What to do With Wake-Up Stroke - PubMed (original) (raw)

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What to do With Wake-Up Stroke

Mark N Rubin et al. Neurohospitalist. 2015 Jul.

Abstract

Wake-up stroke, defined as the situation where a patient awakens with stroke symptoms that were not present prior to falling asleep, represents roughly 1 in 5 acute ischemic strokes and remains a therapeutic dilemma. Patients with wake-up stroke were excluded from most ischemic stroke treatment trials and are often not eligible for acute reperfusion therapy in clinical practice, leading to poor outcomes. Studies of neuroimaging with standard noncontrast computed tomography (CT), magnetic resonance imaging (MRI), and multimodal perfusion-based CT and MRI suggest wake-up stroke may occur shortly before awakening and may assist in selecting patients for acute reperfusion therapies. Pilot studies of wake-up stroke treatment based on these neuroimaging features are promising but have limited generalizability. Ongoing randomized treatment trials using neuroimaging-based patient selection may identify a subset of patients with wake-up stroke that can safely benefit from acute reperfusion therapies.

Keywords: acute stroke; hemorrhage; outcome; tPA; thrombolysis; wake-up stroke.

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Conflict of interest statement

Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Figures

Figure 1.

Figure 1.

Multimodal CT mismatch (or “penumbra”). Panel (A) is a cerebral blood volume (CBV) map. The dark area noted in the left frontal operculum suggests low contrast volume in the region and is considered a surrogate for infarcted tissue, or the “infarct core.” The other maps—cerebral blood flow (CBF) in panel (B), time to peak (TTP) in panel (C), and mean transit time (MTT) in panel (D)—are different measures of contrast movement through cerebral vasculature (see Table 3) and clearly involve much more of the left hemisphere than the CBV map. This discordance is referred to as a multimodal CT mismatch or “penumbra” and may represent tissue at risk of infarction but potentially salvageable by reperfusion therapy. Siemens SOMATOM, syngo perfusion software. CT indicates computed tomography.

Figure 2.

Figure 2.

The DWI/FLAIR mismatch. These 2 axial images of the brain at a level just above the lateral ventricles represent the so-called DWI/FLAIR mismatch that can be seen in the early hours after symptom onset when DWI (left) hyperintensity—which can arise in minutes from symptom onset—occurs in the absence of T2-based FLAIR (right) hyperintensity, which takes 3 to 6 hours to develop. DWI indicates diffusion-weighted imaging; FLAIR, fluid attenuated inversion recovery.

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