1. Home>
2. Specialties>
3. Emergency Medicine>
4. Summary and Comment

How Good Are CT Readings Before t-PA Use in Stroke?

To be effective in acute ischemic stroke, t-PA must be given within three hours of onset. But because t-PA can exacerbate intracranial hemorrhage (ICH), it must not be used when there is evidence of ICH or acute cerebral infarct on cranial CT. This study evaluated whether 38 EPs, 29 neurologists, and 36 general radiologists could identify such evidence.

The physicians, all randomly selected, received hard copies of 15 CT scans and were asked to state whether the scans permitted thrombolytic administration. They were told which side of the patient's body was affected and given a list of cranial-CT contraindications to thrombolytics (hemorrhage, early hypodensity, mass effect, shift). All the neurologists and radiologists were board-certified and routinely read cranial CTs as part of their practice; of the EPs, only 74% were board-certified and just 24% routinely read cranial CTs.

The average correct score was 77%: 83% each for neurologists and radiologists, 67% for EPs, and 71% for EPs who routinely read cranial CTs. "Easy" cases of hemorrhage and "easy" acute infarcts were read with near-perfect sensitivity, but only 17% of EPs, 40% of neurologists, and 52% of radiologists achieved 100% sensitivity in detecting all cases of ICH.

Comment: The study's convenience sampling limits generalization of these results, and the extent of physician training in CT interpretation is unknown. Still, the bottom line is that even board-certified physicians in neurology and general radiology may be ill-prepared to determine which stroke patients should receive t-PA. Dedicated cranial CT training or telemedicine access to a neuroradiologist may be needed.

— JA Marx

Published in Journal Watch Emergency Medicine August 1, 1998

Citation(s):

Schriger DL et al. Cranial computed tomography interpretation in acute stroke: Physician accuracy in determining eligibility for thrombolytic therapy. JAMA 1998 Apr 22/29 279 1293-1297.

• Original article (Subscription may be required)
• Medline abstract (Free)