CRANIAL COMPUTED TOMOGRAPHY INTERPRETATION IN ACUTE STROKE: PHYSICIAN ACCURACY IN DETERMINING ELIGIBILITY FOR THROMBOLYTIC THERAPY.

Schriger DL, et al. JAMA 1998 Apr 22-29;279(16):1293-7.

CONTEXT: Intracranial hemorrhage must be excluded prior to administration of thrombolytic agents in acute stroke.

OBJECTIVE: To evaluate physician accuracy in cranial computed tomography scan interpretation for determining eligibility for thrombolytic therapy in acute stroke.

DESIGN: Administration of randomly selected, randomly ordered series of 15 computed tomography scans from a pool of 54 scans that demonstrated intracerebral hemorrhage, acute infarction, intracerebral calcifications (impostor for hemorrhage), old cerebral infarction (impostor for acute infarction), and normal findings.

PARTICIPANTS: A convenience sample of 38 emergency physicians, 29 neurologists, and 36 general radiologists.

MAIN OUTCOME MEASURES: Physician determination of eligibility for thrombolytic therapy based on computed tomography scan interpretation.

RESULTS: Average correct score by all physicians on all computed tomography scans was 77% (95% confidence interval, 74%-80%). Of 569 computed tomography readings by emergency physicians, 67% were correct; of 435 readings by neurologists, 83% were correct; and of 540 readings by radiologists, 83% were correct. Overall sensitivity for detecting hemorrhage was 82% (95% confidence interval, 78%-85%); 17% of emergency physicians, 40% of neurologists, and 52% of radiologists achieved 100% sensitivity for identification of hemorrhage.

CONCLUSION: Physicians in this study did not uniformly achieve a level of sensitivity for identification of intracerebral hemorrhage sufficient to permit safe selection of candidates for thrombolytic therapy.

COMMENT: Another reason to seriously consider before initiating thrombolysis for suspected CVA. For other papers regarding thrombolysis in CVA, see the Cleveland experience, and this Hoffman opinion paper.