Reperfusion Therapies for Wake-Up Stroke

Abstract

Patients who present with stroke symptoms on awakening, often referred to as wake-up stroke (WUS), account for ≈25% of acute ischemic strokes.1 In this group, onset time is unknown and usually defined conservatively as time last seen well (LSW) before sleeping.2,3 Onset time is important because benefit from intravenous thrombolysis is time dependent until 4.5 hours after symptoms start.4 Patients with WUS are not treated routinely unless awake and symptom free within standard timescales. However, evidence suggests that clinical and imaging characteristics of patients with WUS do not differ significantly from those with stroke while awake (SWA) presenting within 0- to 3-hour thrombolysis time windows.1,5,6 Imaging findings for many patients with WUS are consistent with an onset immediately before waking.6 As patients with WUS may benefit from reperfusion treatment if promptly delivered, we systematically reviewed studies of patients with WUS treated with intravenous and intra-arterial reperfusion therapies to consider the strength of evidence and make future recommendations. ### Search Strategy/Selection Criteria An unlimited PubMed search (MEDLINE) was performed on April 16, 2013, using the terms: wake* OR awake* OR sleep* OR asleep OR unclear-onset OR unclear onset OR unwitness* OR witness* AND stroke. Further PubMed alerts were received until June 30, 2013. One author (D.B.) reviewed abstracts to identify potentially eligible studies. Because of the small number of publications anticipated, all study designs were included. Articles were included if they described additional analyses using data from previously identified cohorts. ### Data Extraction Two authors (D.B. and L.S.) independently extracted data. Discrepancies were resolved by discussion with C.P. as the final adjudicator. The data extracted were 1. inclusion criteria, 2. type(s) of data comparison/numbers of patients, 3. type(s) of intervention, drugs/doses, 4. time to treatment (TTT) from wake-up and LSW, 5. imaging findings, 6. stroke severity (baseline National Institute of Health Stroke Scale …