[Risk of stroke during left atrial catheter ablation for atrial fibrillation]

Periprocedural stroke is one of the most relevant complications of left atrial catheter ablation for atrial fibrillation. Procedure-specific and patient-specific factors as well as the experience of the interventionalists and the intervening center are relevant for the risk of periprocedural stroke. In recent years, the risk of periprocedural stroke has been reduced to less than 0.5% in specialized centers, due to technical advances and the interdisciplinary implementation of magnetic resonance imaging (MRI)-based studies on the risk of procedure-associated cerebral embolism. In addition to appropriate awareness, a standard operating procedure (SOP) is particularly important for the treatment of periprocedural and postprocedural stroke. The SOP should include preventive strategies to avoid stroke, periprocedural blood pressure management, peri- and postprocedural anticoagulation and potential antagonists in cases of (intracranial) bleeding. Furthermore, the SOP should outline further intrahospital treatment pathways. In the event of acute ischemic stroke the possibility of systemic thrombolysis should be evaluated within 4.5 h of symptom onset in cases of a clinically relevant neurological deficit, based on an individual risk-benefit assessment and taking present guideline recommendations as well as product-specific information provided by the manufacturer into account. If an acute proximal occlusion of a brain-supplying artery as well as corresponding clinical symptoms are present, catheter-based ("mechanical") recanalization is indicated within a time window of up to 24 h after (possible) onset of symptoms as this can be performed independently of anticoagulant medication. Notably, no randomized studies on the efficacy and safety of these treatments aimed at recanalization in periprocedural stroke are available to date. Based on a selective literature review and own preliminary work, this review article aims to provide recommendations on the prevention and acute treatment of periprocedural stroke.