From the Guidelines
Not all suspected stroke patients require admission to the Intensive Care Unit (ICU) for at least 24 hours, as the decision for ICU admission should be individualized based on the patient's clinical condition, including stroke severity, neurological status, and need for intensive monitoring or interventions. According to the Canadian Stroke Best Practice Recommendations [ 1 ], patients with acute stroke or TIA should be treated on an inpatient stroke unit as soon as possible, ideally within 24 hours of hospital arrival. The recommendations emphasize the importance of a specialized, geographically defined hospital unit dedicated to the management of stroke patients, with a core interdisciplinary team consisting of healthcare professionals with stroke expertise.
The decision for ICU admission depends on several factors, including:
- Stroke severity and neurological status
- Need for mechanical ventilation or intensive monitoring
- Presence of comorbidities, such as hemodynamic instability or large vessel occlusions
- Risk of neurological deterioration requiring close monitoring
- Need for thrombolysis with tPA (alteplase) or mechanical thrombectomy
Patients with minor strokes or transient ischemic attacks (TIAs) who are neurologically stable may be appropriately managed in a stroke unit or regular medical ward [ 1 ]. However, patients with severe strokes, decreased level of consciousness, or those who require intensive monitoring or interventions may benefit from ICU admission [ 1 ]. The first 24-48 hours after stroke onset are critical for monitoring and managing complications, and the level of care should be tailored to the individual patient's needs.
Key considerations for ICU admission include:
- Close monitoring for signs of hemorrhagic transformation, such as changes in level of consciousness, elevation of blood pressure, or deterioration in motor examination [ 1 ]
- Management of bleeding complications, including discontinuation of rtPA infusion and administration of cryoprecipitate and platelets [ 1 ]
- Prevention of trauma during oral care and avoidance of invasive procedures in the first 24 hours after thrombolytic therapy [ 1 ]
Ultimately, the decision for ICU admission should be made on a case-by-case basis, taking into account the individual patient's clinical condition and needs, rather than applying a blanket rule for all stroke patients.
From the Research
Admission Requirements for Suspected Stroke Patients
- Not all suspected stroke patients require admission to the Intensive Care Unit (ICU) for at least 24 hours 2
- The decision to admit a patient to the ICU should be based on the severity of the stroke and the patient's overall condition 3, 4
- Patients with mild strokes (National Institutes of Health Stroke Scale score <8) may not require ICU admission, as they may have fewer complications and more favorable discharge outcomes when admitted to a general ward 2
ICU Management of Stroke Patients
- The main goal of ICU management is to prevent secondary brain injury by optimizing systemic physiological homeostasis, controlling intracranial pressure, and managing cardiorespiratory parameters 3, 4
- Specialized neuro-intensive care teams can help improve functional outcomes after acute ischemic stroke 3
- ICU management may involve invasive and non-invasive neuro-monitoring, decision making in decompressive neurosurgery, and specific cardiorespiratory management, nutrition, temperature management, and mobilization strategies 3, 4
Guidelines for ICU Management
- Guidelines for the early management of stroke, commonly used in Stroke Units, should be followed, even in critically ill patients in an ICU setting 5
- There is a need for more research on the epidemiology and consequences of stroke in the ICU setting, as well as the impact of ICU management on patient outcomes 5, 4