Population-based study of wake-up strokes

Mackey, Jason; Kleindorfer, Dawn; Sucharew, Heidi; Moomaw, Charles J.; Kissela, Brett M.; Alwell, Kathleen; Flaherty, Matthew L.; Woo, Daniel; Khatri, Pooja; Adeoye, Opeolu; Ferioli, Simona; Khoury, Jane; Hornung, Richard; Broderick, Joseph P.

doi:10.1212/wnl.0b013e318219fb30

Cited by 210 publications

(154 citation statements)

References 26 publications

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“…Studies suggest that WUS occurs predominantly in the early hours of the morning 1,8 ; therefore, the more suitable time point for defining WUS onset and for defining a therapeutic window may be that of symptom recognition rather than time since last known normal. Our findings are in accordance to the evidence that clinical and early CT findings in WUS patients are not different from patients with stroke of known onset, [9][10][11][12][13] and suggest that WUS may occur predominantly in a time period shortly before awakening. Selection of WUS patients for thrombolysis based on "low-tech" criteria, such as time from awakening-to-needle and quantification of early signs of ischemia in CT, 14 although having the limitation of not providing information regarding penumbra or definite core ischemic lesion may be sufficient to guarantee safety of thrombolysis and more advantageous regarding time to treatment, availability, and costeffectiveness.…”

Section: Discussionsupporting

confidence: 91%

Wake-up Stroke and Stroke within the Therapeutic Window for Thrombolysis Have Similar Clinical Severity, Imaging Characteristics, and Outcome

Costa

Pinho

Alves

et al. 2016

Journal of Stroke and Cerebrovascular Diseases

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Background: Wake-up stroke (WUS) represents 25% of all ischemic strokes. There is conflicting evidence concerning clinical severity, imaging characteristics, and outcome when WUS is compared with stroke of known time of onset. Our aim was to compare WUS patients with patients with ischemic stroke within the therapeutic window (STW) for thrombolysis. Methods: This is a retrospective hospitalbased study of all consecutive patients hospitalized for acute ischemic stroke during 2013. Patients with STW, WUS, and WUS with computed tomography (CT) at 3 hours or less after awakening (WUS≤3h) were selected for the study. The methods used include a review of clinical records, an independent quantification of early signs of ischemia on admission CT scan, and determination of functional outcome on follow-up. Results: Of 554 patients evaluated, 190 had STW, 113 had WUS (20.4%), and 25 had WUS≤3h. Among all WUS patients, 33.6% did not have any other formal contraindication for thrombolysis besides undetermined time of onset. WUS patients had demographic characteristics, vascular risk factors, and clinical severity similar to STW patients. Mild or absent early signs of ischemia on admission CT in WUS≤3h patients were similar to those in STW patients when adjusted for clinical severity (odds ratio [OR] = .50, 95% confidence interval [CI]=.17-1.47). Favorable prognosis in WUS≤3h was similar to STW when adjusted for age, clinical severity, and thrombolysis (OR = .53, 95% CI=.09-3.14). Conclusions: This study strengthens the evidence that clinical and early imaging characteristics of WUS patients are similar to those of patients with stroke who are eligible for thrombolysis based on the time window criteria, and patients with WUS do not have a worse short outcome. Key Words: Wake-up stroke-ischemic stroke-computed tomography-stroke outcome.

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Section: Discussionsupporting

confidence: 91%

Wake-up Stroke and Stroke within the Therapeutic Window for Thrombolysis Have Similar Clinical Severity, Imaging Characteristics, and Outcome

Costa

Pinho

Alves

et al. 2016

Journal of Stroke and Cerebrovascular Diseases

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“…The same study concludes, that WUS do not differ from non-wake up strokes (NWUS) in clinical features, risk factors, or outcome. 1 There is a diurnal variation in the onset of stroke. Sleep tends to promote ischemic stroke, and there is a higher frequency of strokes occurring in the morning.…”

Section: Introductionmentioning

confidence: 99%

Association of Sleep Disordered Breathing with Wake-Up Acute Ischemic Stroke: A Full Polysomnographic Study

