Do all stroke patients require admission to the Intensive Care Unit (ICU) for at least 24 hours?

From the Guidelines

No, not all stroke patients require admission to the Intensive Care Unit (ICU) for at least 24 hours. The decision for ICU admission depends on several factors including stroke severity, neurological status, comorbidities, and the need for intensive monitoring or interventions. Patients with minor strokes who are neurologically stable may be admitted directly to a stroke unit or regular medical ward. However, patients with large vessel occlusions requiring thrombectomy, those receiving thrombolysis with tPA (alteplase, typically 0.9 mg/kg with 10% as bolus and remainder over 60 minutes) 1, patients with hemorrhagic strokes, or those with impaired consciousness, unstable vital signs, or requiring ventilatory support would benefit from ICU care. Additionally, patients with malignant cerebral edema at risk for herniation, those requiring continuous blood pressure management (with medications like nicardipine, labetalol, or clevidipine), or those needing close neurological monitoring may need ICU admission.

Some key considerations for ICU admission include:

• The need for close monitoring of vital signs and neurological status
• The requirement for intensive interventions such as thrombectomy or continuous blood pressure management
• The presence of comorbidities that may complicate stroke care
• The potential for neurological worsening or complications such as hemorrhagic transformation

Recent guidelines from the American Heart Association/American Stroke Association 1 and the European Stroke Organisation 1 emphasize the importance of individualized care and the need for rapid admission to a stroke unit or ICU for patients with acute stroke. The primary goal is to provide the appropriate level of care based on the individual patient's condition rather than applying a universal rule for all stroke patients. Emerging evidence suggests that direct admission to a stroke unit for patients receiving thrombolysis with tPA may be safe and effective, and may improve continuity of care and outcomes 1.

From the Research

ICU Admission for Stroke Patients

• Not all stroke patients require admission to the Intensive Care Unit (ICU) for at least 24 hours, as the need for ICU care depends on the severity of the stroke and the presence of other medical conditions 2, 3.
• The most frequent reasons for ICU admissions in stroke patients include large infarction with potential swelling, reduced level of consciousness, secondary hemorrhagic transformation, acute symptomatic seizures or respiratory failure, and stroke-related disorders of the brain-heart interaction 2.
• Patients with severe strokes, such as those with large infarctions or significant neurological deficits, may require ICU care to prevent secondary brain injury and optimize systemic physiological homeostasis 2, 4.
• The implementation of specialized neuro-intensive care teams can help improve functional outcomes after acute ischemic stroke 2.
• The decision to admit a stroke patient to the ICU should be based on individual patient factors, including the severity of the stroke, the presence of other medical conditions, and the need for close monitoring and intensive care 3.

Predictors of Mortality in Stroke Patients

• Impaired consciousness and acute physiologic abnormalities are independent predictors of mortality for severe ischemic stroke during the acute stage 3.
• Neurologic factors predict early mortality from intrinsic cerebral dysfunction, while non-neurologic factors, especially the associated physiologic abnormalities, predict late mortality from medical complications 3.
• The use of direct oral anticoagulants (DOACs) within 48 hours of thrombolysis is not a contraindication to thrombolysis for ischemic stroke, and may even be associated with lower mortality rates and reduced incidence of intracranial hemorrhage 5.

Management of Stroke Patients in the ICU

• The main goal in the ICU management of stroke patients is to prevent secondary brain injury by optimizing systemic physiological homeostasis, controlling intracranial pressure, cerebral perfusion, hemodynamic and respiratory parameters 2.
• A comprehensive approach to ICU management should include invasive and non-invasive neuro-monitoring, decision making in decompressive neurosurgery, specific cardiorespiratory management, nutrition, temperature management, and mobilization strategies 2, 4.