one of the most daunting complications of cardiac catheterization is a cerebrovascular event ( cve ) .
stroke after cardiac catheterization procedures occurs mostly in older patients with vascular comorbidities , undergoing complicated invasive procedures .
the incidence of stroke following percutaneous coronary intervention ( pci ) has been variably reported between 0.3% and 0.4% .
the aim of our study was to assess the reallife incidence , etiology , risk factors , and temporal trends of cardiac catheterizationrelated acute cves ( ischemic stroke ; transient ischemic attack ; intracerebral hemorrhage ) in a large cohort of patients treated in a single center .
all authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation .
the study population consists of all patients undergoing coronary angiography and/or a coronary intervention over the period 19922011 at the shaare zedek medical center , jerusalem , israel .
all noncoronary procedures were excluded , particularly peripheral interventions ( including carotid ) , structural heart procedures , and right heart catheterizations .
the data were derived from the electronic medical record of the cardiology department , based on clicks software ( roshtov software industries ltd ) .
this record contains data including demographics , diagnoses , risk factors , angiographic and procedural details , medications , hospitalization course , ancillary tests , and outpatient followup for all patients undergoing cardiac catheterization .
data collection was performed using computerized queries , retrieving all angiographic and procedural details and discharge summaries .
cve patients were identified by searching for any of the terms  cerebrovascular accident  or  c.v.a .  or  t.i.a .  or 
stroke  or  intracranial hemorrhage  in the diagnoses of discharge summaries and in the complications recorded in the angiographic summaries .
in addition hospitalization courses after the procedure were searched for keywords such as  neurologic consultation , 
 ct referral ,   weakness or paralysis of one side of the body , 
all files with one of these diagnoses or keywords were reviewed by an experienced neurologist ( ilk ) , including computed tomography ( ct ) scans .
events with an onset time within 24 hours from procedure completion were included and defined as cve group . due to the specific local health fund system , readmissions of patients discharged in less than 24 hours from the index procedure
the study was approved by the ethics committee of the shaare zedek medical center , jerusalem , israel .
as the considered risk period was 24 hours , the assessment unit used was procedural days .
if a patient underwent both a diagnostic and an interventional procedure within the same 24hour period , this was considered an interventional procedural day .
stroke was diagnosed according to world health organization criteria , which defines a stroke as a focal deficit that lasts for more than 24 hours .
transient ischemic attack ( tia ) was defined as focal neurological signs lasting fewer than 24 hours .
ischemic strokes ( is ) and intracerebral hemorrhages ( ich ) were differentiated by the findings on brain ct , performed between day 1 and day 2 after the onset of the stroke .
anatomical localization of stroke was performed based upon clinical subtypes of ischemic stroke using the oxfordshire community stroke project classification .
onset time was defined as the first appearance of abnormal signs that were noticed by the treating team during the cardiac catheterization or after , while hospitalized in the cardiology department .
the principal outcome of this study was periprocedural cve ( cve that occurred within 24 hours of the procedure ) .
the following explanatory variables were assessed : ( 1 ) patient demographics : gender , ethnicity , and age ; ( 2 ) clinical characteristics and risk factors : hypertension , diabetes mellitus , smoker , hyperlipidemia , prior myocardial infarction ( mi ) , prior coronary arteries bypass surgery ( cabg ) , prior stroke , renal disease , peripheral vascular disease ( pvd ) , previously diagnosed carotid artery disease , atrial fibrillation ( af ) , and acute coronary syndrome ( acs ) ; ( 3 ) procedural characteristics and findings : puncture site , performance of ventriculography , percutaneous coronary intervention ( pci ) , stent implantation , drug eluting stent ( des ) , number of catheters , use of eptifibatide or bivalirudin , vessel treated , triple vessel disease , bifurcation lesion , chronic lesion , and coronary artery thrombus .
categorical variables were compared using chisquare test or fisher exact test and continuous variables using unpaired student t test .
a multivariate forward , stepwise logistic regression analysis was performed to determine independent predictors for periprocedural stroke .
