Post rtPA CT brain may not be mandatory in all stroke patients when resources are limited

Background: Routine neuroimaging of the brain is performed after recombinant-tissue-plasminogen activator (rtPA) treatment in patients with acute ischemic stroke. However, in situation where resources are limited, it is not known if a follow-up computed tomography (CT) is beneficial for guiding the treatment plan or not. The purpose of this study is to investigate the need for a follow-up CT in patients with acute stroke after rtPA treatment. Methods: Patients who were treated with intravenous rtPA were included. Clinical symptoms/signs of the patients were evaluated at 24 h after rtPA treatment compared with baseline NIHSS. The need for a follow-up CT after rtPA treatment was assessed by comparison of the early clinical changes with the CT brain results that would affect the management plan: presence of hemorrhagic transformation, malignant MCA infarction, or large cerebellar infarction. Results: 200 patients were included. 19 patients (9.5%) had complete recovery. CT post rtPA revealed no change in these patients. In 105 patients who had early improvement with NIHSS of 1–10 at 24 h, follow-up CT findings did not change the plan of management in 85%. Follow-up CTs may help in planning further management in 65% and 67% of the patients who had NIHSS > 10 at 24 h and early worsening, respectively. Conclusions: CT post rtPA may not be required in patients with early clinical recovery (NIHSS = 0). However, in patients with residual severe deficit post rtPA or patients with early worsening or suspected posterior circulation stroke, CT post rtPA is still needed.