Intravenous thrombolysis and endovascular thrombectomy are effective in treating some ischaemic strokes of awakening

Cochrane Pre-hospital and Emergency Care

Intravenous thrombolysis and endovascular thrombectomy are effective in treating some ischaemic strokes of awakening

SOURCE
Roaldsen MB, Lindekleiv H, Mathiesen EB. (2021)
Intravenous thrombolytic treatment and endovascular thrombectomy for ischaemic wake-up stroke.
Cochrane Database Syst Rev 12:CD010995

CONTEXT
About one in 5 strokes occurs during sleep. Stroke of awakening has long been excluded from emergency care for lack of information on the time between the onset of stroke and awakening. Some waking strokes, via rigorous selection based on imaging criteria,seem to benefit from aggressive management with improved outcomes in some patients.

CLINICAL QUESTION
Are intravenous (IV) thrombolysis and endovascular thrombectomy in ischaemic stroke of awakening effective compared to usual treatments?

BOTTOM LINE
Thrombectomy and IV thrombolysis signficantly improve favourable neurological course at 90 days(high-certainty
evidence). The effect is greater for thrombectomy than for IV thrombolysis. There is no significant effect for the 2 treatments on 90 day mortality (high-certainty evidence). The risk of symptomatic cerebral haemorrhage is not significantly modified by IV thrombolysis (high-certainty evidence). The effectiveness of thrombolysis is similar regardless of age, sex, initial severity of stroke (NIHSS score), diameter of the occluded vessel or the time elapsed between awakening and thrombolysis.

CAVEAT
Patients in the controlled clinical trials included in this meta-analysis were carefully selected according to sophisticated imaging criteria (MRI and infusion scan). Only strokes with occlusion of the large vessels of the anterior carotid circulation were included and alteplase was the only drug evaluated. The authors highlight a possible increased risk of symptomatic
intracranial hemorrhages with thrombolysis.

AUTHORS
J. Dumouchel
dumouchel.julie76@yahoo.fr
Département de médecine d’urgence,
CHU de Tours
Tours, France
S. Beroud
sebastien.beroud@chu-lyon.fr
Service d’Accueil des Urgences & SAMU de Lyon
CHU Lyon Sud
Lyon, France
K. Magee
Kirk.magee@dal.ca
Dalhousie University, Halifax Infirmary
Nova Scotia, Canada