Abstract
Introduction: Trials using advanced imaging have shown a benefit from intravenous thrombolysis in patients with wake-up stroke, but real-world data is limited. This study presents data on outcomes in patients presenting with wake-up stroke at a comprehensive stroke center comparing those who received thrombolysis to those who did not. Methods: In February 2022, our institution implemented a wake-up stroke protocol utilizing emergent MRI-based evaluation for possible thrombolysis. The protocol combines clinical criteria (suspected ischemic stroke with disabling neurologic deficits; last known normal within 12 hours; time from symptom discovery to arrival within 4.5 hours) and imaging criteria (absence of proximal large vessel occlusion; FLAIR-DWI mismatch; signal intensity ratio < 1.15 in those able to receive perfusion imaging). In this study, we compared discharge outcomes and hospital length of stay for patients with ischemic stroke selected for wake-up protocol with vs. without thrombolytic therapy. In addition, we assessed the proportion of patients with reversibility of diffusion restriction, defined as a decrease in infarct volume on ADC sequence between the pre-treatment to 24-hour post-treatment MRI. Results: Between February 2022 & June 2023, there were 31 wake-up stroke activations (~2 per month). Median admission NIHSS was 6. 30% had medium or distal vessel occlusions. 71% of stroke activations had a final diagnosis of ischemic stroke; 32% of cases were eligible per protocol and treated with thrombolysis. Compared to patients diagnosed with ischemic stroke but not eligible for treatment, those treated with thrombolysis were more likely to be discharged home (70% vs. 17%, p = 0.02) and had a shorter hospital stay by ~1.5 days (mean LOS 3.6 days vs. 4.8 days; median LOS 3 days vs. 4.5 days; p <0.01). ADC reversibility was demonstrated in ~30% of patients who underwent thrombolysis. Conclusions: Intravenous thrombolysis for patients presenting with wake-up stroke was feasible, improved outcomes, and reduced potential cost. It also demonstrated ADC reversibility in 30% of cases. Further steps are needed to increase availability of emergent MRI and optimize door to thrombolysis times in order to streamline access for potential treatment.
Published Version
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