the criterion for entrance into the model was a univariate probability value of p<0.05 and p>0.10 for removal from the model .
the discriminatory power of the model was examined using c statistics , whereas c value ranges from 0.5 ( the model 's predictions are not better than chance ) to 1.0 ( the model always assigns higher probabilities to correct cases than to incorrect cases ) .
c values of 0.7 to 0.8 are considered to show acceptable discrimination , values of 0.8 to 0.9 to indicate excellent discrimination , and values of 0.9 to show outstanding discrimination .
the statistical tests were 2 sided . a p value < 0.05 was considered as statistically significant .
analyses were carried out using spss version 15.0 statistical package ( spss , inc ) .
the study population consists of all patients undergoing coronary angiography and/or a coronary intervention over the period 19922011 at the shaare zedek medical center , jerusalem , israel .
all noncoronary procedures were excluded , particularly peripheral interventions ( including carotid ) , structural heart procedures , and right heart catheterizations .
the data were derived from the electronic medical record of the cardiology department , based on clicks software ( roshtov software industries ltd ) .
this record contains data including demographics , diagnoses , risk factors , angiographic and procedural details , medications , hospitalization course , ancillary tests , and outpatient followup for all patients undergoing cardiac catheterization .
data collection was performed using computerized queries , retrieving all angiographic and procedural details and discharge summaries .
cve patients were identified by searching for any of the terms  cerebrovascular accident  or  c.v.a .  or  t.i.a .  or 
stroke  or  intracranial hemorrhage  in the diagnoses of discharge summaries and in the complications recorded in the angiographic summaries .
in addition hospitalization courses after the procedure were searched for keywords such as  neurologic consultation ,   ct referral ,   weakness or paralysis of one side of the body ,   speech problems ,  etc . all files with one of these diagnoses or keywords
were reviewed by an experienced neurologist ( ilk ) , including computed tomography ( ct ) scans .
events with an onset time within 24 hours from procedure completion were included and defined as cve group . due to the specific local health fund system , readmissions of patients discharged in less than 24 hours from the index procedure
the study was approved by the ethics committee of the shaare zedek medical center , jerusalem , israel .
as the considered risk period was 24 hours , the assessment unit used was procedural days .
if a patient underwent both a diagnostic and an interventional procedure within the same 24hour period , this was considered an interventional procedural day .
stroke was diagnosed according to world health organization criteria , which defines a stroke as a focal deficit that lasts for more than 24 hours .
transient ischemic attack ( tia ) was defined as focal neurological signs lasting fewer than 24 hours .
ischemic strokes ( is ) and intracerebral hemorrhages ( ich ) were differentiated by the findings on brain ct , performed between day 1 and day 2 after the onset of the stroke .
anatomical localization of stroke was performed based upon clinical subtypes of ischemic stroke using the oxfordshire community stroke project classification .
onset time was defined as the first appearance of abnormal signs that were noticed by the treating team during the cardiac catheterization or after , while hospitalized in the cardiology department .
the principal outcome of this study was periprocedural cve ( cve that occurred within 24 hours of the procedure ) .
the following explanatory variables were assessed : ( 1 ) patient demographics : gender , ethnicity , and age ; ( 2 ) clinical characteristics and risk factors : hypertension , diabetes mellitus , smoker , hyperlipidemia , prior myocardial infarction ( mi ) , prior coronary arteries bypass surgery ( cabg ) , prior stroke , renal disease , peripheral vascular disease ( pvd ) , previously diagnosed carotid artery disease , atrial fibrillation ( af ) , and acute coronary syndrome ( acs ) ; ( 3 ) procedural characteristics and findings : puncture site , performance of ventriculography , percutaneous coronary intervention ( pci ) , stent implantation , drug eluting stent ( des ) , number of catheters , use of eptifibatide or bivalirudin , vessel treated , triple vessel disease , bifurcation lesion , chronic lesion , and coronary artery thrombus .
categorical variables were compared using chisquare test or fisher exact test and continuous variables using unpaired student t test .
a multivariate forward , stepwise logistic regression analysis was performed to determine independent predictors for periprocedural stroke .
