Many stroke patients on 'clot-busting' tPA may not need long stays in the ICU

February 12, 2014, Johns Hopkins University School of Medicine

A Johns Hopkins study of patients with ischemic stroke suggests that many of those who receive prompt hospital treatment with "clot-busting" tissue plasminogen activator (tPA) therapy can avoid lengthy, restrictive monitoring in an intensive care unit (ICU).

The study challenges the long-standing protocol that calls for intensive monitoring, mostly done in ICUs, for the first 24 hours after tPA infusion to catch bleeding in the brain, a side effect seen in 6 percent of treated with the medication.

Results show that a relatively simple measure of stroke severity can accurately single out which patients need ICU monitoring and which can be managed outside of a critical care setting in the hospital.

"What we saw in this preliminary study was that, after the initial hour-long infusion of tPA, if an need had not developed, the chance of needing ICU monitoring - including a symptomatic 'bleed' - was extremely low for a large majority of patients, namely those with milder strokes," says Victor Urrutia, M.D., medical director of the Comprehensive Stroke Center at The Johns Hopkins Hospital and head of the research team.

Ischemic stroke, caused by a clot in a blood vessel that cuts off blood flow to the brain, is the most common form of stroke and the second leading cause of death for those over 60. In the United States, an estimated 795,000 people suffer a stroke each year. So far, tPA is the only FDA-approved treatment for acute stroke.

In a report on the study published online in the journal PLOS ONE, the Johns Hopkins team analyzed data from 153 stroke patients admitted to the emergency departments of The Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center between 2010 and 2013. After taking into account differences in age, sex, race, hypertension, diabetes, atrial fibrillation, kidney function, blood clotting status, use of statin drugs and other health factors, the team says that what emerged as the best predictor of the need for intensive care was a patient's score on the National Institutes of Health (NIH) Stroke Scale, a trusted measure of stroke severity. The scale is a proven tool administered at the bedside involving 15 measures and observations, including level of consciousness, language ability, eye movements, vision strength, coordination and sensory loss. Scores range from zero to 42, with mild strokes typically registering 10 or lower. The average score for the Johns Hopkins patient group was 9.8.

"What we learned is that the majority of our patients with mild strokes required no critical care, and that we are using scarce, specialized resources for intensive monitoring rather than for intensive care," says Urrutia, an assistant professor of neurology.

"If our upcoming, prospective study verifies what we've found about those who don't need to be in the ICU, our patients will benefit, and we will also reduce costs of care."

Urrutia emphasized that is clearly needed for tPa-linked bleeding, stroke-related brain swelling and critical abnormalities in blood pressure or blood sugar.

But, he says, "For patients with an NIH Stroke Scale score of less than 10 without a need for transfer to the ICU after the first hour, the risk of a problem occurring later that needed ICU attention was only about 1 percent."

In the follow-up study, which is scheduled to begin this spring, consenting patients with a low stroke scale score and no other apparent need for intensive care will enter a unit with a less rigorous monitoring schedule and increased family visiting time.

Patients in the non-ICU setting will be less physically restricted and subjected to fewer sleep interruptions, lowering the risk of ICU-associated delirium and psychological distress. "We expect benefits to extend to the hospital as well, freeing up the ICU staff and beds for sicker patients," says Urrutia.

The financial benefits of the change in protocol could be significant, Urrutia adds. "Present monitoring for patients with tPA is very costly," he says.

Explore further: Hospitals with neurology residency programs more likely to administer life-saving clot-busting drugs

Related Stories

Hospitals with neurology residency programs more likely to administer life-saving clot-busting drugs

November 6, 2013
Stroke patients treated at hospitals with neurology residency programs are significantly more likely to get life-saving clot-busting drugs than those seen at other teaching or non-teaching hospitals, new Johns Hopkins-led ...

Clot-busting drug safe for stroke patients taking blood thinner

May 10, 2012
Acute ischemic stroke patients taking the blood thinner warfarin can be treated safely with the clot-busting drug tissue plasminogen activator (tPA), according to research presented at the American Heart Association's Quality ...

Hands-free ultrasound device with clot-busting drug safe for stroke patients

October 24, 2013
A hands-free ultrasound device combined with a clot-busting drug was safe for ischemic stroke patients in a phase II pilot study, reported in the American Heart Association journal Stroke.

Certified stroke centers more likely to give clot-busting drugs

March 26, 2013
Stroke patients are three times more likely to receive clot-busting medication if treated at a certified stroke center, according to a study in the Journal of the American Heart Association.

Cocaine may increase stroke risk within 24 hours of use

February 12, 2014
Cocaine greatly increases ischemic stroke risk in young adults within 24 hours of use, according to research presented at the American Stroke Association's International Stroke Conference 2014.

Burden of futile care in ICU studied: Patients waiting for care affected negatively, study presented

October 28, 2013
Researchers at UCLA studied the opportunity costs of providing futile care to patients in the ICU, finding that care was delayed or compromised for waiting patients when futile care was being provided in a full ICU. Futile ...

Recommended for you

Heart researchers develop a new, promising imaging technique for cardiac arrhythmias

February 22, 2018
Every five minutes in Germany alone, a person dies of sudden cardiac arrest or fibrillation, the most common cause of death worldwide. This is partly due to the fact that doctors still do not fully understand exactly what ...

Scientists use color-coded tags to discover how heart cells develop

February 22, 2018
UCLA researchers used fluorescent colored proteins to trace how cardiomyocytes—cells in heart muscle that enable it to pump blood—are produced in mouse embryos. The findings could eventually lead to methods for regenerating ...

Beetroot juice supplements may help certain heart failure patients

February 22, 2018
Beetroot juice supplements may help enhance exercise capacity in patients with heart failure, according to a new proof-of-concept study. Exercise capacity is a key factor linked to these patients' quality of life and even ...

'Beetroot pill' could help save patients from kidney failure after heart X-ray

February 22, 2018
Beetroot may reduce the risk of kidney failure in patients having a heart x-ray, according to research led by Queen Mary University of London.

Women once considered low risk for heart disease show evidence of previous heart attack scars

February 20, 2018
Women who complain about chest pain often are reassured by their doctors that there is no reason to worry because their angiograms show that the women don't have blockages in the major heart arteries, a primary cause of heart ...

Can your cardiac device be hacked?

February 20, 2018
Medical devices, including cardiovascular implantable electronic devices could be at risk for hacking. In a paper publishing online today in the Journal of the American College of Cardiology, the American College of Cardiology's ...

0 comments

Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.