Unknown onset ischemic strokes in patients last-seen-well &gt;4.5 h: differences between wake-up and daytime-unwitnessed strokes

Dekker, Luuk; Hund, Hajo; Lemmens, Robin; Boiten, Jelis; Wijngaard, Ido R. van den

doi:10.1007/s13760-017-0830-7

Cited by 17 publications

(17 citation statements)

References 35 publications

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“…These indicators provided a comprehensive assessment of patients during and after hospital discharge. After professional evaluation and timely follow-up, we found that WUS could not be distinguished from non-WUS by the early outcome, which was consistent with the results of a population-based study [5] and other high-quality clinical studies and randomized clinical trials [12,18,32,33].…”

Section: Discussionsupporting

confidence: 86%

Clinical Characteristics and Functional Outcomes of Wake-Up Stroke in the Chinese Population

Zhang

Zou

et al. 2020

Eur Neurol

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Background: Wake-up stroke (WUS) accounts for up to 25% of all new ischemic strokes, but debate exists regarding whether WUS differs from non-WUS in previous studies. Our study aimed to investigate the proportion of WUS cases and to examine differences in clinical characteristics and outcomes in these two groups. Methods: Data from acute ischemic stroke patients who presented to the First Affiliated Hospital of Chongqing Medical University between April 2017 and September 2017 were prospectively collected. Admission demographic information, clinical and radiological characteristics, and 3-month functional outcomes were assessed and compared between patients with WUS and those with non-WUS. Poor functional outcome was defined as modified Rankin Scale ≥ 3 at the 90-day follow-up. Risks of poor outcomes for WUS were estimated with logistic regression analysis. Results: A total of 473 eligible patients were included, of which 132 had been diagnosed with WUS (27.9%). Forty WUS patients had poor functional outcomes and 92 WUS patients had good functional outcomes. WUS and non-WUS patients were similar in regard to stroke risk factors, severity, etiology, and prognosis at 90 days (p > 0.05), but WUS patients were more likely to have had previous stroke (p < 0.001) and a tendency of higher albumin levels (p = 0.051). WUS patients show significant differences in terms of age, gender, prior stroke, atrial fibrillation, impaired consciousness at admission, levels of albumin and triglycerides, stroke severity, and stroke etiology between the good outcome group and the poor outcome group (p < 0.05). Multivariate logistic regression analysis showed that age (odds ratio [OR] 1.079, 95% confidence interval [CI] 1.021–1.141; p < 0.05), previous stroke (OR 4.017, 95% CI 1.197–13.484; p < 0.05), and admission National Institutes of Health Stroke Scale (NIHSS) score ≥5 (OR 5.453, 95% CI 1.510–19.696; p < 0.05) were independently associated with an unfavorable outcome of WUS. Conclusions: WUS accounts for 27.9% of 473 ischemic strokes in the Chinese population. WUS and non-WUS patients were similar in terms of stroke risk factors, severity, etiology, and early outcomes. Age, previous stroke, and a high admission NIHSS score were independent risk factors for unfavorable outcomes in patients with WUS.

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Section: Discussionsupporting

confidence: 86%

Clinical Characteristics and Functional Outcomes of Wake-Up Stroke in the Chinese Population

Zhang

Zou

et al. 2020

Eur Neurol

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“…UOS patients are unable to provide accurate symptom onset time for some reasons, for example, awakening with stroke symptoms, nonwitnessed stroke with aphasia or unconsciousness [30, 31]. They are usually considered as a contraindication for intravenous thrombolysis for the uncertain symptom onset.…”

Section: Discussionmentioning

confidence: 99%

Efficacy and Safety of Intravenous Thrombolysis in Patients with Unknown Onset Stroke: A Meta-Analysis