the criterion for entrance into the model was a univariate probability value of p<0.05 and p>0.10 for removal from the model .
the discriminatory power of the model was examined using c statistics , whereas c value ranges from 0.5 ( the model 's predictions are not better than chance ) to 1.0 ( the model always assigns higher probabilities to correct cases than to incorrect cases ) .
c values of 0.7 to 0.8 are considered to show acceptable discrimination , values of 0.8 to 0.9 to indicate excellent discrimination , and values of 0.9 to show outstanding discrimination .
the statistical tests were 2 sided . a p value < 0.05 was considered as statistically significant .
analyses were carried out using spss version 15.0 statistical package ( spss , inc ) .
over the study period 43 350 procedures were performed on 30 907 procedure days . on these days , 17 150 diagnostic and 13 757 interventional procedures ( comprising 1314 interventional only and 12 443 combined procedures ) were performed . from this total cohort ,
110 patient admission files were individually assessed based upon the predetermined keywords in the search .
fifty inhospital cves were identified . of these , 1 occurred prior to the index catheterization and 2 others appeared to not be related to the index procedure and were beyond the predetermined 24hour window . fortyseven ( 0.15% ) procedurerelated cves were identified with 37 ischemic strokes ( is ) , 6 tias , 3 ich intracerebral hemorrhages , and 1 undetermined stroke ( ct not performed ) ( figure 1 ) .
cve indicates cerebrovascular event ; ich , intracerebral hemorrhage ; tia , transient ischemic attack .
twentyseven ischemic strokes were located in the anterior circulation ( right hemisphere 15 ; left hemisphere 12 ) while 10 strokes were within the posterior circulation . of the 47 cves occurring in the entire cohort , 31 occurred related to a pci and 16 related to a diagnostic coronary angiogram .
the cve rate for the entire cohort was 0.15% , while the rates for pci and diagnostic coronary angiography were 0.23% and 0.09% , respectively .
baseline patient and procedural characteristics of the patients undergoing cve and those of the remaining population are presented in table 1 . when compared with patients not suffering a cve ,
those experiencing cves were older ( 71.311.3 years versus 63.311.8 years , p<0.0001 ) , more likely to suffer from hypertension ( 74% versus 51% , p=0.008 ) , had prediagnosed carotid artery disease ( 6% versus 1% , p=0.002 ) , had suffered a previous stroke ( 51% versus 5% , p<0.0001 ) , had prior or current af ( 15% versus 6% , p=0.021 ) , were admitted with acs ( 55% versus 35% , p=0.014 ) , were nonsmokers ( 81% versus 62% , p=0.003 ) , and were undergoing an intervention ( 66% versus 44% p=0.003 ) .
there was a trend to increased risk for a cve in patients with known pvd ( 0.34% with pvd versus 0.15% without pvd , p=0.08 ) .
no increased risk for cves was associated with female gender , ethnicity , presence of diabetes mellitus , hyperlipidemia , obesity , previous mi , prior cabg , congestive heart failure , left ventricular dysfunction , or use of intraortic balloon pump .
patients ' baseline and procedural characteristics acs indicates acute coronary syndrome ; af , atrial fibrillation ; cabg , coronary artery bypass graft surgery ; cve , cerebrovascular event ; cx , circumflex ; lad , left anterior descending ; lima , left internal mammary artery ; lm , left main ; mi , myocardial infarction ; pvd , peripheral vascular disease ; rca , right coronary artery ; svg , saphenous vein graft .
multiple procedural characteristics were assessed for relationships with cves ( table 1 ) . these included , but were not limited to , access site , performance of ventriculography , the number of catheters used , extent of coronary disease ( single , double , or triple vessel ) , presence of a coronary artery thrombus , intervened vessel , chronic or bifurcation lesions , and treatment with eptifibatide or bivalirudin . at univariate analysis ,
the presence of coronary artery thrombus and triple vessel disease were the only procedural variables found to be significant and a trend to increased risk was found in patients treated with eptifibatide or bivalirudin .
