Dulka Manawadu D, Shankaranand Bodla S, Jeff Keep J and Lalit Kalra. Influence of Age on Thrombolysis Outcome in Wake-Up Stroke. Stroke. 2013

Manawadu and colleagues present yet another interesting study about thrombolysis (with rtPA) in wake up ischemic stroke (WUIS). Outcomes of 68 WUIS patients (33 >80 years) who were thrombolysed >4.5 hours but <12 hours of onset of symptoms and 54 non-thrombolysed WUIS patients (21 >80 years) were studied. Selection criteria also included no or early ischemic changes in less than a third of MCA territory. Reference group (n=117) was patients >80 years thrombolysed within 4.5 hours of onset.

In this prospective registry, baseline characteristics of patients >80 years and <80 years in both groups were similar. Atrial fibrillation and cardioembolic etiology was more common in >80 years. The decision to thrombolyse was based on physician’s judgment. Thromblysis outcomes in WUIS patients >80 years were better, both in terms of mortality and function (modified rankin score), than non-thrombolysed WUIS patients >80 years.

Although selection bias is inherent in this design, the study does suggest that carefully selected elderly patients not only benefit from thrombolysis but do so even when time of onset in unclear. This shift in treatment paradigm from “time window” to “tissue-status window” whereby status of the brain tissue guides acute intervention rather than key historical points provided by patients or their relatives has potential to increase thrombolysis rate and, by extension, improve outcomes in patient population that is denied thrombolytic treatment based on current guidelines. 

Although, there isn’t enough evidence to justify routine use of this approach in treatment of acute strokes, this study highlights the importance of prospective large multi-center randomized controlled studies to further clarify the question of management of WUIS. This also suggests that being elderly doesn’t necessarily mean no or little potential to improve and that a certain age may not be appropriate exclusion criteria.