An Observational Study of Thrombolysis Outcomes in Wake-up Ischemic Stroke Patients
Patients who wake up with stroke symptoms account for ≈8% to 27% of all ischemic strokes. Because of their unknown symptom onset time, they are not thrombolyzed. These patients have worse functional outcome. This study sought to determine the outcome of a specific subset of wake-up stroke patients who received thrombolysis. Wake-up stroke patients made up 10.5% (193/1836) of all stroke admissions. The inclusion criteria consisted of the following: (1) last seen normal >4.5 hours and <12 hours before presentation; (2) National Institutes of Health Stroke Scale score ≥5; (3) no or early ischemic changes <1/3 middle cerebral artery territory on computed tomography scan; and (4) no absolute contraindications to thrombolysis. Inclusion criteria were met by 122 patients, of whom 68 (56%) were thrombolyzed. There was no difference in modified Rankin Scale 0 to 2, death, and symptomatic intracerebral hemorrhage between thrombolyzed and nonthrombolyzed patients. After adjusting for age, sex, and baseline National Institutes of Health Stroke Scale score, thrombolysis was associated with an odds ratio of 5.2 for modified Rankin Scale 0 to 2 at 90 days and odds ratio of 0.09 for death. This study suggests that thrombolysis in a subset of wake-up stroke patients based on clinical and imaging criteria is feasible and may be associated with better outcomes. Further data from prospective clinical trials, such as MR WITNESS, are needed before making changes to current treatment guidelines for thrombolysis in wake-up ischemic stroke patients. See p 427.
Pilot Randomized Trial of Outpatient Cardiac Monitoring After Cryptogenic Stroke
Several studies have recently shown that the detection rate of atrial fibrillation with outpatient cardiac monitoring in patients with recent stroke is 5% to 20%. This study by Kamel et al is the first randomized trial of cardiac monitoring after cryptogenic stroke and transient ischemic attack (TIA). In this pilot trial, 40 patients with cryptogenic stroke or high-risk TIA (ABCD2 score ≥4) were randomized to mobile cardiac outpatient telemetry monitor by CardioNet for 21 days or to receive routine clinical follow-up. In the cardiac monitoring group, compliance was an issue. Patients wore monitors for 64% of the assigned days, and 25% of patients were not compliant with the monitoring at all. No patients in either group were diagnosed with atrial fibrillation. Although cardiac monitoring revealed atrial fibrillation in zero patients, brief episodes (<10 seconds) of atrial tachycardia were found in 2 patients and nonsustained ventricular tachycardia were found in 2 patients. These results are clearly in contrast to previous studies using similar monitoring techniques. This highlights the need for further clinical trials. The Cryptogenic Stroke and underlying Atrial Fibrillation (CRYSTAL AF) trial is one such trial that uses implantable cardiac monitors and aims to help clarify this question. See p 528.
Effect of Medical Treatment on Stroke/TIA Risk in Asymptomatic Carotid Stenosis
Carotid endarterectomy has been shown in several trials to reduce the risk of stroke in asymptomatic carotid stenosis. The absolute benefit of carotid endarterectomy in these trials is small because of the low risk of stroke per year (2%) in medically treated patients. These trials were also performed in a time when medical therapy is not up to today’s standards. In fact, recent evidence suggests that with newer and more effective medical treatments, the stroke risk is even lower. Using Asymptomatic Carotid Emboli Study (ACES) prospective data, this current study sought to determine the effect of current treatment on the risk of future stroke and TIA. Four hundred seventy-seven patients with asymptomatic carotid stenosis were followed every 6 months for 2 years. On univariate analysis, statins, antihypertensives, blood pressure, antiplatelets, and smoking were all associated with lower risk of ipsilateral stroke/TIA and any stroke/cardiovascular disease death. On multivariate analysis, antiplatelets and lower mean blood pressure were independent predictors of reduced risk of ipsilateral stroke/TIA. Antiplatelets and antihypertensives were independent predictors of a lower risk of any stroke/cardiovascular disease death. These results highlight the importance of controlling risk factors in patients with asymptomatic carotid stenosis. See p 542.
- © 2011 American Heart Association, Inc.