Luan

Zhang

Yang

et al. 2019

Behavioural Neurology

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Objectives. Unknown onset stroke (UOS) is usually excluded from intravenous thrombolysis concerning the unclear symptom onset time. Attempts have been done to use thrombolytic therapy in these patients. The current meta-analysis was done to examine the efficacy and safety of intravenous thrombolysis in UOS. Methods. PubMed, Web of Science, and Cochrane Library were searched for studies comparing thrombolysis with conservative therapy among UOSs. Data of good outcome (mRS, 0-2), mortality, and intracerebral hemorrhage (ICH) and symptomatic ICH (sICH) were extracted and analyzed using the Revman 5.2 software. Results. In total, 8 studies with 1271 subjects (542 with thrombolysis and 729 with conservative therapy) were included in this meta-analysis. The data showed that patients receiving thrombolysis had a higher incidence of 90-day good outcome (P=0.0005) than conservative therapy. The comparison of discharge (P=0.89) and 90-day mortality (P=0.10) in both groups did not find any significances. The incidences of ICH (P=0.42) and sICH (P=0.06) were relatively comparable between the two therapies. Conclusions. Intravenous thrombolysis is a better choice for UOS patients for its efficacy and safety. In addition, pretreatment imaging assessment is beneficial for improving the efficacy of thrombolytic therapy. However, it needs more supporting evidences for clinical use in the future.

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“…In this series, up to 36% of cases of AIS had UTO. Some had stroke on awakening (wake-up stroke, WUS) and others had daytime-unwitnessed stroke 4–6. For the patients with UTO, the time of onset exceeded the therapeutic time window for intravenous tPA since the time of onset was calculated as the patient was LSN 7 8…”

Section: Discussionmentioning

confidence: 99%

Outcome of multimodal MRI-guided intravenous thrombolysis in patients with stroke with unknown time of onset

Zhao

Zhao²,

et al. 2019

Stroke Vasc Neurol

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ObjectiveIntravenous tissue plasminogen activator (tPA) is the standard therapy for patients with acute ischaemic stroke (AIS) within 4.5 hours of onset. Recent trials have expanded the endovascular treatment window to 24 hours. We investigated the efficacy and safety of using multimodal MRI to guide intravenous tPA treatment for patients with AIS of unknown time of onset (UTO).MethodsData on patients with AIS with UTO and within 4.5 hours of onset were reviewed. Data elements collected and analysed included: demographics, National Institutes of Health Stroke Scale (NIHSS) score at baseline and 2 hours, 24 hours, 7 days after thrombolysis and before discharge, the modified Rankin Scale (mRS) score at 3 months after discharge, imaging findings and any adverse event.ResultsForty-two patients with UTO and 62 in control group treated within 4.5 hours of onset were treated with intravenous tPA. The NIHSS scores after thrombolysis and/or before discharge in UTO group were significantly improved compared with the baseline (p<0.05). Between the two groups, no significant differences in NIHSS score were observed (p>0.05). Utilising the non-inferiority test, to compare mRS scores (0–2) at 3 months between the two groups, the difference was 5.2% (92% CI, OR 0.196). Patients in the UTO group had mRS scores of 0-2, which were non-inferior to the control group. Their incidence of adverse events was similar.ConclusionsUtilising multimodal MRI to guide intravenous only thrombolysis for patients with AIS with UTO was safe and effective. In those patients with AIS between 6 and 24 hours of time of onset but without large arterial occlusion, intravenous thrombolysis could be considered an option.

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Unknown onset ischemic strokes in patients last-seen-well >4.5 h: differences between wake-up and daytime-unwitnessed strokes

Cited by 17 publications

References 35 publications

Clinical Characteristics and Functional Outcomes of Wake-Up Stroke in the Chinese Population

Clinical Characteristics and Functional Outcomes of Wake-Up Stroke in the Chinese Population

Efficacy and Safety of Intravenous Thrombolysis in Patients with Unknown Onset Stroke: A Meta-Analysis

Outcome of multimodal MRI-guided intravenous thrombolysis in patients with stroke with unknown time of onset

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