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

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.