Treatment of wake-up stroke in neuro critical care

Fernanda Bellolio guides the listener through an approach to the treatment of wake-up stroke in neuro critical care. What time did the symptoms start? This is one of the most common questions that is asked when taking a history from a patient. However, what happens when this can not be answered. This is the case with “wake-up strokes”. A wake-up stroke is when a person goes to sleep without symptoms and wakes up with deficits. Similar problems in management arise when a person cannot accurately tell the clinician what time the symptoms began. Up to 20% of stokes are wake-up strokes and a further in a 10% of strokes the patient nor family can say exactly when it started. This presents a challenge as many therapies that currently exist are time sensitive and therefore not approved for wake-up strokes. Fernanda reviews the current evidence in the quest to answer three questions: 1) What is the evidence for tPA use in wake-up strokes; 2) Can endovascular treatments be used in wake-up strokes and 3) How can these patients be approached clinically? tPA has not been approved for this patient population due to the inability to know the time of the stroke. However, utilising advanced imaging techniques including MRI, it is possible to get a estimation of the temporality. Using these methods, studies have looked at the use of tPA and shown likely benefit, with acceptable rates of intracranial haemorrhage. Despite this, imaging techniques such as used in the studies are not widely available. Endovascular therapy has a wider window of availability, and the early research indicates this therapy can be beneficial. Thrombectomy similarly showed good outcomes in early trials when compared to tPA. Fernanda sums up the overall approach to the wake-up stroke presentation. Treat it as an emergency, get the history, send off labs and request imaging. Be guided by the stroke protocols that exist in your hospital. For management – at this stage Fernanda highlights that no routine therapy can be offered based on the evidence at the time of the talk. However, multiple ongoing trials will guide future treatment selection.

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