title: Critical Care Needs in Patients with Diffusion-Weighted Imaging Negative MRI after tPA--Does One Size Fit All?
abstract: OBJECTIVE
  Patients who receive intravenous (IV) tissue plasminogen activator (tPA) for ischemic stroke are currently monitored in an intensive care unit (ICU) or a comparable stroke unit for at least 24 hours due to the high frequency of neurological exams and vital sign checks. The present study evaluates ICU needs in patients with diffusion-weighted imaging (DWI) negative MRI after IV tPA.
  
  
  METHODS
  A retrospective chart review was performed for 209 patients who received IV tPA for acute stroke. Data on stroke risk factors, physiologic parameters, stroke severity, MRI characteristics, and final diagnosis were collected. The timing and nature of ICU interventions, if needed, was recorded. Multivariable logistic regression was used to determine factors associated with subsequent ICU needs.
  
  
  RESULTS
  Patients with cerebral infarct on MRI after tPA had over 9 times higher odds of requiring ICU care compared to patients with DWI negative MRI (OR 9.2, 95% CI 2.49-34.15). All DWI negative patients requiring ICU care did so by the end of tPA infusion (p = 0.006). Among patients with DWI negative MRI, need for ICU interventions was associated with higher NIH Stroke Scale (NIHSS) scores (p<0.001), uncontrolled hypertension (p<0.001), seizure at onset (p = 0.002), and reduced estimated glomerular filtration rate (eGFR) (p = 0.010).
  
  
  CONCLUSIONS
  Only a small number of DWI negative patients required ICU care. In patients without critical care needs by the end of thrombolysis, post-tPA MRI may be considered for triaging DWI negative patients to a less resource intense monitoring environment.
authors.affiliation: Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America.
authors.forename: Roland
authors.initials: R
authors.lastname: Faigle
authors.affiliation: Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America.
authors.forename: Elisabeth B
authors.initials: EB
authors.lastname: Marsh
authors.affiliation: Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America.
authors.forename: Rafael H
authors.initials: RH
authors.lastname: Llinas
authors.affiliation: Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America.
authors.forename: Victor C
authors.initials: VC
authors.lastname: Urrutia
mesh_terms: D061605:Administration, Intravenous; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000150:complications* / Q000000981:diagnostic imaging / Q000188:drug therapy; D003422:Critical Care / Q000706:statistics & numerical data*; D038524:Diffusion Magnetic Resonance Imaging; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage* / Q000627:therapeutic use; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D011859:Radiography; D020521:Stroke / Q000000981:diagnostic imaging / Q000188:drug therapy*; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage* / Q000627:therapeutic use; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator