Resource Allocation: Stable Patients Remain Stable 12–24 h Post-tPA

Abstract

Background and Purpose: Stroke patients are currently monitored for neurological deterioration for 24 h following treatment with intravenous tissue plasminogen activator (IV tPA) or mechanical thrombectomy. This requires low nursing ratios and an intensive-care-like setting. As the half-life of IV tPA is short, many patients may not require such prolonged intensive monitoring and could be downgraded much earlier. We evaluate the frequency of neurological deterioration in the 0-12 and 12-24 h post-treatment windows. Methods: Patients presenting with acute ischemic stroke treated with IV tPA and/or thrombectomy at our institution from 2016-2018 were prospectively followed per protocol for 24 h post-therapy (examinations every 15 min for 2 h, every 30 min for 6 h, and hourly thereafter). Neurological deteriorations were recorded along with interventions and complications. Frequency of deterioration within the 0-12 and 12-24 h post-treatment windows was determined, along with factors associated with decline at each time point. Results: A total of 172 patients were treated (IV:135, IA:65, both:30). Thirty-six (21%) experienced a documented neurologic deterioration [8 due to intracerebral hemorrhage (4.7%)]. Five patients deteriorated in the 12-24 h window; all but one had experienced earlier examination changes. Elevated NIHSS was associated with a higher likelihood of deterioration overall. Early fluctuation was associated with decline after 12 h. Conclusions: New onset of neurologic deterioration is rare 12-24 h after treatment of acute stroke. Stable patients with low NIHSS scores and no ICU needs may not require intensive monitoring greater than 12 h post-treatment.

Reflection on the Past, Present, and Future of Thrombolytic Therapy for Acute Ischemic Stroke

“…10 Recent studies have suggested that less frequent assessments, or only 12 hours of intensive care unit monitoring, following alteplase therapy may be reasonable in selected patients. 21,22…”

“…10 Recent studies have suggested that less frequent assessments, or only 12 hours of intensive care unit monitoring, following alteplase therapy may be reasonable in selected patients. 21,22 New Frontiers, Challenges, and Future of Thrombolytics in AIS Care Prehospital Alteplase: Mobile Stroke Units and Telestroke Given the early emphasis on time to administration from symptom onset, multiple analyses have highlighted the number needed to treat as low as 4.5 within 1.5 hours compared to 9 within 3 hours and 14 within 3-4.5 hours. 23 The concept of a mobile stroke unit (MSU) for hyperacute stroke treatment was initially proposed in 2003, 23 and proven feasible years later.…”

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

“…[5] This feared complication reassuringly occurs in a minority of patients. [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.…”

Shorter Intensive Care Unit Stay (12 Hours) Post Thrombolysis Is Safe and Reduces Length of Stay for Minor Stroke Patients

“…3 Deterioration in patients with no critical care needs after 12 hours in patients with low NIHSS is rare. 4 Because of the COVID-19 pandemic, the need for ICU capacity grew exponentially and the resources available within our ICUs dwindled. Our approach of early transfer out of ICU for post-tPA patients enabled us to optimize available resources within our ICUs.…”