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Concise Review of Lytics and Endovascular Therapy for ‘Wake Up’ Stroke

November 24, 2022

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Written by Christopher Thom

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In patients presenting with ‘wake-up’ strokes, endovascular therapy improves functional outcomes, while intravenous alteplase may also provide a small beneficial impact.

Why does this matter?
Wake-up strokes are those wherein the exact time of onset of stroke symptoms is not known; thus, the benefit of stroke interventions is much less clear. These patients are often excluded from IV alteplase and other interventions given the lack of known duration of stroke symptoms. However, these patients may still benefit from intervention.

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This systematic review summarizes a Cochrane meta-analysis from 2021 that targeted this population. This meta-analysis included 7 trials from 2012 to 2020, encapsulating a total of 980 patients. Five of the trials analyzed IV alteplase, while 2 trials evaluated endovascular intervention. Many of the studies used inclusion criteria that utilized advanced imaging for patient selection, including MRI and CT perfusion core/penumbra mismatch.

There were 205 patients within the endovascular thrombectomy cohort. Independent functional outcome (defined as a modified Rankin Scale of 2 or less) was observed in 46% of patients randomized to endovascular thrombectomy and 9% of participants randomized to control (RR 5.12, 95%CI 2.57 to 10.17, P < 0.001). Mortality was not statistically significant between the two groups.

The five trials evaluating IV alteplase had a total of 775 participants. Independent functional outcome (again defined as a modified Rankin Scale of 2 or less) was observed in 66% of patients randomized to alteplase and 58% randomized to control (RR 1.13, 95%CI 1.01 to 1.26, P = 0.03). Mortality was not statistically significant between the two groups. Symptomatic intracranial hemorrhage occurred in 3% of the alteplase group and 1% of the control group (RR 3.47, 95%CI 0.98 to 12.26, P = 0.05).

This evidence suggests a strong and tangible benefit for endovascular thrombectomy. In very carefully selected patients, there may also be benefit for IV alteplase, though note should be made the confidence interval for benefit very nearly crossed 1, and the studies may have been underpowered to detect a true increase in symptomatic intracranial hemorrhage. Note should be made that the above patients had varying degrees of specific advanced perfusion imaging, which makes it difficult to generalize the results across all ‘wake-up’ stroke patients.

What is the Efficacy and Safety of Intravenous Thrombolysis and Thrombectomy Among Patients With a Wake-Up Stroke?. Ann Emerg Med. 2022;80(2):165-167. doi:10.1016/j.annemergmed.2022.02.013

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