Which imaging test must be performed to rule out intracranial hemorrhage before giving IV tPA?

Which imaging test must be performed to rule out intracranial hemorrhage before giving IV tPA?

• A. MRI brain with contrast
• B. CT angiography
• C. Non-contrast head CT (CT head without contrast)
• D. CT perfusion

Answer: (C)

Ruling out intracranial hemorrhage quickly is essential before giving IV tPA. The fastest and most appropriate test to do in the emergency setting is a non-contrast head CT. It is designed to detect acute bleeding without the need for contrast, so it can be performed promptly and safely. If hemorrhage is found, thrombolysis is contraindicated and tPA is withheld. If no bleed is seen, tPA can be pursued within the appropriate time window, provided other eligibility criteria are met. Other imaging modalities, like MRI, CT angiography, or CT perfusion, have roles in stroke evaluation—for example, identifying vessel occlusion or assessing tissue viability—but they are not required to rule out hemorrhage and may take longer or involve contrast, which can delay treatment.

Ruling out intracranial hemorrhage quickly is essential before giving IV tPA. The fastest and most appropriate test to do in the emergency setting is a non-contrast head CT. It is designed to detect acute bleeding without the need for contrast, so it can be performed promptly and safely. If hemorrhage is found, thrombolysis is contraindicated and tPA is withheld. If no bleed is seen, tPA can be pursued within the appropriate time window, provided other eligibility criteria are met.

Other imaging modalities, like MRI, CT angiography, or CT perfusion, have roles in stroke evaluation—for example, identifying vessel occlusion or assessing tissue viability—but they are not required to rule out hemorrhage and may take longer or involve contrast, which can delay treatment.