Development and Implementation of a Standardized Imaging Protocol for Suspected Acute Stroke Patients With Iodinated Contrast Allergies
Madeline Russell1, Robin Dharia2, Alan Cherney3, Shaista Alam2, Katherine Beard2, Nicole Calautti2, Karyn Ding4, Audrey Del Re2, Kathryn Dent2, Kathleen Graveran-Perez2, Helen Hernandez Lage2, Elan Miller2, Danielle Porreca2, Deborah Steinberg2, Diana Tzeng2
1Department of Neurology, Emory University, 2Department of Neurology, 3Department of Emergency Medicine, Thomas Jefferson University, 4Department of Neurology, New York University
Objective:
We aimed to evaluate the efficacy of a standardized protocol we developed to reduce care delays for patients with iodinated contrast allergies who present to the emergency department with acute stroke symptoms.
Background:
Emergent head and noninvasive vessel imaging are standard of care in the evaluation of patients with stroke symptoms. CT angiography (CTA) is the preferred vessel-imaging modality given ease of acquisition and widespread availability. In patients with iodinated contrast allergies, concern for adverse reactions may prohibit or delay CTA. The American College of Radiology recommends these patients receive pretreatment hours prior to contrast exposure, but this is an unrealistic option for those undergoing evaluation for emergent interventions such as mechanical thrombectomy.
Design/Methods:
We designed a protocol to guide management of patients with iodinated contrast allergies who present to our emergency department with stroke symptoms using information we gathered from retrospective chart review, literature review, and stakeholder interviews. Our protocol was approved by stakeholders and included a recommendation for pretreatment with intravenous hydrocortisone 200mg and diphenhydramine 50mg. We implemented this protocol at our institution and evaluated its efficacy in reducing time to CTA and in preventing adverse reactions.
Results:
During the first six months of implementation, there were 10 unique stroke alert encounters involving patients with contrast allergies. Nine patients received pretreatment and CTA. One patient had a reaction after contrast exposure, reported as angioedema; this patient had also received tenecteplase. Neither of the two patients with a history of anaphylaxis to contrast had a reaction following CTA. The average time from completion of CT head to CTA was 12.5 minutes compared to 124 minutes prior to protocol implementation.
Conclusions:
Emergent pretreatment with hydrocortisone and diphenhydramine prior to CTA is well-tolerated and effective in reducing delays to imaging in patients with contrast allergies that present to the emergency department with acute stroke symptoms.
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