Does a stroke patient with worsening symptoms after IV thrombolysis require an urgent repeat CT scan?

Urgent Repeat CT Scan for Stroke Patient with Worsening Symptoms After IV Thrombolysis

An immediate repeat CT scan is urgently needed for this patient with worsening neurological symptoms after IV thrombolysis to rule out hemorrhagic transformation. 1

Rationale for Urgent Imaging

• The patient has demonstrated significant neurological deterioration (NIHSS progression from 5 to 9) after receiving IV thrombolysis, which is a critical red flag requiring immediate evaluation
• According to American Heart Association guidelines, deterioration in a patient's clinical condition should prompt consideration of a non-contrast CT of the head to evaluate for possible hemorrhagic conversion 1
• Even without complaints of headache, vomiting, or changes in level of consciousness, neurological worsening alone is sufficient indication for urgent reimaging

Clinical Decision Algorithm

1. Immediate non-contrast CT scan is indicated when:

   • Any neurological deterioration occurs after thrombolysis
   • NIHSS score increases (as in this case from 5 to 9)
   • Even in the absence of classic symptoms of intracranial hemorrhage

2. Timing considerations:

   • Do not wait for the scheduled 24-hour post-thrombolysis scan
   • Hemorrhagic transformation occurs early after stroke and is an independent predictor of mortality and poor functional outcome 1
   • The highest frequency of hemorrhagic expansion occurs within the first 6 hours after stroke onset 1

Potential Complications to Evaluate

The urgent CT scan will help identify:

• Hemorrhagic transformation - occurs in approximately 17.8% of patients after thrombolysis 2
• Infarct extension - due to failure of thrombolysis or new embolism
• Cerebral edema - which may require additional interventions

Management Implications

The results of the urgent CT will guide critical next steps:

• If hemorrhagic transformation is present: immediate cessation of antithrombotic agents, consideration of reversal agents, blood pressure management, and possible neurosurgical consultation
• If no hemorrhage but infarct extension: consideration for endovascular therapy if within the treatment window
• If cerebral edema: implementation of anti-edema measures

Important Considerations

• All symptomatic intracranial hemorrhages in the PROACT-II trial occurred in patients with baseline NIHSS scores ≥11 1, and this patient's score is approaching that threshold
• Asymptomatic intracranial hemorrhage after thrombolysis should not be considered clinically innocuous, as it is also associated with increased odds of poor clinical outcomes 2
• The risk of hemorrhagic transformation is influenced by stroke severity, baseline blood pressure, and time from onset 3

Conclusion

While a 24-hour post-thrombolysis CT scan is standard protocol, the patient's neurological deterioration necessitates immediate reimaging rather than waiting until tomorrow. This approach is consistent with current stroke management guidelines and is essential for optimizing patient outcomes by allowing timely intervention for potential complications.