Introduction: Current AHA guidelines recommend obtaining a brain imaging study usually a computed tomography scan of the head (CTH) at 24-hours after thrombolysis with intravenous recombinant tissue plasminogen activator (IV r-tPA) before starting anti-platelets (AP) or anticoagulant (AC) therapy due to concerns for intracerebral hemorrhage. Several studies argued against the utility of a 24-hour post-thrombolysis CTH in AIS patients especially if they recover early or are clinically stable, and suggested that it would not alter clinical management.
Hypothesis: The authors hypothesize that new findings after the 24-hour post-thrombolysis CTH alter management decisions regardless of clinical stability in patients with AIS.
Methods: Stroke patients admitted to the Neurocscience Critical Care Unit (NCCU) after thrombolytic therapy from January 2013 to June 2016 were identified retrospectively. Clinically stable patients with new 24-hour post-thrombolysis CTH findings were included. Patient characteristics and outcome were compared according to cohorts of “with management change”(with MC) versus “with no management change”(no MC). Primary outcome were types and frequencies of MC. Secondary outcomes were hospital length of stay (HLOS), discharge and 30-day NIHSS and MRS, in-patient mortality and discharge disposition.
Results: A total of 223 AIS patients were admitted to the NCCU after thrombolysis. Forty-two patients were included for analysis. Based on new CTH findings, 28(67%) had MC. The most common types of MC were repeating CTH (24, 86%) followed by AC delay (18, 64%). Majority of the “with MC” cohort had CTH findings of ventricular compression due to mass effect (20, 71%). They also had longer HLOS (median[IQR] 7.5vs 4,p-value=0.012) and higher 30-days NIHSS (9.5vs 2,p=0.042) and MRS on discharge (4vs 1.5,p=0.002) compared to the “no MC” group.
Conclusion: We showed that a 24-hour CTH after IV r-tPA is necessary prior to starting AP or AC therapies for AIS patients and affects management decisions regardless of the patients’ clinical stability. Patient outcome was worse among those with management change. Studies should be done to analyze long-term effect of these managements and their impact on healthcare costs.