(615) Striking the Balance: Optimizing Post-Thrombolysis ICU Monitoring Duration in Acute Stroke

Introduction: Alteplase, an FDA-approved tissue plasminogen activator, is commonly used for acute ischemic stroke (AIS). Guidelines recommend 24-hour monitoring in the intensive care unit (ICU) post-thrombolysis, but recent studies challenge this practice. This study aims to identify potential candidates for early transition to a lower level of care by evaluating risk factors for adverse outcomes within 24 hours post-thrombolysis. Early transition out of the ICU could optimize resources, decrease length of stay, and reduce healthcare costs.

Methods: We conducted a retrospective cohort study at a tertiary care center, enrolling adult AIS patients (≥18 years) who received thrombolysis. Patients transferred to other facilities, transitioned to comfort or hospice care within 24 hours, or lacking imaging and National Institutes of Health Stroke Scale (NIHSS) score data were excluded. The primary endpoint was the incidence of symptomatic intracranial hemorrhage (sICH) within 0-12 hours and 12-24 hours post-thrombolysis. Secondary endpoints included need for ICU intervention and rates of neurological deterioration.

Results: The analysis included 204 patients who received full dose 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 12 hours (p=0.415). Multivariable analysis identified 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 occur beyond 12 hours after thrombolytic administration. These findings suggest that while a subset of patients receiving thrombolysis, particularly those undergoing mechanical thrombectomy, may require full 24 hours of intensive monitoring, other patients could be considered for early transition out of the ICU, leading to reduced hospital costs and optimized resource utilization.