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Article ; Online: Elevated C-reactive protein increases diagnostic accuracy of algorithm-defined stroke-associated pneumonia in afebrile patients.

Kalra, Lalit / Smith, Craig J / Hodsoll, John / Vail, Andy / Irshad, Saddif / Manawadu, Dulka

International journal of stroke : official journal of the International Stroke Society

2018 Volume 14, Issue 2, Page(s) 167–173

Abstract: Background and aim: Pyrexia-dependent clinical algorithms may under or overdiagnose stroke-associated pneumonia. This study investigates whether inclusion of elevated C-reactive protein as a criterion improves diagnosis.: Methods: The contribution of ...

Abstract	Background and aim: Pyrexia-dependent clinical algorithms may under or overdiagnose stroke-associated pneumonia. This study investigates whether inclusion of elevated C-reactive protein as a criterion improves diagnosis. Methods: The contribution of C-reactive protein ≥30 mg/l as an additional criterion to a Centers for Disease Control and Prevention-based algorithm incorporating pyrexia with chest signs and leukocytosis and/or chest infiltrates to diagnose stroke-associated pneumonia was assessed in 1088 acute stroke patients from 37 UK stroke units. The sensitivity, specificity, and positive predictive value of different approaches were assessed using adjudicated stroke-associated pneumonia as the reference standard. Results: Adding elevated C-reactive protein to all algorithm criteria did not increase diagnostic accuracy compared with the algorithm alone against adjudicated stroke-associated pneumonia (sensitivity 0.74 (95% CI 0.65-0.81) versus 0.72 (95% CI 0.64-0.80), specificity 0.97 (95% CI 0.96-0.98) for both; kappa 0.70 (95% CI 0.63-0.77) for both). In afebrile patients (n = 965), elevated C-reactive protein with chest and laboratory findings had sensitivity of 0.84 (95% CI 0.67-0.93), specificity of 0.99 (95% CI 0.98-1.00), and kappa 0.80 (95% CI 0.70-0.90). The modified algorithm of pyrexia or elevated C-reactive protein and chest signs with infiltrates or leukocytosis had sensitivity of 0.94 (95% CI 0.87-0.97), specificity of 0.96 (95% CI 0.94-0.97), and kappa of 0.88 (95% CI 0.84-0.93) against adjudicated stroke-associated pneumonia. Conclusions: An algorithm consisting of pyrexia or C-reactive protein ≥30 mg/l, positive chest signs, leukocytosis, and/or chest infiltrates has high accuracy and can be used to standardize stroke-associated pneumonia diagnosis in clinical or research settings. Trial registration: http://www.isrctn.com/ISRCTN37118456.
MeSH term(s)	Aged ; Aged, 80 and over ; Algorithms ; C-Reactive Protein/metabolism ; Clinical Decision-Making ; Diagnostic Errors/prevention & control ; Female ; Fever ; Humans ; Male ; Pneumonia/diagnosis ; Pneumonia/epidemiology ; Sensitivity and Specificity ; Stroke/diagnosis ; Stroke/epidemiology ; United Kingdom/epidemiology ; Up-Regulation
Chemical Substances	C-Reactive Protein (9007-41-4)
Language	English
Publishing date	2018-09-10
Publishing country	United States
Document type	Clinical Trial ; Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	2303728-3
ISSN	1747-4949 ; 1747-4930
ISSN (online)	1747-4949
ISSN	1747-4930
DOI	10.1177/1747493018798527
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Article ; Online: Comparison of the diagnostic utility of physician-diagnosed with algorithm-defined stroke-associated pneumonia.

Kalra, Lalit / Hodsoll, John / Irshad, Saddif / Smithard, David / Manawadu, Dulka

Journal of neurology, neurosurgery, and psychiatry

2016 Volume 87, Issue 11, Page(s) 1163–1168

Abstract: Objective: Diagnosing stroke-associated pneumonia (SAP) is challenging and may result in inappropriate antibiotic use or confound research outcomes. This study evaluates the diagnostic accuracy of algorithm-defined versus physician-diagnosed SAP in 1088 ...

