Aaron Tansy, MD
Manawadu D, Bodla S, Jarosz J, Keep J, and Kalra L. A case-controlled comparison of thrombolysis outcomes between wake-up and known time of onset ischemic stroke patients. Stroke. 2013

Unknown symptom duration, often a problem in patients with wake-up ischemic stroke (WUIS), is a major barrier to the use of t-PA. Consequently, there has been a strong interest within the stroke community to evaluate the feasibility and safety of ways to identify ways to expand thrombolytic eligibility to this cohort. Dulka Manawadu and colleagues show, in a forthcoming paper in stroke, that thrombolysis is a potential treatment option in some patients who wake up with a stroke. Analyzing clinical data culled from a comprehensive stroke center registry, they performed a small, retrospective comparison of post-thrombolytic clinical outcomes (90 day mRS, ICH, and mortality) in patients with symptom duration between 4.5 – 12 hours (WUIS) and <4.5 hours (reference group, RG). WUIS major screening criteria for t-PA eligibility included NIHSS >/5 and no significant evidence of early ischemic change (EIC) on head CT by ASPECTS scoring. Data were analyzed from 68 WUIS and 326 RG cases treated with t-PA. Results revealed that there were no significant differences between the demographically well-matched treatment groups in any of the prescribed clinical outcome metrics.

Although the group’s study has some significant limitations including its retrospective nature, small case size and high potential for selection bias in the WUIS cohort, it nevertheless holds significance: the findings support the idea that certain cases of WUIS may be amenable to thrombolytic therapy. Not only does this study foster hope that t-PA may be a future treatment option in WUIS but it also provides data for planning a prospective, randomized controlled studies, like the SPOTRIAS-sponsored MR WITNESS trial currently underway. Only then we will truly know if t-PA for wake-up strokes is more than just a dream.