forward , stepwise logistic regression analysis was used to assess associations of all background demographics , risk factors , and procedural characteristics with catheterizationrelated cve adjusted for other significant risk factors .
a total of 5 significant predictors were thus defined : prior stroke ( or=15.09 , 95% ci [ 8.11 to 28.08 ] , p<0.0001 ) , the presence of coronary arterial thrombus ( or=2.79 , 95% ci [ 1.25 to 6.22 ] , p=0.012 ) , age greater than 75 years ( or=3.33 , 95% ci [ 1.79 to 6.19 ] , p<0.0001 ) , triple vessel disease ( or=2.24 , 95% ci [ 1.20 to 4.18 ] , p=0.011 ) , and the performance of an intervention ( or=2.21 , 95% ci [ 1.12 to 4.33 ] , p=0.021 ) .
this logistic regression is presented in table 2 model a. predictors for cve after cardiac catheterization : multiple logistic regression ci indicates confidence interval ; cve , cerebrovascular event ; or , odds ratio ; pci , percutaneous coronary intervention ; tvd , triple vessel disease .
although in the first half of the study period the rate of cve was 0.08% and rose to 0.22% over the next 10 years , this did not achieve statistical significance .
this is despite the numerical increase of strokes noted since 2005 ( chisquare analysis p=0.264 ) ( figure 2 ) .
temporal analyses of patients ' and procedural characteristics revealed significant increase rates of almost all variables found to be independent risk factors
. rates of prior stroke increased from 2% to 7% , presence of thrombus rose from 4% to 10% , percent of elderly population ( age over 75 years ) undergoing procedure increased from 10% to 24% and finally percent of interventional procedures performed over the study period changed from 14% in 1992 to over 50% since 2005 ( p<0.0001 for all ) ( figure 3 ) .
temporal variation of procedurerelated cve risk factors over the study period . in order to assess its impact as a possible cofounder
, the year of procedure was forced into the model developed from the previous stepwise method as an additional step and referred to as model b. this further step did not reduce the strength nor the statistical significance of the independent stroke predictors that were identified in model a ( table 2 , model b). the c statistic was 0.866 , still indicating an excellent discriminatory power of the model .
all were treated with aspirin , clopidogrel , and heparin , with 2 patients treated with additional eptifibatide and 1 with bivalirudin .
the first case was a 78yearold male that presented with an acute anterior wall myocardial infarction .
he had no known coronary disease but had a history of paroxysmal af treated with amiodarone and had suffered an ischemic stroke 4 months prior . at catheterization
he was treated with iv heparin and eptifibatide and underwent stent implantation to the midleft anterior descending ( lad ) artery . at the completion of the procedure
, he became nonresponsive and urgent ct revealed severe left occipital intraparenchymal and subarachnoid bleeding with mass effect on the left lateral ventricle .
the second patient was a 48yearold male that presented with an acute anterior wall mi .
he had a past history of ischemic heart disease , hypertension , smoking , and hyperlipidemia .
he was pretreated with aspirin , clopidogrel , and heparin and received intravenous ( iv ) eptifibitide following the diagnostic study .
six hours following the procedure , he became noncommunicative and was found to have a right hemiplegia with facial palsy .
urgent ct scan demonstrated a left parieto temporo hemorrhage with mass effect on the left lateral ventricle intraparenchymal and subarachnoid .
twelve hours later he became bradycardic and repeat ct revealed intraventricular extension of the bleed .
the third patient was a 55yearold woman with no significant past history that presented with an acute anterior wall mi .
she underwent successful primary pci to lad while being treated periprocedurally with aspirin , clopidogrel , and bivalirudin .
supportive therapy only was instituted and at 6month followup her vision had returned to normal .
although in the first half of the study period the rate of cve was 0.08% and rose to 0.22% over the next 10 years , this did not achieve statistical significance .
this is despite the numerical increase of strokes noted since 2005 ( chisquare analysis p=0.264 ) ( figure 2 ) .
