Treatment Concepts for Wake-Up Stroke and Stroke With Unknown Time of Symptom Onset

Thomalla, Götz; Gerloff, Christian

doi:10.1161/strokeaha.115.009701

Cited by 44 publications

(30 citation statements)

References 41 publications

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“…Patients who wake up with stroke symptoms or wake-up strokes represent an undertreated subgroup of AIS patients (≈20%) who are generally excluded for recanalization therapies because of the unknown time of symptom onset. 115 A series of DEFUSE trials (Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution) 116,117 have explored the role of perfusion imaging in assessing reversibility of brain ischemia in patients who present at a later time window. DEFUSE-3 is currently enrolling selected AIS patients ≤16 hours from symptom onset.…”

Section: Second-generation Stent Retriever Trialsmentioning

confidence: 99%

Acute Ischemic Stroke Therapy Overview

Catanese

Tarsia

Fisher

2017

Circulation Research

293

178

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A cute ischemic stroke (AIS) is a common disorder with almost 700 000 new or recurrent events per year in the United States. The risk of AIS varies by region, with the highest incidence occurring in the so-called stroke belt in the southern part of the country.1 The risk of AIS varies among African Americans, Latinos, and Caucasians, with the highest risk in African Americans. The risk of AIS increases with age, and the ageing of the US population portends an increase in AIS incidence and prevalence over the next several decades, despite increasingly effective efforts to treat stroke risk factors and the use of other preventive strategies.2 The incidence of AIS is also increasing in many other countries, largely related to potentially modifiable risk factors, especially in the developing world.3 The incidence of AIS is also greater among women beginning with an increased risk in the perimenopausal period and continuing into older age groups. Abstract: The treatment of acute ischemic stroke has undergone dramatic changes recently subsequent to the demonstrated efficacy of intra-arterial (IA) device-based therapy in multiple trials. The selection of patients for both intravenous and IA therapy is based on timely imaging with either computed tomography or magnetic resonance imaging, and if IA therapy is considered noninvasive, angiography with one of these modalities is necessary to document a large-vessel occlusion amenable for intervention. More advanced computed tomography and magnetic resonance imaging studies are available that can be used to identify a small ischemic core and ischemic penumbra, and this information will contribute increasingly in treatment decisions as the therapeutic time window is lengthened. Intravenous thrombolysis with tissue-type plasminogen activator remains the mainstay of acute stroke therapy within the initial 4.5 hours after stroke onset, despite the lack of Food and Drug Administration approval in the 3-to 4.5-hour time window. In patients with proximal, large-vessel occlusions, IA device-based treatment should be initiated in patients with small/moderate-sized ischemic cores who can be treated within 6 hours of stroke onset. The organization and implementation of regional stroke care systems will be needed to treat as many eligible patients as expeditiously as possible. Novel treatment paradigms can be envisioned combining neuroprotection with IA device treatment to potentially increase the number of patients who can be treated despite long transport times and to ameliorate the consequences of reperfusion injury. Acute stroke treatment has entered a golden age, and many additional advances can be anticipated. (Circ Res. 2017;120:541-558.

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Section: Second-generation Stent Retriever Trialsmentioning

confidence: 99%

Acute Ischemic Stroke Therapy Overview

Catanese

Tarsia

Fisher

2017

Circulation Research

293

178

View full text Add to dashboard Cite

show abstract

“…Epidemiologic studies suggest that 1 of every 3 patients with stroke may either wake up with symptoms or have unwitnessed onset, and this proportion may increase with an aging population. [11][12][13][14] Patients with unwitnessed stroke onset may have a last known well time many hours before or immediately proximate to the time of stroke recognition. Among this group, 2 types of patients can be identified.…”

Section: 4mentioning

confidence: 99%

Time for a Time Window Extension: Insights from Late Presenters in the ESCAPE Trial

Evans¹,

Graham²,

Pordeli

et al. 2017

AJNR Am J Neuroradiol

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“…Previous studies have reported rates of approximately 30% (24–28). Determination of time of symptom onset sometimes requires time for additional phone calls with patients’ relatives and caregivers whose contact details may not be immediately known.…”

Section: Discussionmentioning

confidence: 99%

Access to Thrombolysis for Non-Resident and Resident Stroke Patients—A Registry-Based Comparative Study from Berlin

et al. 2017

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ObjectivesStroke can happen to people away from home. It is unknown whether non-resident and resident stroke patients have equal access to thrombolysis.Materials and methodsConsecutive patients cared for by the Stroke Emergency Mobile between 2011 and 2016 after prompting suspicion of acute stroke during the emergency call were included in our registry. Patients were categorized as residents or non-residents based on their main address. Clinical characteristics, thrombolysis rates, and time intervals from symptom onset/last seen well to alarm and to thrombolysis were compared between groups adjusting for age, pre-stroke modified Rankin Scale (mRS) score, and National Institutes of Health Stroke Scale (NIHSS) score.ResultsOf 4,254 patients for whom a stroke dispatch was activated, 2,451 had ischemic or hemorrhagic strokes, including 73 non-residents. Non-resident stroke patients were younger (median 69.4 vs. 76.6 years, p < 0.001), had less pre-stroke disability (mRS ≥ 2:17.8 vs. 47.5%, p < 0.001) and less severe strokes (median NIHSS 4 vs. 5, p = 0.02). Thrombolysis rates were higher in non-residents (30.9 vs. 22.0% of ischemic stroke patients, p = 0.04) and emergency calls were made faster (symptom onset/last-seen-well-to-alarm time 35 vs. 144 min, p = 0.04). A lower proportion of non-residents had unknown time of symptom onset (21.9 vs. 46.4%, p < 0.001). For patients with known time of symptom onset, thrombolysis rates, and prehospital delays were similar among non-residents and residents.ConclusionIn this study, non-resident stroke patients had higher rates of thrombolysis than residents. This may be explained by a lower proportion of patients with unknown time of symptom onset.

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Treatment Concepts for Wake-Up Stroke and Stroke With Unknown Time of Symptom Onset

Cited by 44 publications

References 41 publications

Acute Ischemic Stroke Therapy Overview

Acute Ischemic Stroke Therapy Overview

Time for a Time Window Extension: Insights from Late Presenters in the ESCAPE Trial

Access to Thrombolysis for Non-Resident and Resident Stroke Patients—A Registry-Based Comparative Study from Berlin

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