Management of a wake-up stroke

Abstract

Current national guidelines advocate intravenous thrombolysis to treat patients with acute ischaemic stroke presenting within 4.5 hours from symptom onset, and thrombectomy for patients with anterior circulation ischaemic stroke from large vessel occlusion presenting within 6 hours from onset. However, a substantial group of patients presents with acute ischaemic stroke beyond these time windows or has an unknown time of onset. Recent studies are set to revolutionise treatment for these patients. Using MRI diffusion/FLAIR (fluid-attenuated inversion recovery) mismatch, it is possible to identify patients within 4.5 hours from onset and safely deliver thrombolysis. Using CT perfusion imaging, it is possible to identify subjects with a middle cerebral artery syndrome who have an extensive area of ischaemic brain but as yet have only a small area of infarction who may benefit from urgent thrombectomy in up to 24 hours. Here, we highlight the recent advances in late window stroke treatment and their potential contribution to clinical practice.

Wake-Up Stroke: relato de caso, importância e perspectivas futuras / Wake-Up Stroke: case report, importance and future perspectives

“…Durante as 1-4h seguintes, com a progressão da cascata isquêmica, há quebra da barreira hematoencefálica e extravasamento de macromoléculas para o espaço extracelular, com aumento da osmolalidade tecidual. A sequência FLAIR é responsável por detectar esse estágio de edema vasogênico, sendo superior à imagem em T2, especialmente em lesões próximas ao espaço do líquido cefalorraquidiano (4,15,16) .…”

Stroke: What's Sleep Got to Do With It?

“…Current US guidelines recommend IV alteplase in patients with acute ischemic strokes who present #4.5 hours from symptom onset and mechanical thrombectomy for patients with anterior circulation ischemic stroke from large vessel occlusion presenting # 6 hours from onset. 99 Alteplase given within 4.5 hours of stroke symptom onset increases the likelihood of having minimal or no functional disability at 90 days by 11% to 15% compared with placebo. 100 Using alteplase, the number needed to treat to achieve functional independence in patients with acute ischemic infarcts are nine by 3 hours and 14 by 4.5 hours.…”

Acute Ischemic Stroke With Mild Symptoms–To Thrombolyse or Not to Thrombolyse?

“…This suggests that the stroke may have occurred shortly before awakening, though the true time of onset is unknown. Modern imaging technologies, such as MRI DWI and FLAIR mismatch and or perfusion imaging, can help identify those who may benefit from thrombolysis or thrombectomy ( 18 ). The WAKE-UP trial showed that those with strokes evident from sleep with favorable MRI findings (DWI and FLAIR mismatch) who were treated with IV alteplase had significantly better functional outcomes, though more intracranial hemorrhages, than placebo at 90 days ( 19 ).…”