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"On-the table" stroke management

The most efficient workflow for the management of patients with suspected “on-the-table” stroke is illustrated. On recognition of acute neurologic changes during a heart procedure, if the patient is not back at his or her baseline following the administration of sedation reversing drugs, the next step depends on the availability in that particular catheterization suite of cone-beam CT. This modality, increasingly available in modern catheterization suites, allows rapid, "on the spot" image acquisition of the brain without having to move the patient. If this is carried out and a hemorrhagic stroke is diagnosed, the cardiac index procedure should be aborted and the patient moved to the neurointensive care unit for further care. If, on the other hand, there is no imaging evidence of an intracranial hemorrhage, urgent neuroangiography should be the next step because it can be carried out without moving the patient. IV-tPA = intravenous tissue plasminogen activator; LAO = large arterial occlusion; NCCT = non-contrast computed tomography; NICU = neurointensive care unit. (Contributed by Dr. Jose Biller.)