Background: Early neurological deterioration (END) prompting urgent brain imaging occurs in up to 15% of ischemic stroke patients receiving intravenous tissue plasminogen activator (tPA). Most of these are not related to symptomatic intracranial hemorrhage (sICH) but lead to unnecessary interruption of the tPA infusion. We aim to determine predictors of sICH in ischemic stroke patients undergoing emergent brain imaging after tPA.
Methods: We queried our prospective stroke database and included all patients who received tPA for ischemic stroke from March 1st, 2015 until March 1st, 2017. We then identified patients who underwent emergent brain imaging before the planned 24-hour brain imaging and divided these patients into: sICH+ and sICH- defined by NINDS criteria. We compared baseline clinical factors, pre-admission medications, admission blood pressure, symptoms prompting repeat scan [change in level of consciousness (LOC); worsening or new (W/N) neurological symptoms without change in LOC; headache/nausea/vomiting), thrombectomy, 24-hour NIHSS and 90 day outcome.
Results: We identified 511 patients who received tPA (sICH rate 4.1%). Emergent repeat brain CT was performed on 108 (21.1%); 17.5% (19/108) had sICH and 21.3% (23/108) occurred during the tPA infusion with only one being related to sICH. The mean time from tPA infusion to symptoms prompting brain imaging in sICH was 7.3 ± 5.3 hours. In patients who underwent emergent brain imaging, sICH+ patients were older (80.2 ± 15.8 vs. 70.8 ± 15.4, p = 0.026), with higher admission NIHSS (14 vs. 7, p = 0.0016) and 90-day mortality (87.5% vs. 22.4%, p<0.001), more likely to have a change in LOC (78.9% vs. 21.3%, p<0.001) and less likely to have W/N symptoms without LOC change (5.3% vs. 42.7%, p=0.002). On multivariable analyses, the only predictor of sICH was LOC change (OR 6.62 95% CI 1.64-26.70, p=0.008).
Conclusion: Nearly 95% of patients with ischemic stroke had unnecessary interruption of the tPA infusion for new symptoms shortly after the tPA infusion. A change in LOC was the only predictor of sICH among tPA patients undergoing emergent brain imaging. In this group of patients, the preparation of tPA reversal agents awaiting brain imaging may help reduce tPA reversal times and improve outcomes