• Ischemic stroke occurs when the blood flow to the brain is blocked by something, usually a clot.
• Hemorrhagic stroke is when a weakened blood vessel ruptures in the brain.
• Computed tomography (CT) is a radioactive imaging study that evaluates the extent of the bleeding.
• Tissue plasminogen activator (tPA) is an IV medication known as a clot buster. It will destroy any clots occluding blood flow to the brain. It is given to patients who have confirmed ischemic stroke by a CT.

If the medical team suspects that the client experienced an ischemic stroke, a CT is done to ensure that it is not a hemorrhagic stroke. The patient is given tPA through their IV if an ischemic stroke is diagnosed.

Routine computed tomography (CT) imaging traditionally occurs 24 hours later to evaluate the bleeding.

Recently, scientists have been wondering how necessary it is to perform a repeat 24-hour CT in stroke patients. Routine repeat imaging in patients rarely changes the plan of care for those who are stable.

The researchers examined the benefits of routine CT scans in ischemic stroke patients who received tPA.₁ The results showed that stroke patients whose National Institute of Health Stroke Scale (NIHSS) score has a baseline of less than ten and remains stable are unlikely to have any effects by routine imaging.

The purpose of the repeat CT scan is to evaluate stroke patients for the overall risk of a cerebral hemorrhage. No patient with an NIHSS score of less than ten experienced a brain hematoma on the routine repeat imaging without first becoming unstable.₁

This study of post-acute ischemic stroke patients who received tPA determined that routine repeat neuroimaging is unnecessary for clinically stable patients. This will decrease excessive radiation exposure and minimize medical costs.

This study analyzed patients admitted to Tulane Medical Center and seen by the Neurology Department between 2008 and 2011. In order to be included in the study, patients had to have a documented 24-hour NIHSS score and tPA therapy.₁   A specialist reviewed the repeat CT scans.

The study split patients into two groups:

1. those whose 24-hour NIHSS score remained the same from baseline
2. those that worsened after admission.

The study promotes nursing independence, minimizes radiation exposure to patients, and decreases medical costs.

What does this mean?

• Initially, the nursing staff can identify clinically unstable stroke patients at risk of a cerebral hemorrhage.
• By minimizing the client’s exposure to radiation, the medical staff encourages optimal health for patients who do not need an MRI.
• Finally, eliminating unnecessary and expensive imaging studies significantly decreases a client’s medical expenses.

The weakness of this study is that it did not show how this new protocol impacts nurses. This study did not directly evaluate nursing staff and their reflection on this new data.

Nurse buy-in is SO important.

If staffing doesn’t allow close observation of the patient to catch signs of stroke, this entire protocol will fail.

Currently, it may not be necessary to perform routine and repeat 24-hour CT imaging to evaluate for a brain hemorrhage. However, nurses must remain vigilant while watching over their clients.

If a client becomes clinically unstable or their NIHSS score worsens, the nurse should immediately report the situation to the appropriate provider.

1. George, A. J., Boehme, A. K., Dunn, C. R., Beasley, T., Siegler, J. E., Albright, K. C…Martin-Schild, S. (2015). Trimming the fat in acute ischemic stroke: An assessment of 24-h CT scans in tPA patients. International Journal of Stroke, 10(1), 37-41. https://www.doi.org/10.1111/ijs.12293