Evaluation of Post-thrombolytic Events to Determine Appropriate ICU Monitoring Duration for Patients with Ischemic Stroke

Abstract

Background:Alteplase, a tissue plasminogen activator, is the only FDA-approved medication for acute ischemic stroke (AIS). Current guidelines recommend monitoring patients in an intensive care unit (ICU) for 24 hours after thrombolytic therapy. However, recent studies have questioned the need for prolonged ICU monitoring. This retrospective cohort aims to identify potential candidates for early transition to a lower level of care by assessing risk factors for neurological deterioration, symptomatic intracranial hemorrhage (sICH), or need for ICU intervention within 24-hours post-thrombolysis. Methods:This retrospective cohort study included adult AIS patients 18 years and older who received thrombolysis in a tertiary care center. Patients were excluded if they were transferred to another facility, transitioned to comfort care or hospice care within 24 hours, or lacked imaging and National Institutes of Health Stroke Scale (NIHSS) score data. The primary endpoint was incidence of sICH between 0-12-hours and 12-24hours. Secondary endpoints include the need for ICU intervention and rates of neurological deterioration. Results:The analysis included 204 patients who received the full dose of alteplase. Among them, 10 patients (4.9%) developed sICH, with the majority (n=7) occurring within 12 hours post-thrombolysis (p=0.350).Sixty-two patients required ICU interventions within 12 hours compared to 4 patients after 12 hours (p=0.022). Twenty-four patients had neurological deterioration within 12 hours and 7 patients after (p=0.415). Multivariable analysis identi ed mechanical thrombectomy and increased blood pressure at presentation as predictors of ICU need beyond 12 hours post-thrombolysis. Conclusions:Our study demonstrates that sICH, neurological deterioration, and need for ICU intervention rarely occurs beyond 12 hours after thrombolytic administration. These ndings suggest that patients receiving thrombolysis for AIS, particularly those undergoing mechanical thrombectomy, may require 24 hours of ICU monitoring. Our results support the potential for early transition out from the ICU, leading to reduced hospital costs and optimized resource utilization.Current guidelines recommend a 24-hour monitoring period in an intensive care unit (ICU) for AIS patients following thrombolytic therapy. 3 This practice aims to promptly detect and manage potential complications, such as symptomatic intracranial hemorrhage (sICH) and neurological deterioration.Nevertheless, extended ICU stays impose strain on hospital resources, increase healthcare costs and prolong patients' length of stay.Recent studies have challenged the necessity of prolonged ICU monitoring following alteplase administration. [4][5][6][7][8] These arguments are further strengthened by the pharmacodynamic and pharmacokinetic properties of alteplase. Alteplase has a half-life of approximately 5 minutes and 80% is cleared from plasma within 10 minutes, although actual brinolytic activity persists for about an hour after the infusion is terminated. 2 To contribute ...