Therapeutic Dilemma of Wake-up Stroke: Clinical and Brain Imaging Characteristics and Reperfusion as a Treatment Option.

Objective: Wake-up stroke (WUS) comprises a significant proportion of ischemic strokes. However, due to unclear onset, these patients are often not considered for reperfusion therapy. The objective of this study was to investigate the clinical and imaging differences between WUS patients and those with clear-onset stroke, documenting any sex, age, or risk factor predilection for WUS.Methods: This prospective observational cohort study used an ongoing stroke registry to identify patients with acute ischemic stroke admitted to a hospital in Saudi Arabia within 5 days of symptom onset from April 2018 to March 2020. Patients were classified into 2 groups: WUS and clear-onset stroke.Results: Among 645 patients, 448 met the criteria for acute ischemic stroke and were included in the study. WUS was identified in 112 (25%) patients. There were no differences in sex or median age between the 2 groups. Diabetes mellitus, hypertension, and dyslipidemia were higher in the WUS group, while atrial fibrillation, history of stroke and epilepsy were higher in the clear-onset stroke group. Bihemispheric stroke was higher in the clear-onset stroke group than in the WUS group (6.0% vs 2.7%).Conclusions: Only minor dissimilarities between clinical and radiologic features of WUS and clear-onset stroke were found. Circadian patterns of stroke onset were observed in both groups. Stroke was more likely to occur during waking than during sleep, and a diurnal pattern of common occurrence during the morning was documented. Recognition of the acceptable timeframe for acute reperfusion therapy in unwitnessed strokes is crucial so that thrombolytic treatment can be started for these patients.

Timing to start anticoagulants after acute ischemic stroke with non-valvular atrial fibrillation.

OBJECTIVE: To identify timing for initiation of anticoagulation therapy in acute ischemic stroke (AIS) with non-valvular AF as regards safety and efficacy by detecting the rate of intracranial haemorrhage (ICH) and recurrent ischemic symptoms (RIS) during follow-up. METHODS: This is a prospective observational cohort study conducted at King Fahd Hospital of the University including 120 patients with AIS/TIAs from July 2016 till July 2018. We compared patients who received anticoagulants 1-6 days (Group I (45.83%), 7-14 days, Group II (35%), and > 14 days after the ischemic event (Group III (19.17%). Follow-up was at least 3 months and included identifying ICH or RIS. RESULT: ICH has occurred in 26.67% (n = 32) patients with a highly statistically significant association with time of treatment (P-value = .01) being higher in group I (n = 17) compared to only 1 case in group III. Subgroup analyses on the ICH patients (n = 32) has revealed statistical significant association with higher NIHSS score (P = .001). Also, the type of anticoagulants used between three groups pointed to an association existence (p = .02), however, the direction of this association cannot be determined. There was no statistical significant association between RIS (occurred in 4.16% (n = 5) with time of treatment (P = .754). Functional outcome at 3-6 months measured by mRS did not differ between 3 groups (worst mRS in group I). CONCLUSION: Early initiation of anticoagulation after stroke, especially in cases of large infarction, is associated with significant risk of ICH. This risk is highest with warfarin and lowest with DOAC.