Recanalisation therapies for wake-up stroke

Review question: Do people who wake up with stroke benefit from treatments to reopen blood vessels (recanalisation therapies)?

Background: Most strokes are caused by a blockage of a blood vessel in the brain by a blood clot (ischaemic stroke), which are a leading cause of death and disability. Treatments to reopen blood vessels (such as clot-dissolving drugs or devices to remove blood clots) may improve recovery after ischaemic stroke if blood flow is rapidly restored.

About one in five strokes occur during sleep (wake-up stroke). People with wake-up stroke have traditionally been considered ineligible for recanalisation therapies because the time of stroke onset is unknown. However, some studies suggest that these people may benefit from recanalisation therapies.

Search date: We searched for randomised controlled trials (a type of experiment in which people are randomly allocated to one or more treatment groups) up until 9 January 2018.

Study characteristics: We included one trial with nine participants randomised to a recanalisation therapy or to placebo (dummy treatment). The trial was a feasibility study for perfusion computed tomography-guided thrombolysis in people with unknown onset of stroke.

Key results: There is insufficient evidence to determine if recanalisation therapies improve outcome in people with wake-up stroke. There are six ongoing trials that may contribute to our review when completed.

Quality of evidence: Low. There were insufficient data to assess the effect of treatment.

Authors' conclusions: 

There is insufficient evidence from randomised controlled trials for recommendations concerning recanalisation therapies for wake-up stroke. Results from ongoing trials will hopefully establish the efficacy and safety of such therapies.

Read the full abstract...
Background: 

About one in five strokes occur during sleep (wake-up stroke). People with wake-up strokes have traditionally been considered ineligible for thrombolytic treatment because the time of stroke onset is unknown. However, some studies suggest that these people may benefit from recanalisation therapies.

Objectives: 

To assess the effects of intravenous thrombolysis and other recanalisation therapies versus control in people with acute ischaemic stroke presenting on awakening.

Search strategy: 

We searched the Cochrane Stroke Group Trials Register (last search: 9 January 2018). In addition, we searched the following electronic databases in December 2017: Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 11) in the Cochrane Library, MEDLINE, Embase, US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), the ISRCTN registry, and Stroke Trials Registry. We also screened references lists of relevant trials, contacted trialists, undertook forward tracking of relevant references, and contacted manufacturers of relevant devices and equipment.

Selection criteria: 

Randomised controlled trials of intravenous thrombolytic drugs or intra-arterial therapies in people with acute ischaemic stroke presenting upon awakening.

Data collection and analysis: 

Two review authors applied the inclusion criteria, extracted data, and assessed trial quality and risk of bias using the GRADE approach. We obtained both published and unpublished data.

Main results: 

We included one pilot trial with nine participants. The trial was a feasibility trial that included participants with an unknown onset of stroke and signs on perfusion computed tomography of ischaemic tissue at risk of infarction, who were randomised to alteplase (0.9 mg/kg) or placebo. One trial was prematurely terminated due to signs of efficacy of the intervention arm; we did not include this trial because we were not able to obtain data for the portion of the participants with wake-up stroke after requesting this information from the trial authors. We identified six ongoing trials.

Share/Save