Original Article
Wake-up Stroke Within 3 Hours of Symptom Awareness: Imaging and Clinical Features Compared to Standard Recombinant Tissue Plasminogen Activator Treated Stroke

https://doi.org/10.1016/j.jstrokecerebrovasdis.2011.10.003Get rights and content

Background

Patients with wake-up stroke (WUS) are excluded from thrombolysis because of unknown time of symptom onset. Previous studies have reported similar stroke severity and early ischemic changes (EICs) in patients with WUS and stroke of known onset. These studies, however, included patients within a large timeframe to imaging or did not quantify EICs. The aim of our study was to quantify EICs of patients with WUS presenting within 3 hours of symptom recognition compared to standard 3-hours recombinant tissue plasminogen activator (rt-PA)–treated patients and assess the extent of ischemic lesion and functional independence at follow-up.

Methods

Patients were selected from our prospectively collected stroke database. Baseline and follow-up computed tomographic scans were graded with Alberta Stroke Program Early Computed Tomography Score (ASPECTS). Clinical outcome measures were modified Rankin Scale score, mortality, and symptomatic intracerebral hemorrhage.

Results

Demographic features, risk factors, stroke severity, and baseline ASPECTS were similar in both groups. WUS and rt-PA–treated patients had similar tissue outcome (median ASPECTS 7.0 vs 7.5; P = .202). Functional outcome was more favorable in rt-PA–treated patients (61.6% vs 43.1%; odds ratio [OR] 2.12; 95% confidence interval [CI] 1.05-4.28; P = .037). After adjusting for age, stroke severity, treatment, and EICs in less than one-third of middle cerebral artery territory, rt-PA and National Institutes of Health Stroke Scale scores remained the only significant predictors of outcome (OR 7.76; 95% CI 2.40-25.05; P = .001 and OR 0.74; 95% CI 0.67-0.82; P < .001, respectively).

Conclusions

Within 3 hours of symptom recognition, patients with WUS have EICs similar to rt-PA–treated patients. It is reasonable to expect that selected WUS patients might benefit from thrombolysis within 3 hours of symptom awareness.

Section snippets

Methods

We selected consecutive patients between February 2005 and July 2010 from our prospectively collected stroke database. The database contains data on demographic features, time of symptom onset, time of arrival to the emergency department, time to CT scan, stroke severity measured with the National Institutes of Health Stroke Scale (NIHSS) score, vascular risk factors, treatment, outcome at hospital discharge and at 3 months measured with modified Rankin Scale (mRS). We split patients with known

Results

A total of 1531 ischemic stroke patients were admitted to our stroke center between February 2005 and July 2010. Of these, 125 patients consecutively arrived within 3 hours of symptom onset and were treated with standard of care rt-PA (8.2%). The exclusion of 26 patients with stroke in the ACA or posterior circulation, 11 patients with missing baseline CT scan images, and 2 patients with prestroke mRS scores ≥3 left 86 patients in the standard rt-PA group. A total of 190 consecutive WUS

Discussion

In the present study WUS patients accounted for 12.4% of all ischemic stroke patients admitted to our stroke centre. Around a third of WUS could have been appropriate candidate for thrombolysis if stroke onset modality were not a factor. Very recently a population-based study found similar figures evaluating the proportion of WUS and how many patients would have been eligible for thrombolisys if time were not a factor.7

Our study was focused on the clinical and imaging features of WUS patients

Acknowledgment

We thank Dr Mariapia Sormani for statistical advice.

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