Stroke Code CT read: Neurologist or Radiologist

[Neurologo]

Hi,

I just wanted to know how it is done at your sites. I am currently covering a primary stroke center with weak radiology department. The issue is the requirement of writing the time of STAT CT head read in chart. Because their radiologists are not fast enough to read, often delayed by 30-60 minutes, they are relying on me to write down my rapid review time in my notes. Typically I review it myself without radiologist input for tPA and feel comfortable doing so. But the issue now is having to write down the time I look at CT. This seems relying too much on neurologists. I never had to write this time down at other comprehensive stroke centers where radiologists are required to read quickly.

What is your thought on this or how is it done at your sites?

I edited the initial posting to clarify the main issue I am having: Requiring me to write the time of my CT review.

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[IRattending2021]

Hi,

I just wanted to know how it is done at your sites. I am currently covering a primary stroke center with weak radiology department. The issue if notating STAT CT head read time in chart before tPA bolus. Because their radiologists are not fast enough to read, often delayed by 30-60 minutes, they are relying on me to write down my rapid review time in my notes. Majority of times I don't rely on radiologists to tell me I can give tPa. But this seems relying too much on neurologists. I never had to do this at other comprehensive stroke centers where radiologists are required to read quickly.

What is your thought on this or how is it done at your sites?

not acceptable. You need better radiologists.

 

[sharkbaitwhohaha]

I'm certainly not disparaging the work of other radiologist. They are amazing.. But for tpa decision making, any pgy2 neurologist should be able to rule out the use of thombolysis on CT.

 

[Phantom Spike]

What about CT angios and perfusion scans for potential interventional candidates? Do most neurologists attending stroke calls read those themselves or await radiologist reports?

 

[Thama]

At my center we would know what we were going to do the moment the CT popped up on the scanner, but we had to wait for a radiologist read before pushing tPA because reasons. So we would have everything ready to push for the moment the radiology resident moved his hand in the general direction of a thumbs up.

 

[Telamir]

I rely on my read for a non con although they’re pretty quick (still 10-15 minutes). I also read the CTA/CTP myself but honestly those are secondary. The non con is the only one you need for TPA. Sometimes I might not see an M3 or a less obvious occlusion but they’ll call me with that as TPA is infusing.

Also remember if you push it and they call you with a small subdural or something you can stop the drip. At worst they got a 10% dose with the bolus which is at most 9mg.

 

[xenotype]

What about CT angios and perfusion scans for potential interventional candidates? Do most neurologists attending stroke calls read those themselves or await radiologist reports?

Read yourself. Immediately call interventionalist if obvious findings and prep patient for thrombectomy/transfer. Confirm with radiologist later to ensure vessels are clean is best practice.

At my center we would know what we were going to do the moment the CT popped up on the scanner, but we had to wait for a radiologist read before pushing tPA because reasons. So we would have everything ready to push for the moment the radiology resident moved his hand in the general direction of a thumbs up.

Crazy. DTN times are tracked everywhere now and you can't afford to be slow although it sounds like there wasn't much delay.

I rely on my read for a non con although they’re pretty quick (still 10-15 minutes). I also read the CTA/CTP myself but honestly those are secondary. The non con is the only one you need for TPA. Sometimes I might not see an M3 or a less obvious occlusion but they’ll call me with that as TPA is infusing.

Also remember if you push it and they call you with a small subdural or something you can stop the drip. At worst they got a 10% dose with the bolus which is at most 9mg.

Yes exactly. Generally, if the occlusion is obscure enough to not be obvious on a quick read right off the CT or from rapid, it is not amenable to intervention anyways.

 

[IRattending2021]

Read yourself. Immediately call interventionalist if obvious findings and prep patient for thrombectomy/transfer. Confirm with radiologist later to ensure vessels are clean is best practice.



Crazy. DTN times are tracked everywhere now and you can't afford to be slow although it sounds like there wasn't much delay.



Yes exactly. Generally, if the occlusion is obscure enough to not be obvious on a quick read right off the CT or from rapid, it is not amenable to intervention anyways.

in your experience, how often are your interpretation differ enough from the radiology read to change management regarding thrombectomy?

 

[Neurologo]

Thank you all for the lively discussion. I did not make myself clear in my original post. I edited it now to make it more clear.
I am comfortable reading the CT myself. I can probably count with my hand the rare occasions that I needed radiologist input before pushing tPA. What I am hoping to hear from you is your thought on requiring us neurologists to write down the exact time that we look at CT head before tPA in our clinical notes. For example, "I rapidly reviewed STAT CT head at 14:05..." The stroke coordinator states this is because the Joint Commission is now requiring this documented time.

 

[Telamir]

I think I can count maybe 3 times in as many years where I might have missed an LVO on my read that went for thrombectomy. In all those cases TPA was already running.

