Department of Cardiology, Austin Health, Melbourne, VIC, Australia.
Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia.
Curr Cardiol Rep. 2023 Nov;25(11):1499-1512. doi: 10.1007/s11886-023-01962-y. Epub 2023 Oct 17.
Coronary angiography-associated acute ischaemic stroke (CAAIS) is an uncommon event but is associated with significant mortality and morbidity. The incidence of CAAIS has increased with a rise in the volume of coronary angiography (CA) and percutaneous coronary intervention (PCI) performed. Intravenous thrombolysis (IVT) is utilized in the general management of acute ischaemic stroke; however, it is associated with a higher risk of intracranial hemorrhage (ICH). As CA or PCI is performed more often in an aging population or high-risk patients that also carry an increased risk of ICH, it is vital to minimize additional complications from the treatment of CAAIS. This article aims to review the pathophysiological mechanisms for CAAIS, clarify the current evidence regarding IVT use in this setting, and thus assist cardiologists in the management of CAAIS.
The pathophysiology for CAAIS may be different from acute ischaemic stroke in the general population. Embolic phenomena from dislodgement of calcium or other debris during manipulation of instrumentation during CA or PCI are likely mechanisms. This may contribute to altered thrombus composition, which affects the efficacy of IVT as suggested in recent studies. Furthermore, IVT in the management of CAAIS has not been evaluated specifically. The utilization of IVT should be carefully considered in CAAIS given a paucity of evidence demonstrating safety and efficacy in this setting. A multidisciplinary pathway that emphasizes the involvement of cardiologists in the treatment decision-making process would aid in thoughtful risk-benefit evaluation for IVT use in CAAIS and reduce adverse patient outcomes. Future studies to assess the impact of this pathway on CAAIS outcomes would be beneficial.
冠状动脉造影相关急性缺血性脑卒中（CAAIS）虽不常见，但与较高的病死率和病残率相关。随着冠状动脉造影（CA）和经皮冠状动脉介入治疗（PCI）数量的增加，CAAIS 的发生率也有所增加。静脉溶栓（IVT）是急性缺血性脑卒中常规治疗的一部分；但它与颅内出血（ICH）风险增加相关。由于 CA 或 PCI 在老年患者或高风险患者中更为常见，而这些患者也有更高的 ICH 风险，因此，必须尽量减少 CAAIS 治疗的其他并发症。本文旨在综述 CAAIS 的病理生理学机制，阐明 IVT 在该治疗环境下应用的现有证据，从而协助心脏病专家对 CAAIS 进行管理。
CAAIS 的病理生理学机制可能与普通人群的急性缺血性脑卒中不同。CA 或 PCI 过程中器械操作引起的钙或其他碎片脱落导致的栓塞现象可能是其机制。这可能导致血栓成分改变，正如最近的研究表明，这会影响 IVT 的疗效。此外，CAAIS 中 IVT 的应用尚未得到专门评估。鉴于缺乏在该环境下证明安全性和疗效的证据，应谨慎考虑 CAAIS 中 IVT 的应用。强调心脏病专家参与治疗决策过程的多学科途径，将有助于对 CAAIS 中 IVT 的应用进行有针对性的风险效益评估，并降低不良患者结局。评估该途径对 CAAIS 结局影响的未来研究将是有益的。
