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Thrombolytic therapy for wake-up stroke: A systematic review and meta-analysis.

Publication ,  Journal Article
Mac Grory, B; Saldanha, IJ; Mistry, EA; Stretz, C; Poli, S; Sykora, M; Kellert, L; Feil, K; Shah, S; McTaggart, R; Riebau, D; Yaghi, S ...
Published in: Eur J Neurol
June 2021

BACKGROUND AND PURPOSE: According to evidence-based clinical practice guidelines, patients presenting with disabling stroke symptoms should be treated with intravenous tissue plasminogen activator (IV tPA) within 4.5 h of time last known well. However, 25% of strokes are detected upon awakening (i.e., wake-up stroke [WUS]), which renders patients ineligible for IV tPA administered via time-based treatment algorithms, because it is impossible to establish a reliable time of symptom onset. We performed a systematic review and meta-analysis of the efficacy and safety of IV tPA compared with normal saline, placebo, or no treatment in patients with WUS using imaging-based treatment algorithms. METHODS: We searched MEDLINE, Web of Science, and Scopus between January 1, 2006 and April 30, 2020. We included controlled trials (randomized or nonrandomized), observational cohort studies (prospective or retrospective), and single-arm studies in which adults with WUS were administered IV tPA after magnetic resonance imaging (MRI)- or computed tomography (CT)-based imaging. Our primary outcome was recovery at 90 days (defined as a modified Rankin Scale [mRS] score of 0-2), and our secondary outcomes were symptomatic intracranial hemorrhage (sICH) within 36 h, mortality, and other adverse effects. RESULTS: We included 16 studies that enrolled a total of 14,017 patients. Most studies were conducted in Europe (37.5%) or North America (37.5%), and 1757 patients (12.5%) received IV tPA. All studies used MRI-based (five studies) or CT-based (10 studies) imaging selection, and one study used a combination of modalities. Sixty-one percent of patients receiving IV tPA achieved an mRS score of 0 to 2 at 90 days (95% confidence interval [CI]: 51%-70%, 12 studies), with a relative risk (RR) of 1.21 compared with patients not receiving IV tPA (95% CI: 1.01-1.46, four studies). Three percent of patients receiving IV tPA experienced sICH within 36 h (95% CI: 2.5%-4.1%; 16 studies), which is an RR of 4.00 compared with patients not receiving IV tPA (95% CI: 2.85-5.61, seven studies). CONCLUSIONS: This systematic review and meta-analysis suggests that IV tPA is associated with a better functional outcome at 90 days despite the increased but acceptable risk of sICH. Based on these results, IV tPA should be offered as a treatment for WUS patients with favorable neuroimaging findings.

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Published In

Eur J Neurol

DOI

EISSN

1468-1331

Publication Date

June 2021

Volume

28

Issue

6

Start / End Page

2006 / 2016

Location

England

Related Subject Headings

  • Treatment Outcome
  • Tissue Plasminogen Activator
  • Thrombolytic Therapy
  • Stroke
  • Risk Factors
  • Retrospective Studies
  • Prospective Studies
  • Neurology & Neurosurgery
  • Ischemic Stroke
  • Humans
 

Citation

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Mac Grory, B., Saldanha, I. J., Mistry, E. A., Stretz, C., Poli, S., Sykora, M., … Schrag, M. (2021). Thrombolytic therapy for wake-up stroke: A systematic review and meta-analysis. Eur J Neurol, 28(6), 2006–2016. https://doi.org/10.1111/ene.14839
Mac Grory, Brian, Ian J. Saldanha, Eva A. Mistry, Christoph Stretz, Sven Poli, Marek Sykora, Lars Kellert, et al. “Thrombolytic therapy for wake-up stroke: A systematic review and meta-analysis.Eur J Neurol 28, no. 6 (June 2021): 2006–16. https://doi.org/10.1111/ene.14839.
Mac Grory B, Saldanha IJ, Mistry EA, Stretz C, Poli S, Sykora M, et al. Thrombolytic therapy for wake-up stroke: A systematic review and meta-analysis. Eur J Neurol. 2021 Jun;28(6):2006–16.
Mac Grory, Brian, et al. “Thrombolytic therapy for wake-up stroke: A systematic review and meta-analysis.Eur J Neurol, vol. 28, no. 6, June 2021, pp. 2006–16. Pubmed, doi:10.1111/ene.14839.
Mac Grory B, Saldanha IJ, Mistry EA, Stretz C, Poli S, Sykora M, Kellert L, Feil K, Shah S, McTaggart R, Riebau D, Yaghi S, Gaines K, Xian Y, Feng W, Schrag M. Thrombolytic therapy for wake-up stroke: A systematic review and meta-analysis. Eur J Neurol. 2021 Jun;28(6):2006–2016.
Journal cover image

Published In

Eur J Neurol

DOI

EISSN

1468-1331

Publication Date

June 2021

Volume

28

Issue

6

Start / End Page

2006 / 2016

Location

England

Related Subject Headings

  • Treatment Outcome
  • Tissue Plasminogen Activator
  • Thrombolytic Therapy
  • Stroke
  • Risk Factors
  • Retrospective Studies
  • Prospective Studies
  • Neurology & Neurosurgery
  • Ischemic Stroke
  • Humans