temporal analyses of patients ' and procedural characteristics revealed significant increase rates of almost all variables found to be independent risk factors
. rates of prior stroke increased from 2% to 7% , presence of thrombus rose from 4% to 10% , percent of elderly population ( age over 75 years ) undergoing procedure increased from 10% to 24% and finally percent of interventional procedures performed over the study period changed from 14% in 1992 to over 50% since 2005 ( p<0.0001 for all ) ( figure 3 ) .
temporal variation of procedurerelated cve risk factors over the study period . in order to assess its impact as a possible cofounder
, the year of procedure was forced into the model developed from the previous stepwise method as an additional step and referred to as model b. this further step did not reduce the strength nor the statistical significance of the independent stroke predictors that were identified in model a ( table 2 , model b). the c statistic was 0.866 , still indicating an excellent discriminatory power of the model .
all were treated with aspirin , clopidogrel , and heparin , with 2 patients treated with additional eptifibatide and 1 with bivalirudin .
the first case was a 78yearold male that presented with an acute anterior wall myocardial infarction .
he had no known coronary disease but had a history of paroxysmal af treated with amiodarone and had suffered an ischemic stroke 4 months prior . at catheterization
he was treated with iv heparin and eptifibatide and underwent stent implantation to the midleft anterior descending ( lad ) artery . at the completion of the procedure
, he became nonresponsive and urgent ct revealed severe left occipital intraparenchymal and subarachnoid bleeding with mass effect on the left lateral ventricle .
the second patient was a 48yearold male that presented with an acute anterior wall mi .
he had a past history of ischemic heart disease , hypertension , smoking , and hyperlipidemia .
he was pretreated with aspirin , clopidogrel , and heparin and received intravenous ( iv ) eptifibitide following the diagnostic study .
six hours following the procedure , he became noncommunicative and was found to have a right hemiplegia with facial palsy .
urgent ct scan demonstrated a left parieto temporo hemorrhage with mass effect on the left lateral ventricle intraparenchymal and subarachnoid .
twelve hours later he became bradycardic and repeat ct revealed intraventricular extension of the bleed .
the third patient was a 55yearold woman with no significant past history that presented with an acute anterior wall mi .
she underwent successful primary pci to lad while being treated periprocedurally with aspirin , clopidogrel , and bivalirudin .
supportive therapy only was instituted and at 6month followup her vision had returned to normal .
over the past 2 decades interventional cardiology has made enormous strides in progressing from balloon angioplasty to relatively simple lesions through early stenting with anticoagulants and subsequently antiplatelets through to drug eluting stents and multiple ancillary devices with powerful intravenous antiplatelet agents . with the progression of interventional hardware and escalation of the interventionalist 's capabilities leading to a reduction in intraprocedural and
improved longterm outcomes , a concomitant change has occurred in the patient profile being treated . whereas in the initial period , relatively simple patients were treated , the lesion and patient complexity has developed such that primary pci in many centers can reach 30% of their patient load , multivessel disease and intervention is a matter of course as well as the routine treatment of octogenarians with diffuse atherosclerosis .
our findings of low cve rate ( 0.15% ) have been relatively stable over the entire study period with the benefits of improved hardware and techniques being offset by a far more challenging population as demonstrated by our temporal analysis .
our principal findings demonstrate , similar to previously reported analyses , that age greater than 75 years , prior stroke and triple vessel disease all are strongly associated with a procedurerelated cve .
the increased risk in this population has been attributed in part to the increased incidence of aortic plaques , particularly if mobile , that are present in this population .
this has been further substantiated by the finding of atherosclerotic debris derived from the aorta in catheter aspirates .
interestingly in our study we failed to find a correlation with the number of catheters used or previous cabg , both of which would have increased the amount of aortic passages and intraaortic manipulations , likely increasing stroke risk if this was the predominant mechanism .
the additional 2 independent predictors that we found ( undergoing an intervention and the presence of coronary artery thrombus ) suggest that an alternative source for embolic material is present . in distinction to previously published analyses we have shown that the presence of an intracoronary thrombus is independently associated with a periprocedural cve .
