Safety Trial of Low-Intensity Monitoring After Thrombolysis: Optimal Post Tpa-Iv Monitoring in Ischemic STroke (OPTIMIST)

Abstract

Background and Purpose: At present, stroke patients receiving intravenous thrombolysis (IVT) undergo monitoring of their neurological status and vital signs every 15 minutes for the first 2 hours, every 30 minutes for the next 6 hours, and every hour thereafter up to 24 hours post-IVT. The present study sought to prospectively evaluate whether post-IVT stroke patients with low risk for complications may safely be cared for utilizing a novel low-intensity monitoring protocol. Methods: In this pragmatic, prospective, single-center, open-label, single-arm safety study, we enrolled 35 post-IVT stroke patients. Adult patients were eligible if their NIH Stroke Scale (NIHSS) was less than 10 at the time of presentation, and if they had no critical care needs by the end of the IVT infusion. Patients underwent a low-intensity monitoring protocol during the first 24 hours after IVT. The primary outcome was need for a critical care intervention in the first 24 hours after IVT. Results: The median age was 54 years (range: 32-79), and the median pre-IVT NIHSS was 3 (interquartile range [IQR]: 1-6). None of the 35 patients required transfer to the intensive care unit or a critical care intervention in the first 24 hours after IVT. The median NIHSS at 24 hours after IVT was 1 (IQR: 0-3). Four (11.4%) patients were stroke mimics, and the vast majority was discharged to home (82.9%). At 90 days, the median NIHSS was 0 (IQR: 0-1), and the median modified Rankin Scale was 0 (range: 0-6). Conclusion: Post-IVT stroke patients may be safely monitored in the setting of a low-intensity protocol.

Extrapulmonary manifestations of COVID-19

“…Provisional guidelines during the COVID-19 crisis call for continued adherence to established guidelines for acute ischemic stroke, including providing access to thrombolysis and thrombectomy, while recognizing the need to minimize the use of personal protective equipment 209 . Post-acute-care monitoring guidelines may be adjusted for pandemic constraints 210 . The liberal use of 'telestroke' , or remote video evaluation of patients who have had a stroke, which has been a mainstay of stroke care for hospitals without access to specialists for many years, is also recommended and may have a role even within large hospitals.…”

Temporary Emergency Guidance to US Stroke Centers During the Coronavirus Disease 2019 (COVID-19) Pandemic

“…In the absence of data supporting current practice, we suggest that it is feasible to move stable stroke patients to step-down or other units if an intensive care unit bed is needed. 8 In general, patients with intracerebral hemorrhage and subarachnoid hemorrhage have higher mortality and are more likely to undergo an interventional or surgical procedure and require intubation and prolonged time in an intensive care unit, compared with patients with ischemic stroke. Physicians and other healthcare personnel should follow the most upto-date and evolving guidelines regarding intubation, interventional procedures, and critical care for these patients in setting of the pandemic.…”

Streamlined Poststroke Treatment Order Sets During the SARS-CoV-2 Pandemic

“… 4 A recent small single-center single-arm study found that low-intensity monitoring following intravenous thrombolysis was safe. 5 Furthermore, the yield of each patient encounter was maximized by grouping together different components of poststroke care into single bedside visits (Table 1 ).…”