What tests and management are required for a patient admitted to the Intensive Care Unit (ICU) with a Middle Cerebral Artery (MCA) stroke after receiving Tenecteplase (TNK) (tissue plasminogen activator)?

From the Guidelines

For a patient admitted to the ICU with an MCA stroke after receiving TNK, comprehensive monitoring and management are essential to prevent secondary injury and optimize neurological recovery. The management of such patients should be guided by the most recent and highest quality evidence, which emphasizes the importance of a multidisciplinary approach to care 1.

Key Components of Care

• Continuous cardiac monitoring to screen for atrial fibrillation and other potentially serious cardiac arrhythmias for at least the first 24 hours, as recommended by the World Stroke Organization 1.
• Frequent neurological assessments using the NIH Stroke Scale to monitor for any signs of neurological deterioration.
• Strict blood pressure control, typically maintaining systolic BP <180 mmHg and diastolic BP <105 mmHg, to prevent hemorrhagic transformation, in line with guidelines for the management of acute ischemic stroke 1.
• Laboratory tests should include complete blood count, coagulation studies (PT/INR, PTT), comprehensive metabolic panel, and cardiac enzymes to identify any potential complications early.
• A follow-up CT scan should be performed within 24 hours or immediately if neurological deterioration occurs to assess for hemorrhagic transformation, as part of the standard protocol for monitoring patients post-thrombolysis.
• Antithrombotic therapy should be initiated after confirming the absence of hemorrhage, typically with aspirin 81-325 mg daily, followed by consideration of dual antiplatelet therapy or anticoagulation based on stroke etiology, as per the recommendations for the management of patients with acute ischemic stroke 1.
• Deep vein thrombosis prophylaxis, typically with intermittent pneumatic compression devices initially, should be implemented to prevent venous thromboembolism, a common complication in immobilized patients 1.
• Swallowing assessment before oral intake, glycemic control maintaining blood glucose between 140-180 mg/dL, temperature management targeting normothermia, and early mobilization when stable are crucial components of care to prevent secondary complications and improve outcomes 1.
• Patients should receive appropriate hydration while avoiding hypotonic solutions to maintain optimal fluid balance and prevent cerebral edema.

Considerations for Specific Complications

• Urinary retention, constipation, gastrointestinal bleeding, and psychosocial issues such as depression, pseudobulbar affect, and delirium should be assessed and managed according to established guidelines to improve patient comfort and outcomes 1.
• Early mobilization and rehabilitation assessment are critical for preventing impaired mobility and promoting recovery, with interventions such as daily stretching of the hemiplegic limbs, positioning, and use of supportive devices to prevent contractures and subluxation 1. By prioritizing these components of care and managing potential complications proactively, healthcare providers can significantly improve morbidity, mortality, and quality of life outcomes for patients admitted to the ICU with MCA stroke after receiving TNK.

From the Research

Management of MCA Stroke Post TNK in ICU

The management of patients admitted to the ICU for MCA stroke post TNK (tissue plasminogen activator) involves several key aspects:

• Airway and ventilation management: Patients with severe MCA stroke may require ventilatory support to maintain adequate oxygenation and ventilation 2, 3.
• Hemodynamic and fluid optimization: Close monitoring and management of blood pressure, fluid status, and electrolytes are crucial to prevent further brain injury 2, 3.
• Fever and glycemic control: Fever and hyperglycemia can exacerbate brain injury, and their control is essential in the ICU management of MCA stroke 2, 3.
• Management of anticoagulation, antiplatelet, and thromboprophylaxis therapy: The use of these therapies should be carefully considered and managed in patients with MCA stroke to prevent further thrombotic or hemorrhagic complications 2, 3.
• Control of seizures: Seizures can occur in patients with MCA stroke, and their control is essential to prevent further brain injury 2, 3.
• Surgical interventions: Decompressive craniectomy may be considered in patients with malignant MCA infarction to reduce intracranial pressure and improve outcomes 4.

Tests and Monitoring

Patients with MCA stroke post TNK in the ICU require close monitoring and regular tests, including:

• Frequent neurological assessments to monitor for signs of deterioration or improvement 2, 3.
• Imaging studies, such as CT or MRI scans, to monitor the extent of brain infarction and detect any complications 2, 3.
• Laboratory tests, such as blood glucose and electrolyte levels, to monitor for any metabolic disturbances 2, 3.
• Hemodynamic monitoring, such as blood pressure and cardiac output, to optimize cardiovascular management 2, 3.

Specific Considerations

The use of hypertonic saline to reduce intracranial pressure in patients with acute traumatic brain injury has been studied, but its effectiveness in MCA stroke is not well established 5. The management of MCA stroke post TNK in the ICU should be individualized and based on the best available evidence, with consideration of the patient's specific clinical circumstances and needs 2, 3, 6.