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Wake-up stroke and stroke of unknown onset: a critical review.

Wouters A, Lemmens R, Dupont P, Thijs V - Front Neurol (2014)

Bottom Line: Currently, this subset of patients is excluded from revascularization-therapy since no exact time of onset is known.The different imaging-selection criteria that can be used to treat these patients are discussed.Additional research on imaging findings associated with recent stroke and penumbral imaging will eventually lead to a shift from a rigid time-frame based therapy to a tissue-based individualized treatment approach.

View Article: PubMed Central - PubMed

Affiliation: KU Leuven Department of Neurosciences and Experimental Neurology, KU Leuven , Leuven , Belgium ; Department of Neurology, University Hospital Leuven , Leuven , Belgium ; Medical Imaging Research Center, UZ Leuven , Leuven , Belgium.

ABSTRACT
Patients, who wake up with an ischemic stroke, account for a large number of the total stroke population, due to circadian morning predominance of stroke. Currently, this subset of patients is excluded from revascularization-therapy since no exact time of onset is known. A large group of these patients might be eligible for therapy. In this review, we assessed the current literature about the hypothesis that wake-up-strokes occur just prior on awakening and if this subgroup differs in characteristics compared to the overall stroke population. We looked at the safety and efficacy of thrombolysis and interventional techniques in the group of patients with unknown stroke-onset. We performed a meta-analysis of the diagnostic accuracy of the diffusion-FLAIR mismatch in identifying stroke within 3 and 4.5 h. The different imaging-selection criteria that can be used to treat these patients are discussed. Additional research on imaging findings associated with recent stroke and penumbral imaging will eventually lead to a shift from a rigid time-frame based therapy to a tissue-based individualized treatment approach.

No MeSH data available.


Related in: MedlinePlus

The different imaging techniques used to select stroke-patients who would benefit from therapy. Patient 1 exhibits no FLAIR-lesion (A) and a clear DWI-lesion (B), the so-called DWI-FLAIR mismatch pattern. Patient 2 has a PWI/DWI mismatch on imaging, with (C) representing the lesion on Tmax, and (D) the corresponding diffusion lesion.
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Figure 2: The different imaging techniques used to select stroke-patients who would benefit from therapy. Patient 1 exhibits no FLAIR-lesion (A) and a clear DWI-lesion (B), the so-called DWI-FLAIR mismatch pattern. Patient 2 has a PWI/DWI mismatch on imaging, with (C) representing the lesion on Tmax, and (D) the corresponding diffusion lesion.

Mentions: Unknown time of onset is clearly a major reason not to receive thrombolysis (45). In the studies with off-label treatment of unknown-onset stroke patients, different imaging selection criteria have been used [Table 2; (46)]. These include visual or semi-quantitative analysis of the FLAIR-DWI mismatch, PWI-DWI mismatch, or CT perfusion based approaches (Table 3; Figure 2).


Wake-up stroke and stroke of unknown onset: a critical review.

Wouters A, Lemmens R, Dupont P, Thijs V - Front Neurol (2014)

The different imaging techniques used to select stroke-patients who would benefit from therapy. Patient 1 exhibits no FLAIR-lesion (A) and a clear DWI-lesion (B), the so-called DWI-FLAIR mismatch pattern. Patient 2 has a PWI/DWI mismatch on imaging, with (C) representing the lesion on Tmax, and (D) the corresponding diffusion lesion.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4129498&req=5

Figure 2: The different imaging techniques used to select stroke-patients who would benefit from therapy. Patient 1 exhibits no FLAIR-lesion (A) and a clear DWI-lesion (B), the so-called DWI-FLAIR mismatch pattern. Patient 2 has a PWI/DWI mismatch on imaging, with (C) representing the lesion on Tmax, and (D) the corresponding diffusion lesion.
Mentions: Unknown time of onset is clearly a major reason not to receive thrombolysis (45). In the studies with off-label treatment of unknown-onset stroke patients, different imaging selection criteria have been used [Table 2; (46)]. These include visual or semi-quantitative analysis of the FLAIR-DWI mismatch, PWI-DWI mismatch, or CT perfusion based approaches (Table 3; Figure 2).

Bottom Line: Currently, this subset of patients is excluded from revascularization-therapy since no exact time of onset is known.The different imaging-selection criteria that can be used to treat these patients are discussed.Additional research on imaging findings associated with recent stroke and penumbral imaging will eventually lead to a shift from a rigid time-frame based therapy to a tissue-based individualized treatment approach.

View Article: PubMed Central - PubMed

Affiliation: KU Leuven Department of Neurosciences and Experimental Neurology, KU Leuven , Leuven , Belgium ; Department of Neurology, University Hospital Leuven , Leuven , Belgium ; Medical Imaging Research Center, UZ Leuven , Leuven , Belgium.

ABSTRACT
Patients, who wake up with an ischemic stroke, account for a large number of the total stroke population, due to circadian morning predominance of stroke. Currently, this subset of patients is excluded from revascularization-therapy since no exact time of onset is known. A large group of these patients might be eligible for therapy. In this review, we assessed the current literature about the hypothesis that wake-up-strokes occur just prior on awakening and if this subgroup differs in characteristics compared to the overall stroke population. We looked at the safety and efficacy of thrombolysis and interventional techniques in the group of patients with unknown stroke-onset. We performed a meta-analysis of the diagnostic accuracy of the diffusion-FLAIR mismatch in identifying stroke within 3 and 4.5 h. The different imaging-selection criteria that can be used to treat these patients are discussed. Additional research on imaging findings associated with recent stroke and penumbral imaging will eventually lead to a shift from a rigid time-frame based therapy to a tissue-based individualized treatment approach.

No MeSH data available.


Related in: MedlinePlus