The effect of 24 hour post-intravenous alteplase CT head on management decisions: a single center experience (S47.004)

Objectives: Evaluate impact of 24 hour CT head on post-alteplase management decisions. Background: According to American Heart Association guidelines, patients with ischemic strokes who receive alteplase should have a 24 hour CT head to evaluate for hemorrhagic conversion. Effects of CT on patient management and detecting hemorrhages without neurological deterioration is unclear. Methods: Patients given alteplase and cared for at University of North Carolina Hospitals between January 1, 2012 and June 30, 2015 were extracted from Get with the Guidelines database. Patient records were reviewed for presence of hemorrhagic conversion, symptomatic hemorrhage (NIHSS change), and management changes. Cases with hemorrhagic conversion were collected and divided into symptomatic vs asymptomatic. Percentages of documented management changes related to hemorrhagic conversion were calculated. Results: 280 patients included, 25(8.9[percnt]) had hemorrhagic transformation (10 symptomatic, 14 asymptomatic and 1 unknown had hemorrhage at another hospital). Those with hemorrhage had an older average age (73 vs 65) and higher NIHSS (18 vs 11). Of 14 patients with asymptomatic hemorrhage, antithrombotics were held in 9(64[percnt]) for 1-7 days. Four asymptomatic patients had no delay in antithrombotics without complication and one made comfort care. Conclusion: For 95[percnt] of asymptomatic patients, a 24 hour post-alteplase CT head had no clinical impact. Antithrombotic treatment was delayed by asymptomatic hemorrhage in 2/3 of patients, depriving them of early antiplatelet therapy that reduces the risk of stroke within the first 14 days (Lancet. 349:1569-81). With an estimated 30,000 doses of alteplase given in US, cost of routine CT screening is significant at $6.6 million per year (Jt Comm J Qual Patient Saf. 41:313-22), and there is increased risk of cancer from radiation of 1/10000 (Arch Intern Med. 169:2078-86). Further studies are needed to determine if benefit of withholding antithrombotics for asymptomatic hemorrhagic transformation exists and whether benefit outweighs cost of widespread screening. Disclosure: Dr. Sevilis has nothing to disclose. Dr. Morantes Gomez has nothing to disclose. Dr. Shah has nothing to disclose. Dr. Wang has nothing to disclose. Dr. Huang has received personal compensation for activities with Aldagen/Cytomedix and Dart Neuroscience as a consultant. Dr. Powers has nothing to disclose.