Wake-up stroke: From pathophysiology to management

Peter‐Derex, Laure; Derex, Laurent

doi:10.1016/j.smrv.2019.101212

Cited by 39 publications

(27 citation statements)

References 104 publications

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“…In wake-up IS, 59.1% had a poor functional status at 3 months mainly because they were excluded from acute stroke therapy options. In line with previous studies, we can say that wake-up stroke patients showed an elevated severity at admission [5][6][7]36], but their evolution over 3 months was similar to awake IS patients. No difference was found in DWI volume at admission and in clinical DWI mismatch in both group of patients.…”

Section: Discussionsupporting

confidence: 91%

“…Between 8 and 39% of strokes are wake-up strokes i.e., they occur during sleep [1][2][3]. The concept of wake-up stroke emerged because of the limitations of the intravenous recombinant tissue plasminogen activator (rtPA) treatment (time window < 4.5) [2][3][4][5]. This means that the time when patients were last known well is used as a reference time for the stroke onset.…”

Section: Introductionmentioning

confidence: 99%

“…Consequently, wake-up ischemic stroke (IS) has been usually excluded from acute stroke therapy options for being outside of the safe treatment window. However, different comparisons between wake-up and awake ischemic strokes have demonstrated clinical and radiological similarities between them [5][6][7]. In this line, studies on the timing of the onset-symptoms of ischemic stroke determined that there is a peak incidence in the early morning hours, suggesting that many wake-up strokes probably occur close to awakening [8,9].…”

Section: Introductionmentioning

confidence: 99%

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Surrogate biomarkers of outcome for wake-up ischemic stroke

Hervella

Alonso-Alonso

Pérez‐Mato

et al. 2022

Preprint

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Background: Wake-up ischemic stroke (IS) has been usually excluded from acute stroke therapy options for being outside of the safe treatment window. We identified risk factors, and clinical or molecular biomarkers that could be therapeutic targets for wake-up stroke prevention, thus hopefully leading to a decrease in its mortality and disability in medium to long-term outcome. Methods: 4,251 ischemic stroke (IS) patients from a prospectively registered database were recruited; 3,838 (90.3%) had known onset-symptom time, and 413 (9.7%) were wake-up strokes. The main endpoint was to analyze the association between different serum biomarkers with wake-up IS episodes and their progression. Leukocytes count, serum levels of C-reactive protein, fibrinogen, interleukin 6 (IL-6), and vitamin D were analyzed as inflammation biomarkers; N-terminal pro-B-type Natriuretic-Peptide and microalbuminuria, used as atrial/endothelial dysfunction biomarkers; finally, glutamate levels as excitotoxicity biomarker. Results: Wake-up IS showed a poorer outcome at 3-months than in patients with known on-set-symptom time (59.1% vs. 48.1%; p<0.0001). Patients with wake-up IS had higher levels of inflammation biomarkers; IL-6 levels at admission (51.5±15.1 vs. 27.8±18.6 pg/ml; p<0.0001), and low vitamin D levels at 24 h (5.6±5.8 vs. 19.2±9.4 ng/ml; p<0.0001) are worthy of attention. In a logistic regression model adjusted for vitamin D, OR was 15.1; CI 95%: 8.6 - 26.3, p<0.0001. Conclusions: Inflammatory biomarkers are the main factors that are strongly associated with wake-up IS episodes. Wake-up IS is associated with lower vitamin D levels. These data indicate that vitamin D deficiency could become a therapeutic target to reduce wake-up IS events.

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Section: Discussionsupporting

confidence: 91%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Surrogate biomarkers of outcome for wake-up ischemic stroke

Hervella

Alonso-Alonso

Pérez‐Mato

et al. 2022

Preprint

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“…This finding might suggest that a longer early morning REM might increase the risk to develop WUS. Peter-Derex who stated that the morning peak in the frequency of vascular events might not only be related to circadian variations, but also to REM sleep morning preeminence support this hypothesis ( Peter-Derex and Derex, 2019 ). This is because the last sleep cycles of the night contain more REM sleep, a state of autonomic instability dominated by remarkable fluctuations between parasympathetic and sympathetic influences, whereas NREM sleep is associated with an increase in vagal drive and a decrease in cardiac sympathetic activity ( Somers et al, 1993 ; Baust et al, 1972 ).…”

