Stroke on awakening: looking for a more rational management

Background and purpose: Stroke on awakening (SOA) is denied the benefits of thrombolytic therapy and is typically excluded from acute clinical trials on the grounds that the time of onset is unknown. In this study we compared the clinical characteristics of SOA and of stroke while awake (SWA), particularly in the subgroup of patients seen within a time frame of 6 h after stroke awareness.

Material and methods: Patients were included consecutively in the Stroke Data Bank of the Spanish Neurological Society (BADISEN) that records 365 different items, including vascular risk factors, neurological findings, stroke severity, aetiopathogenic diagnosis and neuroimaging data.

Results: A total of 1,248 patients with acute cerebral infarction were included in the study, 301 (24.1%) with SOA and 947 (75.9%) with SWA. The peak time for stroke occurrence was between 6:01 a.m. and 12 noon, both in the whole stroke group and in each aetiopathogenic stroke subtype. Age, sex, stroke risk factors, stroke severity at admission, vital signs and stroke subtypes were not significantly different between SOA and SWA, neither in the group as a whole nor in the group of patients seen within 6 h of stroke recognition. Six hundred and fifty-four patients were seen within the potential 6-hour therapeutic window. In this group, the CT scan on admission was normal in 39.4% of SOA but the ultimate CT/MRI scan showed that 46.2% of these had a territorial infarction (in SWA these same figures were 60.8 and 67.7%, respectively).

Conclusion: There are no relevant differences in the clinical, neuroimaging and aetiopathogenic characteristics of SOA and SWA. We should rely on new techniques such as DWI/PWI to indicate the most appropriate treatment in a more rational manner as nearly half of the patients with SOA seen early may benefit from them.