Critical Care After Thrombolytic Therapy in Acute Stroke: Who Really Needs the ICU?

Background/Objectives: Intravenous thrombolytic therapy remains the cornerstone of managing acute ischemic stroke (AIS) patients. Given the potential adverse effects of thrombolysis, patients are admitted to an intensive care unit (ICU) for close monitoring following administration. Alternative post-thrombolytic pathways may provide safe, cost-effective care in certain populations. We aimed to determine the proportion of patients treated with thrombolytics who required ICU care for reasons other than frequent neurologic monitoring and to define their characteristics. Methods: We retrospectively (May 2020-August 2022) reviewed patients ≥ 18 years of age who received Tenecteplase (TNK) or tissue plasminogen activator (tPA) for AIS at our stroke center. Patients were classified as requiring ICU care if they required intubation within 24 h of admission, required neurosurgical intervention, had symptomatic hemorrhagic conversion or brain compression, required a continuous infusion for hemodynamic management, or were in status epilepticus. Univariate and multivariable statistical analyses were performed. The study protocol was deemed exempt by our Institutional Review Board. Results: 262 patients met inclusion criteria. A total of 54 (20.6%) required ICU care. Multivariable analysis showed that patients on antithrombotic therapies prior to arrival (AOR: 3.344, p = 0.002) or who presented with higher initial NIH stroke scale (AOR: 1.116, p < 0.001) had a significantly higher likelihood of requiring an ICU level of care. Conclusions: In our cohort, approximately 21% of patients required critical care. Antithrombotic therapy before admission and greater NIH stroke scale on arrival were associated with an increased likelihood of requiring ICU care. Further prospective studies are indicated to assess the efficacy of alternative settings for post-thrombolytic care in selected AIS patients; however, our findings suggest that a specific subset of patients with AIS can be safely and effectively cared for in a non-ICU setting. This may have implications for the provision of safe, effective care while optimizing healthcare resource utilization.