Wake-up stroke-Amendable for thrombolysis-like stroke with known onset time?

Epidemiological analysis of stroke patients with emphasis on access to acute-phase therapies

BACKGROUND

Stroke is a public health problem. For patients with ischemic stroke, venous thrombolysis and mechanical thrombectomy are effective therapeutic options. However, even after the National Stroke Treatment Guidelines were published in 2012, the number of cases treated is still lower than expected.

OBJECTIVE

To identify the determining factors for obtaining access to acute-phase therapies in the state of Espírito Santo (ES) and investigate the profile of stroke patients treated at the Central State Hospital (HEC).

METHODS

Retrospective data from the medical records of 1078 patients from May 2018 to December 2019 were analyzed.

RESULTS

Among the 1,078 patients, 54.9% were men and the most prevalent age group was 60 to 79 years. Systemic arterial hypertension was the main single risk factor. Regarding treatment modality among the patients who arrived at the HEC within the therapeutic window, 47% received some type of acute-phase therapy. Waking up with the deficit was the main contraindication for venous thrombolysis in these cases.

CONCLUSIONS

Application of the flowchart established by SESA-ES seemed to be effective for enabling responsiveness of care for stroke victims. Public emergency transport services had a fundamental role in this process. In addition, the care provided by the tertiary stroke center provided excellent access to acute-phase therapies. However, despite the efficiency of the service provided at the HEC, it only reached a maximum of 50% of the ES population. This service model therefore needs to be expanded throughout the state.

Clinical outcomes and safety profile of Tenecteplase in wake-up stroke

BACKGROUND

Tenecteplase has probably pharmacological and clinical advantages in the treatment of acute ischemic stroke. There are lacking data about safety and efficacy of tenecteplase in wake-up stroke (WUPS).

AIMS

To investigate safety and efficacy of tenecteplase compared to alteplase in WUPS patients included in NOR-TEST.

METHODS

WUPS patients in NOR-TEST were included in the study based on DWI-FLAIR mismatch. Included patients randomly assigned (1:1) to receive intravenous tenecteplase 0.4 mg/kg (to a maximum of 40 mg) or alteplase 0.9 mg/kg (to a maximum of 90 mg). Neurological improvement was defined as 1) favorable functional outcome at 90 days modified Rankin Scale (mRS) of 0 or 1 and 2) neurological improvement measured with the National Institutes of Health Stroke Scale (NIHSS) of 4 points within 24 hours as compared to admission NIHSS or NIHSS 0 at 24 hours.

RESULTS

Of 1100 patients from 13 stroke centers included in NOR-TEST, 45 were WUPS patients. Of these, 5 patients were stroke mimics and excluded. Of the remaining 40 patients (3.6%), 24 were treated with alteplase (60%). There was no difference in the number of patients achieving a good clinical outcome (mRS 0-1) in either treatment group. Patients treated with tenecteplase showed a better early neurological improvement (87.5% vs 54.2%, P = 0.027). No ICH was detected on MRI/CT 24-28 hours after thrombolysis.

CONCLUSIONS

In WUPS patients treated in NOR-TEST, there was no difference in clinical outcomes at 90 days and no ICH events or deaths were observed in either alteplase- or tenecteplase-treated patients. Clinical Trial Registration-URL: https://www.clinicaltrials.gov. Unique identifier: NCT01949948.

Pathophysiologic mechanisms, neuroimaging and treatment in wake-up stroke

Wake-up stroke (WUS) or ischemic stroke occurring during sleep accounts for 14%-29.6% of all ischemic strokes. Management of WUS is complicated by its narrow therapeutic time window and attributable risk factors, which can affect the safety and efficacy of administering intravenous (IV) tissue plasminogen activator (t-PA). This manuscript will review risk factors of WUS, with a focus on obstructive sleep apnea, potential mechanisms of WUS, and evaluate studies assessing safety and efficacy of IV t-PA treatment in WUS patients guided by neuroimaging to estimate time of symptom onset. The authors used PubMed (1966 to March 2018) to search for the term "Wake-Up Stroke" cross-referenced with "pathophysiology," ''pathogenesis," "pathology," "magnetic resonance imaging," "obstructive sleep apnea," or "treatment." English language Papers were reviewed. Also reviewed were pertinent papers from the reference list of the above-matched manuscripts. Studies that focused only on acute Strokes with known-onset of symptoms were not reviewed. Literature showed several potential risk factors associated with increased risk of WUS. Although the onset of WUS is unknown, a few studies investigated the potential benefit of magnetic resonance imaging (MRI) in estimating the age of onset which encouraged conducting clinical trials assessing the efficacy of MRI-guided thrombolytic therapy in WUS.

Thrombolysis in Stroke With Unknown Onset Based on Non-Contrast Computerized Tomography (TRUST CT)

Background

Intravenous thrombolysis (IVT) in wake‐up stroke (WUS) or stroke with unknown onset (SUO) has been recently proven to be safe and effective using advanced neuroimaging (magnetic resonance imaging or computerized tomography‐perfusion) for patient selection. However, in most of the thrombolyzing centers advanced neuroimaging is not instantly available. We hypothesize that pragmatic non‐contrast computed tomography‐based IVT in WUS/SUO may be feasible and safe.

Methods and Results

TRUST‐CT (Thrombolysis in Stroke With Unknown Onset Based on Non‐Contrast Computerized Tomography) is an international multicenter registry‐based study. WUS/SUO patients undergoing non‐contrast computed tomography‐based IVT with National Institute of Health Stroke Scale ≥4 and initial Alberta Stroke Program Early Computerized Tomography score ≥7 were included and compared with propensity score matched non‐thrombolyzed WUS/SUO controls. Primary end point was the incidence of symptomatic intracranial hemorrhage; secondary end points included 24‐hour National Institute of Health Stroke Scale improvement of ≥4 and modified Rankin Scale at 90 days. One hundred and seventeen WUS/SUO patients treated with non‐contrast computed tomography‐based IVT were included. As compared with 112 controls, the median admission National Institute of Health Stroke Scale was 10 and the median Alberta Stroke Program Early Computerized Tomography score was 10 in both groups. Four (3.4%) IVT patients and one control patient (0.9%) suffered symptomatic intracranial hemorrhage (adjusted odds ratio 7.9, 95% CI 0.65–96, P=0.1). A decrease of ≥4 National Institute of Health Stroke Scale points was observed in 67 (57.3%) of IVT patients as compared with 25 (22.3%) in controls (adjusted odds ratio 5.8, CI 3.0–11.2, P<0.001). A months, 39 (33.3%) IVT patients reached a modified Rankin Scale score of 0 or 1 versus 23 (20.5%) controls (adjusted odds ratio 1.94, CI 1.0–3.76, P=0.05).

Conclusions

Non‐contrast computed tomography‐based thrombolysis in WUS/SUO seems feasible and safe and may be effective. Randomized prospective comparisons are warranted.

Clinical Trial Registration

URL: https://www.clinicaltrials.gov/. Unique identifier: NCT03634748.

Efficacy and Safety of Intravenous Thrombolysis in Patients with Unknown Onset Stroke: A Meta-Analysis. Behav Neurol. 2019;2019:5406923. [PMID: 31565095 PMCID: PMC6745097 DOI: 10.1155/2019/5406923]

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.