hoffman et al found at univariate analysis that intracoronary thrombus was more frequent in the post pci cves , however this remained only as a trend ( p=0.0734 ) when introduced into the multivariate model . in a most recent study demonstration of significantly higher rates ( 1.3% ) of interventionrelated cves in a primary pci population that by definition must have an elevated thrombus burden
it would be extremely interesting to attempt to determine the mechanism of action of this association , particularly if the thrombus is a marker for a prothrombotic state or whether itself is the source of the subsequent embolus .
unfortunately , as our assessable end point ( a clinically manifest neurological event ) may be delayed by several hours , making temporal association analyses potentially misleading .
although it is clear that intervention represents a higher risk there were 2 specific reasons that we analyzed diagnostic studies in conjunction with the interventions .
the first was that in the current environment of ad hoc intervention , the staff and patient facing a procedure should be aware of the potential cve risk with a diagnostic study alone as well as that of a followon intervention .
second , following controlling for all other variables including , atherosclerotic burden as manifested by multiple features such as previously diagnosed carotid artery disease , pvd , and triple vessel disease , the intervention introduces the possibility of extraction of embolic material either associated with aspiration devices , on balloons or stent platforms .
based on the or of 2.35 related to an intervention , this appears to represent a very significant mechanism of pcirelated stroke .
this is supported by multiple reports of thrombi or other filling defects having been displaced to more proximal branches or other coronary arteries following withdrawal of intracoronary devices such as aspiration catheters , balloons , and atherectomy devices .
interestingly the use of eptifibatide or bivalirudin was not protective , possibly due to the intracoronary extraction mechanism not being dependent on thrombus alone as well as the ability of these agents intraprocedurally to only partially reduce the load of thrombus , often with a significant residual thrombus burden .
unfortunately , due to the retrospective nature of this study we were unable to reliably dissect out the exact timing of administration in the total cohort severely limiting our ability to elucidate a relationship with cves . encouragingly , despite the broad adoption of these powerful intravenous antiplatelet agents that were progressively introduced over the study period , the incidence of intracerebral hemorrhage has remained remarkably low .
two of the 3 episodes were associated with the use of eptifibatide or bivalirudin , with devastating outcomes . in the third instance bivalirudin
was used with a much less dramatic presentation and better outcome . when compared to publications assessing stroke incidence postcoronary intervention in the united states such as the single center experience from the washington hospital center ( 0.38% ) and more recently the mayo clinic ( 0.37% ) , including data from the 1990s
we conjecture that this may be due to the relatively early transfer from 8 and 7 french guiding catheters to a 6 french system that occurred in our center several years prior to the united states .
the report from the national cardiovascular data registry that studied stroke incidence in enrolling centers between the years 20042007 found an incidence ( 0.22% ) similar to that in our center over the entire study period . due to the relatively small number of large catheters
we found no impact of catheters smaller than 6f when compared with 6f , however it should be noted that the majority of 5f guiding catheters were used in conjunction with the radial approach presenting a confounding influence .
we chose to limit the cves to those occurring with 24 hours of the procedure .
we assessed all inhospital cves in patients undergoing catheterizations and found an additional 3 cves in the entire population , one prior to the procedure and clearly not related .
the additional 2 were postprocedure and also could not be clearly related to the procedure , although this can not be excluded . in spite of this , the impact of these 2 additional cases on our results would be negligible and so an additional analysis was not performed .
this study is a singlecenter , retrospective analysis of clinically evident cves occurring within 24 hours of a coronary cardiac catheterization . in spite of this , due to the advantage of having access to all the patients ' complete records
furthermore , the access to a large number of procedural characteristics not available in large multicenter registries may offset to some degree the limitation of a singlecenter analysis .
the retrospective analysis of a large number of relatively standard procedures ( cardiac catheterization ) precludes the inclusion of clinically silent cves that would provide stronger statistical power to elucidate risk factors and potential mechanisms of action .
nonetheless , the principal concern of physicians and their patients are those events that are clinically evident .
the relatively small number of cves limits the ability to adequately assess subgroups with any statistical power .
it further can be assumed that many subclinical or very minor events were not identified .
