Abstract Body: Introduction:
Intravenous thrombolysis with alteplase (tPA) or tenecteplase (TNK) is a first-line treatment for acute ischemic stroke. The most serious risk associated with IV thrombolytics is symptomatic intracranial hemorrhage (sICH). Patients are usually monitored in intensive care units for neurologic decline signaling sICH for 24 hours, after which follow up neuroimaging is performed and antithrombotic secondary prevention may be initiated. However, the evidence surrounding the onset of neurologic decline in post-thrombolytic sICH is limited. The current study seeks to provide data regarding onset of clinical worsening in post-thrombolytic sICH, and to identify a subset of patient characteristics for a future clinical trial to test whether earlier imaging, transfer from ICU, and initiation of secondary prevention is feasible and safe.
Methods:
The current study is a multi-center collaboration between University of Texas - Dell Medical Center, Ascension Seton, and Ascension Saint Thomas. We reviewed stroke databases from 2017 to 2024 for patients who received IV thrombolysis with either tPA or TNK and developed sICH within 36 hours of treatment. sICH was defined as a hemorrhage that caused an increase in NIHSS by 4 or more points. Patient charts were reviewed to determine if a decline in neurologic exam prompted neuroimaging that discovered sICH, and for documentation of the timing of clinical worsening that prompted neuroimaging.
Results:
40 patients were identified during the study period to have sICH. Of those, 25 patients were discovered to have sICH after a decline in neurologic exam. 7 patients received tPA and 18 patients received TNK. The median time to documented neurologic decline in all patients was 251 mins (range: 7 mins to 1185 mins). For patients with pretreatment NIHSS < 10, the median time to documented neurologic decline was 134 mins (range: 57 to 259 mins).
Discussion:
All patients with neurologic decline resulting in neuroimaging and discovery of sICH had this decline documented within 20 hours. Among patients with NIHSS < 10, all patients had this decline within 5 hours. Our preliminary data suggests that there may be patients who receive IV thrombolysis who may be candidates for expedited neuroimaging or transition to step-down units and secondary preventive measures. Candidates would likely require stable neurologic exams that could be tracked over time. Further investigation to confirm these results on a larger sample is planned.