Šiarnik

Kollár

Čarnická

et al. 2016

Journal of Clinical Sleep Medicine

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Study Objectives: Sleep disordered breathing (SDB) is a frequent comorbidity in stroke patients. SDB is one of the independent risk factors for ischemic stroke. Conversely, stroke may contribute to SDB onset or aggravate premorbid SDB. Multiple mechanisms underlying SDB might be responsible for the development of stroke. The aim of this study was to compare polysomnographic, clinical, and laboratory characteristics of wake-up (WUS) and non-wake-up acute ischemic strokes (NWUS). Methods: We prospectively enrolled 88 patients with acute ischemic stroke. Clinical characteristics of the population were recorded on admission, and blood samples were obtained in the fasting condition following morning. SDB was assessed using standard overnight polysomnography in the acute phase of the stroke. Results: WUS were present in 16 patients (18.2%), and NWUS in 72 patients (81.8%). In WUS compared to NWUS, we observed significantly higher values of apnea-hypopnea index (24.8 vs. I NTRO DUCTI O NA recent population-based study has shown that wake-up strokes (WUS) comprise 14% of all ischemic strokes. The same study concludes, that WUS do not differ from non-wake up strokes (NWUS) in clinical features, risk factors, or outcome.1 There is a diurnal variation in the onset of stroke. Sleep tends to promote ischemic stroke, and there is a higher frequency of strokes occurring in the morning.2,3 Sleep disordered breathing (SDB) is present in up to 72% of stroke patients and is one of the independent risk factors for stroke. 4,5 However, stroke may also aggravate premorbid SDB or even contribute to SDB onset. 6 Multiple mechanisms might link SDB with the onset of cerebral ischemia during the sleep, including coagulation changes, hemodynamic changes, blood pressure (BP) surges, inflammatory overactivity, increased arterial stiffness, increased sympathetic tone, paradoxical embolization, or the development of cardiac arrhythmias. 7-11Currently, WUS patients are excluded from revascularization therapy; therefore, a thorough search for predictors and risk factors of WUS is desirable. The aim of this study was to compare polysomnographic, clinical, and laboratory characteristics of WUS and NWUS with mild-to-moderate severity. SCIENTIFIC INVESTIGATIONS Association of Sleep M ETHO DSThe study population consists of patients hospitalized in the stroke unit of the 1 st Department of Neurology, Comenius University Bratislava from January 2011 to December 2014 with the BRIEF SUMMARY Current Knowledge/Study Rationale: Currently, wake-up stroke patients are excluded from revascularization therapy, so a precise search for predictors and risk factors of wake-up strokes is desirable. The aim of this study was to compare polysomnographic, clinical, and laboratory characteristics of wake-up strokes and non-wake-up strokes with mild-to-moderate severity. Study Impact: We emphasize the importance of significantly higher frequency of moderate-to-severe sleep apnea syndrome among the wake-up stroke population, as this population is indicated for positive...

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“…among these patients, more than one third would have been eligible for thrombolysis if arrival time were not a factor. 1 if the same pattern holds true for Canada, that would translate to thousands of additional patients eligible for thrombolytic therapy.…”

mentioning

confidence: 91%

Wake-Up to Wake-Up Stroke!

Chan¹

2014

Can. J. Neurol. Sci.

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here is a typical story. a patient arrives at the emergency room. he was well when he went to bed and then he woke up with symptoms suggestive of stroke several hours later. even without further scrutiny, the clinician determines that intravenous thrombolytic therapy is contraindicated. end of story. Such is the plight of patients with wake-up stroke. Can we do more? Can we do better? Wake-up stroke is not rare. about 5 to 30% of patients who presents to the emergency room for presumed acute stroke have wake-up stroke. Because of uncertainty regarding the time of symptoms onset, these patients are routinely excluded from intravenous thrombolytic therapy. in a population-based study, 14% of ischemic strokes presented to an emergency department were wake-up stroke. among these patients, more than one third would have been eligible for thrombolysis if arrival time were not a factor. 1 if the same pattern holds true for Canada, that would translate to thousands of additional patients eligible for thrombolytic therapy. When one deals with wake-up stroke, one needs to re-visit the concept of "last seen well". the time "last seen well" is a good and objective way to time the onset of stroke symptoms. When symptom onset is unwitnessed, such as patients who are aphasic and alone at the time, "last seen well" may become an obstacle to thrombolysis. in the case of wake-up stroke, "last seen well" often puts the patient outside the conventional therapeutic time window. although well-intentioned, we may not be right to assume that the time of symptom onset is close to the time of "last seen well". let us assume that the onset of stroke symptoms occurs in a random fashion during sleep hours. for a patient who was well when he went to bed eight hours earlier, the chances of stroke occurring during the final four hours will be the same as the chance of it starting during the first four hours, or 50%. that means that 50% of these patients are potential candidates for intravenous thrombolytic therapy. of course, the assumption that the chance of stroke occurring equally at every time point during sleep is questionable at best. other vascular events, particularly acute myocardial infarction in which the onset is marked by the development of chest pain, tend to occur in the final hour before arousal. ischemic strokes likely follow the same diurnal pattern. 2 Several studies compared the clinical and radiological features between patients with wake-up stroke and patients with strokes that occurred within the therapeutic windows of alteplase. the two groups of patients were essentially identical in these studies. 3,4 the evidence suggests that wake-up strokes more likely occur in the early morning hours just before arousal. Clinicians involved in thrombolytic therapy for acute stroke know that some patients presenting within 4.5 hours of symptoms onset will show well defined infarct on cranial computed tomogram (Ct) scan. We also have examples of patients who have normal cranial Ct scan even though their symptoms occurred more than 4....

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Population-based study of wake-up strokes

Cited by 210 publications

References 26 publications

Wake-up Stroke and Stroke within the Therapeutic Window for Thrombolysis Have Similar Clinical Severity, Imaging Characteristics, and Outcome

Wake-up Stroke and Stroke within the Therapeutic Window for Thrombolysis Have Similar Clinical Severity, Imaging Characteristics, and Outcome

Association of Sleep Disordered Breathing with Wake-Up Acute Ischemic Stroke: A Full Polysomnographic Study

Wake-Up to Wake-Up Stroke!

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