Abstract	Objective: Diagnosing stroke-associated pneumonia (SAP) is challenging and may result in inappropriate antibiotic use or confound research outcomes. This study evaluates the diagnostic accuracy of algorithm-defined versus physician-diagnosed SAP in 1088 patients who had dysphagic acute stroke from 37 UK stroke units between 21 April 2008 and 17 May 2014. Methods: SAP in the first 14 days was diagnosed by a criteria-based algorithm applied to blinded patient data and independently by treating physicians. Patients in whom diagnoses differed were reassigned following blinded adjudication of individual patient records. The sensitivity, specificity, positive predictive value (PPV) and diagnostic OR of algorithmic and physician diagnosis of SAP were assessed using adjudicated SAP as the reference standard. Agreement was assessed using the κ statistic. Results: Physicians diagnosed SAP in 176/1088 (16%) and the algorithm in 123/1088 (11.3%) patients. Diagnosis agreed in 885/1088 (81.3%) patients (κ 0.22 (95% CI 0.14 to 0.29)). On a blinded review, 129/1088 (11.8%) patients were adjudicated as patients with SAP. The algorithm and the physicians had high specificity (97% (95% CI 96% to 98%) and 90% (95% CI 88% to 92%), respectively) but only moderate sensitivity (72% (95% CI 64% to 80%) and 65% (95% CI 56% to 73%), respectively) in diagnosing SAP. The algorithm showed better PPV (76% (95% CI 67% to 83%) vs 48% (95% CI 40% to 55%)), diagnostic OR (80 (95% CI 42 to 136) vs 18 (95% CI 12 to 27)) and agreement (κ 0.70 (95% CI 0.63 to 0.78) vs 0.48 (95% CI 0.41 to 0.54)) than physician diagnosis with adjudicated SAP. Conclusions: Algorithm-based approaches can standardise SAP diagnosis for clinical practice and research. Trial registration number: ISRCTN37118456; Post-results.
MeSH term(s)	Aged ; Aged, 80 and over ; Algorithms ; Deglutition Disorders/etiology ; Diagnosis, Computer-Assisted ; Female ; Humans ; Male ; Middle Aged ; Physicians ; Pneumonia/diagnosis ; Prospective Studies ; Sensitivity and Specificity ; Software ; Stroke/diagnosis
Language	English
Publishing date	2016-07-18
Publishing country	England
Document type	Comparative Study ; Journal Article ; Multicenter Study ; Randomized Controlled Trial
ZDB-ID	3087-9
ISSN	1468-330X ; 0022-3050
ISSN (online)	1468-330X
ISSN	0022-3050
DOI	10.1136/jnnp-2016-313508
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Article ; Online: Association between nasogastric tubes, pneumonia, and clinical outcomes in acute stroke patients.

Kalra, Lalit / Hodsoll, John / Irshad, Saddif / Smithard, David / Manawadu, Dulka

Neurology

2016 Volume 87, Issue 13, Page(s) 1352–1359

Abstract: Objective: To investigate whether nasogastric tubes (NGTs) increase poststroke pneumonia (PSP), mortality, or poor outcomes in nil-by-mouth acute stroke patients.: Methods: This study analyzed prespecified outcomes of PSP at 14 days and mortality and ...

