What are the immediate goals for a patient with ischemic stroke post thrombolysis with tissue Plasminogen Activator (tPA)?

Immediate Goals for Ischemic Stroke Post-Thrombolysis

The immediate goals after tPA administration are to prevent and detect hemorrhagic transformation through intensive blood pressure control (maintaining BP <180/105 mmHg), perform frequent neurological assessments (at least hourly for the first 24 hours), obtain a 24-hour post-treatment CT scan to exclude intracranial hemorrhage before starting any antithrombotic therapy, and provide organized stroke unit care with early rehabilitation. 1

Critical Monitoring Requirements

Blood Pressure Management

• Maintain strict blood pressure control with systolic BP <180 mmHg and diastolic BP <105 mmHg during and after tPA infusion 1
• Excessive and prolonged hypotension should be avoided, as it can compromise cerebral perfusion 1
• Emergency antihypertensive treatment is warranted if BP exceeds these thresholds to reduce hemorrhagic transformation risk 1

Neurological Surveillance

• Perform neurological assessments at least hourly for the first 24 hours, including level of consciousness, symptom severity, and blood pressure 2
• Immediate notification of the stroke team is required for: change in level of drowsiness/consciousness, change in Canadian Neurological Scale score by ≥1 point, or change in NIHSS score by ≥4 points 2
• Approximately 25% of patients experience neurological worsening during the first 24-48 hours, making close monitoring essential 1, 2
• Continuous oxygen saturation monitoring is needed to identify hypoxia and early complications 2

Hemorrhage Prevention and Detection

Imaging Protocol

• Obtain a CT scan 24 hours after tPA administration to exclude intracranial hemorrhage before initiating any antithrombotic therapy 1
• This 24-hour scan is mandatory as symptomatic intracranial hemorrhage occurs in approximately 6.4% of tPA-treated patients 1
• Any neurological deterioration should prompt immediate repeat imaging 1

Medication Restrictions

• Avoid all antithrombotic drugs (including aspirin) until after the 24-hour post-thrombolysis scan has excluded intracranial hemorrhage 1
• Once hemorrhage is excluded, aspirin (160-325 mg) should be initiated immediately 1
• Anticoagulation should not be started in the acute post-tPA period 1

Optimal Care Environment

Stroke Unit Admission

• Transfer patients to a dedicated stroke unit as soon as possible, ideally within 24 hours of hospital arrival 2
• Stroke unit care reduces death (OR=0.76), death or institutionalization (OR=0.76), and death or dependency (OR=0.80) compared to non-specialized units 2
• The benefits of stroke unit care are comparable to the effects achieved with tPA itself 1

Interdisciplinary Team Approach

• The core team should include physicians, nurses, occupational therapists, physiotherapists, speech-language pathologists, social workers, and clinical nutritionists with stroke expertise 2
• Staffing ratios should be ≥3.0 registered nurses per 10 beds, as lower ratios are associated with higher mortality 2

ICU Monitoring Considerations

Risk Stratification for ICU Needs

• Patients with NIHSS ≥10, African American race, or elevated systolic blood pressure at presentation have higher risk of requiring ICU interventions 3
• Most patients requiring ICU resources (81%) develop these needs prior to the end of tPA infusion 3
• For minor stroke patients (NIHSS 0-5) without ICU needs by the end of tPA infusion, a 12-hour monitoring period may be sufficient rather than the traditional 24 hours 4

When ICU-Level Care Is Indicated

• Patients selected for decompressive hemicraniectomy should be transferred to ICU or neuro step-down unit for close monitoring 2
• Routine ICU admission solely for post-tPA monitoring may be unwarranted and unnecessarily expensive when appropriate stroke unit care is available 2

Early Rehabilitation Initiation

Mobilization and Therapy

• Initial assessment by rehabilitation professionals should be performed within 48 hours of admission 5
• Rehabilitation therapy should begin as soon as possible once the patient is medically stable 5
• The "out of bed within 24-hour principle" should be followed when feasible 1

Common Pitfalls to Avoid

Critical Errors

• Delaying transfer to stroke unit beyond 2 days is associated with increased complications 2
• Failing to maintain strict BP control increases hemorrhagic transformation risk 1
• Starting antiplatelet or anticoagulant therapy before the 24-hour exclusionary CT scan significantly increases bleeding risk 1
• Inadequate neurological monitoring frequency may miss early deterioration requiring intervention 2

Monitoring Gaps

• Failing to recognize that 7% of patients without initial ICU needs may still require intensive care later, particularly those with diabetes mellitus and higher NIHSS scores 3
• Not screening for common post-stroke complications including dysphagia, which affects aspiration risk and medication administration routes 6