Intravenous Thrombolysis Beneficial in Wake-Up Stroke

By Will Boggs MD

January 08, 2019

NEW YORK (Reuters Health) - Intravenous thrombolysis appears to be as beneficial in patients with wake-up stroke as in patients with known-onset stroke, according to results from the Austrian Stroke Unit Registry.

"Thrombolysis rates in wake-up strokes are increasing over the years as advanced neuroimaging becomes more available," Dr. Marek Sykora from St. John's Hospital and Sigmund Freud University Vienna told Reuters Health by email. "Despite being an off-label indication, it seems that thrombolysis performs well in wake-up stroke patients."

The recent WAKE UP study demonstrated the feasibility, safety and efficacy of intravenous thrombolysis in wake-up stroke guided by MRI.

Dr. Sykora's team used nationwide registry data to examine the real-world experience of intravenous thrombolysis in 904 patients with wake-up stroke, compared with nearly 16,700 patients with known-onset stroke.

As measured by improvements in NIH Stroke Scale scores of four points or greater, significantly fewer wake-up stroke patients (38.7%) than non-onset stroke patients (45.4%) showed a benefit from IV thrombolysis.

On the other hand, there was no significant difference between the groups in functional neurological outcome (modified Rankin Scale scores of 0 or 1) at three months (42.1% after wake-up stroke vs. 41.8%), the team reports in the European Journal of Neurology, online December 18.

Symptomatic intracerebral hemorrhage (ICH) rates were also similar (4.1% versus 4%, respectively).

Among patients with wake-up stroke, those who had IV thrombolysis had 80% greater odds of having neurological improvement, 2.8-fold greater odds of symptomatic ICH and similar odds of excellent functional outcome, compared with those who did not have IV thrombolysis, after adjusting for baseline imbalances and endovascular treatment.

"Wake-up stroke patients are comparable candidates for thrombolysis/thrombectomy as stroke patients with known onset," Dr. Sykora said. "Every patient with wake-up stroke fulfilling certain neuroimaging criteria should be treated with thrombolysis/thrombectomy."

Dr. Harold P. Adams, Jr. from Carver College of Medicine at the University of Iowa, in Iowa City, who has also evaluated IV thrombolysis for treating patients with stroke upon awakening, told Reuters Health by email, "The results are of interest because they provide some information about the potential efficacy and safety of intravenous thrombolysis given to patients with stroke present upon awakening."

"Current guidelines restrict the administration of thrombolytics to those patients who could be treated within 4.5 hours of onset of symptoms, which precludes treatment of many patients whose strokes occur during sleep," he said. "The Austrian investigators show that (these patients) can be treated with reasonable safety and efficacy. This is important information. However, with the tremendous advance in endovascular therapy, the role of intravenous thrombolysis for treatment of patients with stroke present upon awakening is changing."


Eur J Neurol 2018.