Abstract	Objective: To investigate whether nasogastric tubes (NGTs) increase poststroke pneumonia (PSP), mortality, or poor outcomes in nil-by-mouth acute stroke patients. Methods: This study analyzed prespecified outcomes of PSP at 14 days and mortality and function measured by the modified Rankin Scale at 90 days in 1,217 nil-by-mouth stroke patients at ≤48 hours of symptom onset in a multicenter randomized controlled trial of preventive antibiotics between April 21, 2008, and May 17, 2014. Generalized mixed models adjusted for age, comorbidities, stroke type and severity, and quality of care were used. No patients were lost to follow-up at 14 days, and 36 (3%) were lost at 90 days. Results: Patients with NGT (298 of 1,217 [24.4%]) had more severe strokes (median NIH Stroke Scale score 17 vs 14, p = 0.0001) and impaired consciousness (39% vs 28%, p = 0.001). NGT did not increase PSP (43 of 298 [14.4%] vs 80 of 790 [10.1%], adjusted odds ratio [OR] 1.26 [95% confidence interval (CI) 0.78-2.03], p = 0.35) or 14- and 90-day mortality (33 of 298 [11.1%] vs 78 of 790 [9.9%], adjusted OR 1.10 [95% CI 0.67-1.78], p = 0.71; and 79 of 298 [26.5%] vs 152 of 790 [19.2%], adjusted OR 0.95 [95% CI 0.67-1.33], p = 0.75, respectively). Ninety-day modified Rankin Scale score distribution was comparable between groups (adjusted OR 1.14 [95% CI 0.87-1.56], p = 0.08). PSP independently increased 90-day mortality (40 of 123 [32.5%] vs 191 of 965 [19.8%], adjusted OR 1.71 [95% CI 1.11-2.65], p = 0.015) and was not prevented by antibiotics in patients with NGT (adjusted OR 1.1 [95% CI 0.89-1.54], p = 0.16). Conclusions: Early NGT does not increase PSP incidence, mortality, or poor functional outcomes and can be used safely in acute stroke patients.
MeSH term(s)	Aged ; Anti-Bacterial Agents/therapeutic use ; Brain Ischemia/complications ; Brain Ischemia/mortality ; Brain Ischemia/therapy ; Comorbidity ; Female ; Follow-Up Studies ; Humans ; Incidence ; Intracranial Hemorrhages/complications ; Intracranial Hemorrhages/mortality ; Intracranial Hemorrhages/therapy ; Intubation, Gastrointestinal ; Male ; Pneumonia/etiology ; Pneumonia/mortality ; Pneumonia/therapy ; Severity of Illness Index ; Stroke/complications ; Stroke/mortality ; Stroke/therapy ; Treatment Outcome ; United Kingdom
Chemical Substances	Anti-Bacterial Agents
Language	English
Publishing date	2016-08-26
Publishing country	United States
Document type	Journal Article ; Multicenter Study ; Randomized Controlled Trial
ZDB-ID	207147-2
ISSN	1526-632X ; 0028-3878
ISSN (online)	1526-632X
ISSN	0028-3878
DOI	10.1212/WNL.0000000000003151
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Article ; Online: The impact of early specialist management on outcomes of patients with in-hospital stroke.

Manawadu, Dulka / Choyi, Jithesh / Kalra, Lalit

PloS one

2014 Volume 9, Issue 8, Page(s) e104758

Abstract: Delays in treatment of in-hospital stroke (IHS) adversely affect patient outcomes. We hypothesised that early referral and specialist management of IHS patients will improve outcomes at 90 days. Baseline characteristics, assessment delays, thrombolysis ... ...

Abstract	Delays in treatment of in-hospital stroke (IHS) adversely affect patient outcomes. We hypothesised that early referral and specialist management of IHS patients will improve outcomes at 90 days. Baseline characteristics, assessment delays, thrombolysis eligibility, 90-day functional outcomes and all-cause mortality were compared between IHS patients referred for specialist stroke management within 3 hours of symptom onset (early referrals) and later referrals. Patients were identified from a prospective stroke registry between January 2009 and December 2010. Inclusion criteria were primary admission with a non-stroke diagnosis, onset of new neurological deficits after admission and early ischaemic changes on CT or MR imaging. Eighty four (4.6%) of 1836 stroke patients had IHS (mean age 74 year; 51% male, median NIHSS score 10). There were no significant differences in baseline characteristics between 53 (63%) early and 31 (37%) late referrals. Thrombolysis was performed in 29 (76%) of the 37/78 (47%) potentially eligible patients; 7 patients were excluded because specialist referral was delayed beyond 4.5 hours despite symptom recognition within 3 hours of onset. Early referral improved functional outcomes (modified Rankin Scale 0-2 at 90 days 40% v 7%, p = 0.001) and was an independent predictor of mRS 0-2 at 90 days after adjusting for age, pre-morbid function, primary cause for hospital admission and stroke severity [OR 1.13 (95% C.I. = 1.10-1.27), p = 0.002]. Early referral and specialist management of IHS patients that includes thrombolysis is associated with better functional outcomes at 90 days.
MeSH term(s)	Aged ; Aged, 80 and over ; Female ; Hospitals/statistics & numerical data ; Humans ; Male ; Middle Aged ; Prospective Studies ; Registries/statistics & numerical data ; Specialization ; Stroke ; Treatment Outcome
Language	English
Publishing date	2014-08-21
Publishing country	United States
Document type	Journal Article
ISSN	1932-6203
ISSN (online)	1932-6203
DOI	10.1371/journal.pone.0104758
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Article ; Online: The impact of early specialist management on outcomes of patients with in-hospital stroke.

