To evaluate rates of complication in patients receiving intravenous Alteplase for treatment of acute ischemic stroke and identify differences in outcome between those transferred vs those not transferred to another facility.

Intravenous Alteplase is currently the only approved medical therapy for treatment of acute ischemic stroke (AIS). Although complications are uncommon, AIS patients receiving IV Alteplase  are routinely transferred to higher level stroke centers for monitoring. This resource intensive treatment paradigm is of unclear medical benefit.

We reviewed the stroke thrombolysis database of a single comprehensive stroke center. All presumed AIS patients who received IV Alteplase without thrombectomy from 01/01/2015 to 12/31/2019 were included. Baseline demographics including age, sex, race, ethnicity, comorbidities and NIHSS were abstracted. Complication rates including angioedema, intracranial and extracranial hemorrhage were recorded. To determine the utility of routine transfer, medical and surgical/neurosurgical interventions to treat complications of Alteplase administration were studied. Complication rates in the transfer and non-transfer cohorts were compared via Fischer’s exact test.

Three hundred eighteen patients were reviewed and 222 consecutive AIS patients (median age 67 [IQR 55.5-77], female 48.6%, median NIHSS 5 [IQR 2-10], transfers 54.5%) were eligible for our analysis. Complication rates were not statistically different between transfer and non-transfer patients. Four (1.8%) patients suffered symptomatic intracranial hemorrhage (sICH). All sICH patients received cryoprecipitate and aggressive blood pressure management; none underwent emergent neurosurgical intervention.

The overall rate of complications post-Alteplase administration for AIS patients was similarly low between transfer and non-transfer patients. These findings call into question the utility of routine transfer of AIS patients treated with Alteplase. Further study of alternative post-Alteplase monitoring strategies, including remote specialist management via telemedicine, should be considered.