, sensation, or motor function or a history of cerebrovascular (carotid) surgery. Severe renal dysfunction was defined as a creatinine of 3.0 mg/dl or a history of dialysis or renal transplant. Elevated cholesterol was defined as total serum cholesterol greater than or equal to 240 mg/dL. Myocardial infarction was diagnosed in the presence of at least 2 of 3 criteria: (1) typical chest pain for at least 20 min; (2) elevation of serum creatine kinase levels (or the myocardial band fraction) two times normal; and (3) a new Q-wave on the electrocardiogram. Cardiogenic shock was defined as a prolonged systolic arterial pressure 95 mm Hg, or systolic arterial pressure 110 mm Hg while on inotropes or with intraaortic balloon pumps support. The number of diseased coronary arteries was defined by the number of major arteries with at least 50% stenosis provided at least 1 of the major arteries had at least 70% stenosis. Patients with 50% stenosis in the left main coronary artery were considered to have twovessel disease if there was right dominance and threevessel disease if there was left dominance. Procedural success was defined as a reduction of residual luminal diameter stenosis to 20% without in-hospital death, Q-wave myocardial infarction, or need for emergency coronary artery bypass graft surgery. Statistical Analysis Continuous variables are summarized as mean 6 SD and categorical variables as frequency (percentage). Conditional logistic regression was used to compare clinical, angiographic, and procedural variables between PCI-stroke patients and the control population. Kaplan-
1035
Meier estimates and the log-rank test were used to assess differences in follow-up outcomes. P-values less than 0.05 were considered statistically significant. RESULTS Clinical, Angiographic, and Procedural Characteristics
Between 1994 and 2009, there were 89 patients who experienced PCI-related acute cerebrovascular events, including six hemorrhagic strokes (n ¼ 6), and 20 TIAs. Thirty-five patients who met strict inclusion criteria for this study experienced radiologically confirmed PCIstroke, and their clinical, angiographic, and procedural characteristics are summarized in Tables I and II. Compared to patients who underwent PCI and did not experience ischemic stroke, patients experiencing radiologically confirmed PCI-stroke were more likely to be older (age 73 6 11 years vs. 66 6 12 years, P ¼ 0.001), female (54% vs. 30%, P ¼ 0.002), have a history of hypertension (91% vs. 69%, P ¼ 0.004), cerebrovascular event (33% vs. 10%, P < 0.001), peripheral vascular disease (26% vs. 10%, P ¼ 0.003), or myocardial infarction within 7 days of PCI (66% vs. 36%, P < 0.001), have intracoronary thrombus (57% vs. 34%, P ¼0.008), have cardiogenic shock before the procedure (17% vs. 4%, P < 0.001), and be treated with an urgent or emergent intervention (83% vs. 64%, P < 0.001). Overall procedural success, defined as a reduction of residual luminal diameter stenosis to 20% without inhospital death, Q-wave myocardial infarction, or need for emergency coronary artery bypass graft surgery, was also lower in the PCI-stroke group than in the control group (63% vs. 89%, P < 0.001). A history of atrial fibrillation was more common in PCI-stroke patients than controls, but the difference was not statistically significant (20% vs. 11%, P ¼ 0.07), nor was the rate of ischemic stroke occurring in procedures that employed thrombectomy (6% vs. 3%, P ¼ 0.22) or a femoral vs. radial approach (0.18% vs. 0.37%, P ¼ 0.31). Cranial Imaging Characteristics Of the 35 patients suffering radiologically confirmed PCI-stroke, both head CT and MRI were performed in 24 patients, while 10 patients underwent CT alone, and one patient underwent MRI alone. The overwhelming majority of strokes (91%) demonstrated an embolic pattern of cerebral infarction on neuroimaging. The remaining strokes (9%) were small subcortical infarctions in the lenticulostriate territory. Figure 1 summarizes the frequency of single and multiple territory infarctions in patients suffering radiologically confirmed PCI-stroke. Multiple and bilateral strokes
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
1036
Hoffman et al.
TABLE I. Clinical Characteristics of Patients With PCI-Stroke Clinical characteristics Variable Age, yrs Male MI within 7 days prior Preprocedural shock Unstable angina Diabetes mellitus Hypertension History of atrial fibrillation Body mass index, kg/m2 History of cholesterol 240 mg/dl Prior PTCA Prior CABG Peripheral vascular disease History of cerebrovascular event Moderate-to-severe renal disease COPD Tumor/lymphoma/leukemia Metastatic cancer Cardiac arrest preprocedure
Imaging (þ) (N ¼ 35)
Controls (N ¼ 19,084)
Angiographic and procedural characteristics P Value
72.8 16 23 6 19 13 32 7 28.3 23
(10.8) (46%) (66%) (17%) (54%) (37%) (91%) (20%) (6.0) (77%)
66.3 13,379 6,726 793 10,770 4,543 12,606 2,007 29.4 12,625
(12.1) (70%) (36%) (4%) (56%) (24%) (69%) (11%) (5.6) (73%)
0.001 0.002