Section: Discussionmentioning

confidence: 99%

Rapid eye movement (REM) sleep microarchitecture is altered in patients with wake-up ischemic stroke: A polysomnographic study

Mekky

Elkholy

Hamdy

et al. 2021

Neurobiology of Sleep and Circadian Rhythms

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It is well established that certain alteration of sleep disorders occur in patients with wake-up stroke (WUS) such as sleep disordered breathing, periodic limb movements and sleep duration. However, the data are lacking about the microarchitecture of different sleep stages among those patients. Aim of work To compare the polysomnographic microarchitecture of rapid eye movement (REM) sleep between WUS and daytime stroke (DTS). Methods A cross-sectional polysomnographic study was conducted on 20 patients with WUS and 20 patients with DTS, with analysis of REM sleep microarchitecture in specific. Results Patients with WUS had significantly shorter REM stage (11.76 ± 5.48% in WUS versus 16.59 ± 5.33% in DTS, P = 0.008), longer early morning REM was (25.70 ± 13.13 min in WUS versus 4.15 ± 4.69 min in DTS, P=<0.001), higher apnea-hypopnea index (AHI) during REM (6.29 ± 10.18 in WUS versus 1.10 ± 4.57 in DTS, P = 0.009), and lower mean Oxygen saturation during REM (92.70 ± 3.63 WUS versus 95.45 ± 1.35 DTS, P = 0.012). The OR of early morning REM duration was 1.8 (CI 1.099–3.130, p = 0.021) for WUS. Conclusion The microarchitecture of REM sleep is disrupted in patients with wake-up stroke.

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“…Until recently, WUS was considered a contraindication to reperfusion therapy due to its unknown onset time and intracerebral hemorrhage that may be associated with thrombolytic therapy. The clinical efficacy of reperfusion therapy in selected patients with WUS was displayed by demonstrating the presence of salvageable brain tissue in advanced brain imaging [61]. Also, in a recent meta-analysis study (77,398 patients), stroke patients with unknown symptom onset were proven to be safely and effectively treated with IV-tPA guided by imaging evaluation [62].…”

Section: Intravenous Thrombolysis In Patients With Acute Ischemic Stroke With Unknown Onset Timementioning

confidence: 99%

Thrombolysis in Acute Stroke

Çetiner¹

2022

Cerebrovascular Diseases - Elucidating Key Principles

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The first step in stroke care is early detection of stroke patients and recanalization of the occluded vessel. Rapid and effective revascularization is the cornerstone of acute ischemic stroke management. Intravenous thrombolysis is the only approved pharmacological reperfusion therapy for patients with acute ischemic stroke. Patient selection criteria based on patient characteristics, time, clinical findings and advanced neuroimaging techniques have positively affected treatment outcomes. Recent studies show that the presence of salvageable brain tissue can extend the treatment window for intravenous thrombolysis and that these patients can be treated safely. Recent evidence provides stronger support for another thrombolytic agent, tenecteplase, as an alternative to alteplase. Endovascular thrombectomy is not a contraindication for intravenous thrombolysis. Evidence shows that the bridging approach provides better clinical outcomes. It is seen that intravenous thrombolysis is beneficial in stroke patients, whose symptom onset is not known, after the presence of penumbra tissue is revealed by advanced neuroimaging techniques. Reperfusion therapy with intravenous thrombolysis is beneficial in selected pregnant stroke patients. Pregnancy should not be an absolute contraindication for thrombolysis therapy. This chapter aims to review only the current evaluation of intravenous thrombolytic therapy, one of the reperfusion therapies applied in the acute phase of stroke.

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Wake-up stroke: From pathophysiology to management

Cited by 39 publications

References 104 publications

Surrogate biomarkers of outcome for wake-up ischemic stroke

Surrogate biomarkers of outcome for wake-up ischemic stroke

Rapid eye movement (REM) sleep microarchitecture is altered in patients with wake-up ischemic stroke: A polysomnographic study

Thrombolysis in Acute Stroke

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