CathLabHub

CathLabHub complications toolkitcathlabhub.com/toolkit/procedural-strokeIn review, October 24, 2026

Recognize

The signs on the monitor, the image and the patient.

  • PatientNew weakness, facial droop, speech trouble, neglect or gaze deviation, often noticed on the table or in recovery 1.
  • PatientA patient who does not wake from sedation as expected.
  • MonitorHypertension or a new arrhythmia may accompany it.
  • LabGlucose and saturation to exclude mimics 2.

Act now

In the order the operator does them. The first three come first, whatever else is happening.

  1. Note the last known well time and stop the procedure as soon as it is safe.
  2. Call the stroke team now; examine with the NIH stroke scale 2.
  3. Check the glucose and oxygen saturation; consider reversing sedation 2.
  4. Brain imaging: CT and CT angiography, or MRI, to exclude bleeding and find an occlusion 2.
  5. Large vessel occlusion: thrombectomy; within 6 hours of onset in the 2019 guideline, and selected patients to 24 hours 3.
  6. IV alteplase only by the stroke team, 0.9 mg/kg (maximum 90 mg) within 4.5 hours when there are no contraindications; recent heparin and an arterial puncture count against it 3.
  7. Keep the blood pressure under 185/110 mmHg before lytic therapy 3.
  8. Air embolism to the brain: 100 percent oxygen, and hyperbaric oxygen if available 4.

Equipment

From the complications cart. Linked items open in the equipment directory.

Drugs

Adult doses as the cited source gives them. Check your formulary and the label.

  • Alteplase0.9 mg/kg IV, maximum 90 mg, 10 percent as a bolus over 1 minute and the rest over 60 minutes, given by the stroke team 3.Product in the directory
  • Naloxone and flumazenilNaloxone 0.1 to 0.2 mg IV, repeat every 2 to 3 minutes; flumazenil 0.2 mg IV, repeat to 1 mg, to unmask a deficit 5.

Who to call

The escalation ladder, first call first.

  1. Stroke team: at once.
  2. Neurointervention: for a large vessel occlusion 23.
  3. Anesthesia: if the airway is at risk.
  4. CT: to be ready for a direct transfer.

The bailout step by step

Stroke code from the cath lab 23

  1. Time of onset or last known well, written on the board.
  2. NIH stroke scale; glucose; saturation; review sedation.
  3. Finish or abandon the case safely; keep the arterial sheath if neurointervention may use it.
  4. CT and CT angiography, or straight to cerebral angiography where the lab and team can do it 2.
  5. Stroke team decides on alteplase and thrombectomy 3.
  6. Blood pressure to target; hold further anticoagulation until bleeding is excluded.

Prevent

  • Aspirate and flush catheters; exchange catheters over a wire in the aorta 1.
  • Meticulous de airing of every line and device 4.
  • Minimize catheter manipulation in a diseased arch; radial or femoral choice by the arch.

After care and documentation

  • Neurologic checks per the stroke unit; swallow screen.
  • Document the deficit, times, imaging, treatment and the procedure step when it happened.

Practice

Emergency simulator cases in the Cath Trainer app. The link opens Cases; type the case number in the search box.

  • EMG-0025: The patient ignores the left side of the room
  • EMG-0050: The left arm lies still on the table
  • EMG-0075: The patient cannot find the words

References

  1. Berg R, Lim MJ. Complications of percutaneous coronary interventions. In: Kern MJ, ed. The Interventional Cardiac Catheterization Handbook. 3rd ed. Saunders, Elsevier; 2013. Chapter 4.
  2. Hamon M, Baron JC, Viader F, Hamon M. Periprocedural stroke and cardiac catheterization. Circulation 2008;118:678-683.
  3. Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines. Stroke 2019;50:e344-e418.
  4. Brilakis ES. Manual of Percutaneous Coronary Interventions. Elsevier; 2021. Chapter 25, Acute vessel closure.
  5. Brilakis ES. Manual of Percutaneous Coronary Interventions: A Step-by-Step Approach. Academic Press, Elsevier; 2021. Chapter 3, Medications.
  6. CathLabHub Cath Trainer app, emergency simulator: case library (cathlabhub.com/app, Cases).

Educational reference for cath lab teams, not medical advice and not a standard of care. Your local policy, the device instructions for use and current guidelines govern. Verify every dose before use. Printed from cathlabhub.com/toolkit/procedural-stroke. First version, in clinical review: an interventional cardiologist is checking every card before it is final. Every number cites its source on the card.