Intravenous thrombolysis in wake‐up stroke: real‐world data from the Austrian Stroke Unit Registry

Abstract

Background and purpose Data on real‐world experience with intravenous thrombolysis (IV tPA) in wake‐up stroke (WUS) are limited. The aim of this study was to examine the efficacy and safety of IV tPA in patients with WUS included in the Austrian Stroke Unit Registry. Methods Data from a large nationwide stroke unit registry including initial stroke severity, vascular risk factors, comorbidities, treatment with IV tPA, symptomatic intracerebral haemorrhage (sICH) and functional outcome were extracted and analysed. Patients with WUS were compared with patients with known‐onset stroke (KOS) regarding the frequency of IV tPA treatment, neurological improvement (National Institutes of Health Stroke Scale score ≥4), sICH and 3‐month functional outcome by modified Rankin Scale score using standard statistical tests. Results A total of 107 895 stroke patients entered the analysis, including 12 534 with WUS and 91 899 with KOS. Altogether, 904 (7.2%) patients with WUS received IV tPA as compared with 16 694 (18.2%) patients with KOS. Patients with WUS who received IV tPA treatment had twofold higher initial National Institutes of Health Stroke Scale score (median 8 vs. median 4) as compared with patients with KOS. There was no statistical difference in functional outcome by modified Rankin Scale score 0–1 at 3 months between patients with WUS and patients with KOS treated with IV tPA (adjusted odds ratio, 1.08; 95% confidence interval, 0.9–1.31). Also, the rate of sICH did not differ (4.1% vs. 4%, P = 0.852). Conclusions In this large non‐randomized comparison, the safety and efficacy of IV tPA in patients with WUS in the real‐world setting seems to be comparable to patients with KOS.

Addressing a real‐life problem: treatment with intravenous thrombolysis and mechanical thrombectomy in acute stroke patients with an extended time window beyond 4.5 h based on computed tomography perfusion imaging

“…However, real-world data from the nationwide Austrian Stroke Unit Registry compared in a non-randomized study the safety and efficacy of IVT in WUS and known onset of symptoms in stroke patients. There was no statistical difference regarding clinical outcome and complication rate [10]. These registry data do not fully reveal the selection parameters for IVT in these patients.…”

“…Compared with this, the WAKE‐UP trial showed a rate of sICH of 2% , whereas in the EXTEND trial sICH occurred in 6.2% . Data from the Austrian Stroke Unit Registry comparing WUS with stroke patients with known symptom onset presented a rate of sICH of 4.1% .…”

“…Of 545 patients treated with IVT from January 2015 to October 2018, 70 patients were included (mean age AE SD 77.6 AE 11.5 years, 50.0% female). Median National Institutes of Health Stroke Scale (NIHSS) score on admission was 8.0 [interquartile range (IQR), [4][5][6][7][8][9][10][11][12][13][14] and median pre-morbid mRS score was 0 (IQR, 0-1). Patients' baseline demographic, clinical and radiological data are summarized in Table 1.…”

Thrombolytic therapy for wake‐up stroke: A systematic review and meta‐analysis

“…Eight studies [22–29] used noncontrast CT (NCCT) scanning as the primary determinant of candidacy for IV tPA, and two studies [30,31] used CT perfusion imaging. Five studies [4,5,32–34] used MRI, whereas one study [35] included a large sample of patients from multiple centers that used multiple types of imaging strategies. In all, the 16 studies (two RCTs and 14 observational studies) included a total of 14,017 patients.…”

“…Mean patient ages were reported in 13 studies [4,5,22,24,26–34] and ranged from 63.9 to 78 years. Median patient ages were reported in three studies [23,25,35] and ranged from 69 to 75 years. Stroke severity in the treated groups, as measured by median NIHSS score, ranged from 5 to 11.9, and thus the included studies reported data for patients with primarily moderate stroke severity.…”