Wake up stroke

[takotsubo]

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Just curious how many of you guys do stroke alerts on wake up strokes at your hospital? Is this standard of care where you are? Are you giving lytics to wake up strokes? Doing CT angios then endovascular?

 

[typhoonegator]

You should probably clarify what a stroke alert is. That is not universal terminology.

This question is why we have the MR-Witness trial. You should not be giving IV tPA to wake-up strokes unless they are 1) part of a clinical trial, or 2) meet standard criteria for tPA administration in the 0-3 or 0-4.5 hour window. I mean, you could wake up from a nap or something and still meet standard criteria.

You could certainly consider IA treatment for those patients, but remember that the trials data is heavily driven by people who got both IV and IA treatment, and so the efficacy of IA treatment alone for wake-up strokes that are potentially far into their ischemia is not a slam dunk. These treatments do have the potential to cause serious harm.

 

[deathmerchant]

No, currently its not recommended to treat (with tpa) wake up strokes( after therapeutic window), even if u get radiological evidence of mismatch. Some people might still be candidates for IR/IA so u still want to do the acute Imaging and may call 'Stroke Alert'(whatever that means!). Although this is going to change soon, many places are doing it on a 'research' basis. I mean, I see patients who normally wake up at say 7 and today they woke up at 3 am w symptoms, big mismatch on perfusion- U know it has to be acute- but u cant treat .

 

[TUGM]

IA therapy has shown benefits up to 6 hours after symptom onset. Though some trials suggest that the window of benefit could be extended to 8 hours, most of the subgroup analyses show, the faster the door-to-groin puncture time, the better the outcomes (generally speaking).

 

[typhoonegator]

No, currently its not recommended to treat (with tpa) wake up strokes( after therapeutic window), even if u get radiological evidence of mismatch. Some people might still be candidates for IR/IA so u still want to do the acute Imaging and may call 'Stroke Alert'(whatever that means!). Although this is going to change soon, many places are doing it on a 'research' basis. I mean, I see patients who normally wake up at say 7 and today they woke up at 3 am w symptoms, big mismatch on perfusion- U know it has to be acute- but u cant treat .

This is exactly what MR-Witness is doing, assessing the safety of using MRI diffusion/FLAIR ratio to assess the radiographic age of the infarct as a surrogate for a LSW time for wake-up strokes.

 

[soulofmpatel]

U know it has to be acute- but u cant treat .

But the MR rescue trial suggests that this information may be meaningless in terms of decision regarding thrombectomy

 

[Hank Rearden]

Let's say you have a 45yo with few comorbidities who comes in, last seen normal 10PM night prior, awoke at 8AM aphasic with right hemiplegia. Arrives at your hospital within an hour. CT/CTA shows proximal left M1 occlusion and ASPECTS 10.

Given the flood of positive thrombectomy trials I would probably strongly consider sending that pt for thrombectomy after getting consent from family. Might send to MRI first to be sure lesion is FLAIR negative. Thankfully I haven't had to deal with this scenario yet. Curious to hear what others would do in this situation.

 

[deathmerchant]

I think 10hrs (10pm- 8am) is probably too late , plus add atleast 1-2 hrs for groin puncture- that's 12hrs. I doubt any interventionalist will be comortable taking the patient to IR. May be if it was 6-8 hrs , u could take consent from family and make a case, especially if u have perfusion imaging showing large penumbra.

 

[typhoonegator]

Agree. Posterior circulation could be a different decision, though. Much more capacity for DWI-reversal if the pons isn't already out. We take those people later.