subgroups although in themselves may be of questionable clinical relevance . in all but one instance , urgent brain imaging was performed .
this has been the standard over the study period and in spite of the increasing use worldwide of mri scanning it is not routinely performed for stroke assessment in israel .
moreover recent reports state that the sensitivity of dwi for the diagnosis of ischemic stroke is now estimated to be only 80% to 90% .
this study is a singlecenter , retrospective analysis of clinically evident cves occurring within 24 hours of a coronary cardiac catheterization . in spite of this , due to the advantage of having access to all the patients ' complete records
furthermore , the access to a large number of procedural characteristics not available in large multicenter registries may offset to some degree the limitation of a singlecenter analysis .
the retrospective analysis of a large number of relatively standard procedures ( cardiac catheterization ) precludes the inclusion of clinically silent cves that would provide stronger statistical power to elucidate risk factors and potential mechanisms of action .
nonetheless , the principal concern of physicians and their patients are those events that are clinically evident .
the relatively small number of cves limits the ability to adequately assess subgroups with any statistical power .
it further can be assumed that many subclinical or very minor events were not identified .
subgroups although in themselves may be of questionable clinical relevance . in all but one instance , urgent brain imaging was performed .
this has been the standard over the study period and in spite of the increasing use worldwide of mri scanning it is not routinely performed for stroke assessment in israel .
moreover recent reports state that the sensitivity of dwi for the diagnosis of ischemic stroke is now estimated to be only 80% to 90% .
in a singlecenter retrospective assessment over nearly 20 years , cves postcardiac catheterization were very rare and nearly exclusively ischemic .
the independent predictors for these events were found to be , not surprisingly , the performance of an intervention and those associated with increased atherosclerotic burden , specifically older age , triple vessel disease and prior stroke .
our findings however , identified an additional highrisk group with more acute coronary disease as manifest by the presence of coronary artery thrombus .
 backgroundone of the most daunting complications of cardiac catheterization is a cerebrovascular event ( cve ) . 
 we aimed to assess the reallife incidence , etiology , and risk factors of cardiac catheterizationrelated acute cves in a large cohort of patients treated in a single center.methods and resultswe undertook a retrospective analysis of 43 350 coronary procedures performed on 30 907 procedure days over the period 19922011 and compared patient and procedural characteristics of procedures complicated by cves with the remaining cohort . 
 cves occurred in 47 cases : 43 were ischemic , 3 intracerebral hemorrhages , and 1 undetermined . 
 the overall cve rate was 0.15% , with percutaneous coronary intervention ( pci ) and diagnostic coronary angiography rates 0.23% and 0.09% , respectively . using a forward stepwise multivariate logistic regression model including patient demographic and procedural characteristics , 
 a total of 5 significant predictors were defined : prior stroke ( or=15.09 , 95% ci [ 8.11 to 28.08 ] , p<0.0001 ) , presence of coronary arterial thrombus ( or=2.79 , 95% ci [ 1.25 to 6.22 ] , p=0.012 ) , age > 75 years ( or=3.33 , 95% ci [ 1.79 to 6.19 ] , p<0.0001 ) , triple vessel disease ( or=2.24 , 95% ci [ 1.20 to 4.18 ] , p=0.011 ) , and performance of intervention ( or=2.21 , 95% ci [ 1.12 to 4.33 ] , p=0.021 ) . 
 an additional analysis excluded any temporal change of cve rates but demonstrated a significant increase of all highrisk patient features.conclusionin a singlecenter , retrospective assessment over nearly 20 years , cardiac catheterizationrelated cves were very rare and nearly exclusively ischemic . 
 the independent predictors for these events were found to be the performance of an intervention and those associated with increased atherosclerotic burden , specifically older age , triple vessel disease , and prior stroke . 
 the presence of intracoronary thrombus appears also to raise the risk of procedurerelated cve . 
Introduction
Materials and Methods
Study Population
Definitions
Study Variables
Statistical Analysis
Results
Temporal Analysis
Intra Cerebral Hemorrhages
Discussion
Study Limitations
Conclusion