 

[Neurogeneral]

Seems like they afd

 

[xenotype]

in your experience, how often are your interpretation differ enough from the radiology read to change management regarding thrombectomy?

Almost never. Occasionally a very distal M3 will be subtle and the radiologist can see it better, but this won't change management.

Thank you all for the lively discussion. I did not make myself clear in my original post. I edited it now to make it more clear.
I am comfortable reading the CT myself. I can probably count with my hand the rare occasions that I needed radiologist input before pushing tPA. What I am hoping to hear from you is your thought on requiring us neurologists to write down the exact time that we look at CT head before tPA in our clinical notes. For example, "I rapidly reviewed STAT CT head at 14:05..." The stroke coordinator states this is because the Joint Commission is now requiring this documented time.

May not be a way to get around that.

 

[IRattending2021]

Almost never. Occasionally a very distal M3 will be subtle and the radiologist can see it better, but this won't change management.


May not be a way to get around that.

Good for you that management almost never changed. If someone who have never done a diagnostic radiology residency like yourself (correct me if you did) can interpret stroke imaging to this effect, it certainly seems that it’s absolutely redundant to require an additional year or two of neuro imaging fellowship for radiologists to do mechanical thrombectomy.

 

[Telamir]

And out of nowhere IRAttending from the top rope! That poor dead horse never stood a chance! Oh the beatings won’t stop; the humanity!

 

[IRattending2021]

And out of nowhere IRAttending from the top rope! That poor dead horse never stood a chance! Oh the beatings won’t stop; the humanity!

I thought we are discussing radiology and mechanical thrombectomy right here in this topic.

If a neurologist in my hospital is taking poor care of my patients, I’ll advocate for a better group of neurologists. I am not going to go pretend I am a neurologist myself and go start diagnosing migranes.

 

[xenotype]

Good for you that management almost never changed. If someone who have never done a diagnostic radiology residency like yourself (correct me if you did) can interpret stroke imaging to this effect, it certainly seems that it’s absolutely redundant to require an additional year or two of neuro imaging fellowship for radiologists to do mechanical thrombectomy.

You saw I agreed with you at the end of all of that right?

 

[Neurogeneral]

neurologists c

 

[Neurogeneral]

I feel that this is not acceptable. Yes neurologists are usually pretty comfortable with reading head CTs or even CTAs for the purposes of making decisions in acute stroke management. Some tele stroke jobs even require that you be comfortable doing a “wet read” of the CT. So doing this from time to time or occasionally is reasonable depending on whether radiology coverage is very responsive or not. However doing the CT interpretation yourself for each and every acute stroke code (without any radiology input) as if this is the norm, I feel is asking for trouble malpractice wise. If you want to be a stroke center, you should have good responsive radiology coverage IMO.

 

[nikolaite]

Not trying to be doom and gloom here, but as a research archivist who has to pore over records, having an accurate timeline of events is extremely beneficial for time-based treatment studies. If you’re concerned about legal implications of medical errors, pay the $1,000.00 for an hour consult with a decent attorney to discern whether recording the time you judged a pt’s non con study for tPA has any bearing on personal liability. My guess is that it has no bearing at all; and that it will actually have a protective effect in the case of another MD’s a breach of duty with subsequent damages: timeline will show you supplied the lack of rad attention in order to get pt treatment for emergent crisis. That’s the opposite of breach of duty.

 

[IRattending2021]

If a radiology group cannot meet stroke read time target they need to be replaced. Full stop.

 

[Clean7795]

Sounds like a recipe for medicolegal troubles IMO. Even if you are completely comfortable reading the CT/CTAs yourself, if there is a bad outcome and a patient decides to sue, you don't want to be caught in this situation.

 

[Neurologo]

Although rapid wet read is done by me, the official report is written by oncall radiologists.

I wish all primary stroke centers would be like comprehensive centers where radiologists are available on site 24/7 and are reading CTs STAT and record their time. But the reality of many places is simply different from academic centers or well equipped CSCs. If we require or demand that CT head be read and cleared first by rad before tPA is given, not small number of so called primary stroke centers (PSCs) will have to stop giving tPA including most of those places where tele neurologists cover where immediate radiologists are simply not available. Ultimately this will deprive many patients of tPA or force significant delay in tPA time leading to poor clinical outcome. How do we reconcile this reality?

Does AHA/ASA forbid neurologists to read CT head to clear for tPA? Are we medicolegally justified to deny tPA to patients because remote radiologists cannot read these fast enough when in reality many of us simply bypass radiologists telling us there is no acute bleed or clear hypodensity?

Either rules and practice will have to change where neurologists will be "expected" to read CTs for tPA purpose and CTA for LVO and provided with medicolegal protection to allow all the existing and growing number of PSCs to continue to give tPA, or many PSCs will have to be suspended until they can ensure 24/7 STAT radiology review and communication to neurologists to give clear for tPA.

 

[Neurologo]

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