Causes, Predictors, and Timing of Early Neurological Deterioration and Symptomatic Intracranial Hemorrhage After Administration of IV tPA

Abstract

Background Acute ischemic stroke (AIS) is a major contributor toward healthcare-associated costs and services. Symptomatic intracranial hemorrhage (sICH) and early neurologic decline (END), defined as a National Health Institute Stroke Scale score decline of ≥ 4 within 24 h (with or without sICH), remain major concerns when administering intravenous tissue plasminogen activator (IV tPA) despite improved functional neurologic outcomes with its use. Given these risks, current guidelines recommend comprehensive stroke care (most often in an intensive care unit setting) for 24 h posttreatment. However, a number of patients may remain stable after IV tPA and thus not require such intensive resources. We sought to determine causes of END, along with timing and predictors of both sICH and END, to identify patients at lower risk of neurological deterioration and those suitable for earlier transition to a lower level of care. Methods This present study analyzed patients with AIS that presented within 4.5 h of being last seen well and received IV tPA. Baseline demographic, clinical, and radiographic findings were collected. Outcomes included END from any cause, parenchymal hemorrhage (PH1 or PH2), sICH, and mortality at 90 days. Results A total of 1238 patients with AIS without acute treatment of large vessel occlusion received IV tPA. 9.4% (116) had presence of any degree of ICH on noncontrast computed tomography head and 7.4% (91) experienced associated END. 2.7% (33) of patients experienced sICH, while 6.7% (83) experienced asymptomatic ICH. Of the patients with END, 63.7% did not have ICH. Predictive factors at presentation for END included an older age (72.6 ± 16.1 vs. 69.1 ± 14.8, p = 0.03), history of tobacco use (odds ratio [OR] 2.1 [1.1–4.3], p = 0.04), and hyperlipidemia (OR 1.7 [1.1–2.8], p = 0.02), along with the presence of an untreated large vessel occlusion (OR 2.1 [1.4–3.1], p = 0.02). Most END occurred within a mean time of 242 ± 251 min (4 ± 4 h). Because of the small proportion of patients suffering from sICH (33), predictors could not be determined; however, for patients with any ICH, predictive factors included an older age (74.6 ± 12.4 vs. 68.8 ± 15.1, p = 0.001), higher baseline National Health Institute Stroke Scale score (14.6 ± 7.3 vs. 10.8 ± 7.9, p = 0.002), and higher baseline glucose levels (155.1 ± 87.5 vs. 140.4 ± 70.5, p = 0.04). Conclusions In this study, only a small proportion suffered from either sICH and/or END, typically within 12 h of tPA administration. These findings may support earlier deescalation of higher acuity monitoring in clinically stable post-IV tPA patients without large vessel occlusion.

Safety and Feasibility of a “Fast-Track” Monitoring Protocol for Patients Treated with Intravenous Thrombolytic Therapy

“…[6,7] An earlier retrospective database analysis found a mean time from intravenous tissue plasminogen activator (IV tPA or IV alteplase) administration to END of less than 5 hours, with over 80% of cases occurring within 12 hours. [8] Several factors were predictive of END and any ICH, including an untreated large vessel occlusion and higher baseline NIHSS, consistent with prior studies. [9][10][11] Moreover, the OPTIMIST safety trial found all patients in their population of NIHSS less than 10 on presentation without initial ICU needs remained clinically stable and could be safely monitored with a lower intensity protocol.…”

“…Previous studies of stroke systems of care show that over 80% of those with END occurs within the first 6 hours from IVT, providing further proof of the safety of transferring patients out of the ICU sooner. [8] The guidelines to ensure adequate care of neuro-critically ill patients during a pandemic highlights the need for alternate strategies beyond currently routine practices. [14,15] Potential solutions to acute shortages include increasing ICU capacity by discharging suitable patients earlier to lower intensity units.…”

“…Demographic characteristics, treatment information, and clinical and radiological data were extracted and compared to a similar retrospective database of AIS patients at our institution who received IV Alteplase from 2013-2019. [8]…”

Timing of symptomatic intracranial hemorrhage after endovascular stroke treatment

“…reocclusion, infarct extension, cerebral edema, seizures) also warrant frequent neurological assessments. 11 Other studies should investigate the timing patterns of these complications.…”

“…To further improve protocols, selecting patients for which frequent neurological assessments after more than 12 h are not of additional value could reduce workload, length of stay, and hospital costs. 10 , 11 In addition, it could be helpful to select patients which warrant stricter and longer neurological assessments. Therefore, we evaluated a potential association with various characteristics and the timing of sICH occurrence.…”