Dulka Manawadu / Jithesh Choyi / Lalit Kalra

PLoS ONE, Vol 9, Iss 8, p e

2014 Volume 104758

Abstract	Delays in treatment of in-hospital stroke (IHS) adversely affect patient outcomes. We hypothesised that early referral and specialist management of IHS patients will improve outcomes at 90 days. Baseline characteristics, assessment delays, thrombolysis eligibility, 90-day functional outcomes and all-cause mortality were compared between IHS patients referred for specialist stroke management within 3 hours of symptom onset (early referrals) and later referrals. Patients were identified from a prospective stroke registry between January 2009 and December 2010. Inclusion criteria were primary admission with a non-stroke diagnosis, onset of new neurological deficits after admission and early ischaemic changes on CT or MR imaging. Eighty four (4.6%) of 1836 stroke patients had IHS (mean age 74 year; 51% male, median NIHSS score 10). There were no significant differences in baseline characteristics between 53 (63%) early and 31 (37%) late referrals. Thrombolysis was performed in 29 (76%) of the 37/78 (47%) potentially eligible patients; 7 patients were excluded because specialist referral was delayed beyond 4.5 hours despite symptom recognition within 3 hours of onset. Early referral improved functional outcomes (modified Rankin Scale 0-2 at 90 days 40% v 7%, p = 0.001) and was an independent predictor of mRS 0-2 at 90 days after adjusting for age, pre-morbid function, primary cause for hospital admission and stroke severity [OR 1.13 (95% C.I. = 1.10-1.27), p = 0.002]. Early referral and specialist management of IHS patients that includes thrombolysis is associated with better functional outcomes at 90 days.
Keywords	Medicine ; R ; Science ; Q
Language	English
Publishing date	2014-01-01T00:00:00Z
Publisher	Public Library of Science (PLoS)
Document type	Article ; Online
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Article ; Online: Influence of age on thrombolysis outcome in wake-up stroke.

Manawadu, Dulka / Bodla, Shankaranand / Keep, Jeff / Kalra, Lalit

Stroke

2013 Volume 44, Issue 10, Page(s) 2898–2900

Abstract: Background and purpose: Thrombolysis in patients >80 years remains controversial; we hypothesized that >80-year-old patients with wake-up ischemic stroke (WUIS) will benefit from thrombolysis despite risks because of poor outcomes with no treatment.: ... ...

Abstract	Background and purpose: Thrombolysis in patients >80 years remains controversial; we hypothesized that >80-year-old patients with wake-up ischemic stroke (WUIS) will benefit from thrombolysis despite risks because of poor outcomes with no treatment. Methods: The study included 68 thrombolysed patients with WUIS (33 [48%] >80 years), 54 nonthrombolysed patients with WUIS (21 [39%] >80 years), and 117 patients (>80 years old) thrombolysed within 4.5 hours of symptom onset (reference group). Mortality and modified Rankin Scale (mRS) were assessed at 90 days. Results: Baseline characteristics of thrombolysed and nonthrombolysed >80 and ≤80-year-old patients with WUIS were comparable. Thrombolysis outcomes in >80-year-old patients with WUIS were better than in nonthrombolysed >80-year-old patients with WUIS (90-day mortality: 24% versus 47%, P=0.034; mRS 0-2: 30% versus 5%, P=0.023; mRS 0-1: 15% versus 5%, P=0.24) and comparable with thrombolysed ≤80-year-old patients with WUIS. Thrombolysis was associated with odds ratio 0.27 (95% confidence interval, 0.05-0.97) for mortality and odds ratio 28.6 (95% confidence interval, 1.8-448) for mRS 0 to 2 at 90 days in >80-year-old patients with WUIS after adjusting for stroke severity and risk factors. Conclusions: Thrombolysis may be associated with greater benefit in >80-year-old patients with WUIS but a selection bias favoring thrombolysis in those most likely to benefit may significantly reduce interpretability of these findings.
MeSH term(s)	Age Factors ; Aged ; Aged, 80 and over ; Aging ; Brain Ischemia/mortality ; Brain Ischemia/therapy ; Disease-Free Survival ; Female ; Humans ; Male ; Middle Aged ; Registries ; Stroke/mortality ; Stroke/therapy ; Survival Rate ; Thrombolytic Therapy ; Time Factors
Language	English
Publishing date	2013-10
Publishing country	United States
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	80381-9
ISSN	1524-4628 ; 0039-2499 ; 0749-7954
ISSN (online)	1524-4628
ISSN	0039-2499 ; 0749-7954
DOI	10.1161/STROKEAHA.113.002273
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Article ; Online: Health professionals' knowledge of driving restrictions following stroke and TIA: experience from a hyperacute stroke centre.

Batool, Saiqa / Roberts, Adele Pryce / Kalra, Lalit / Manawadu, Dulka

Postgraduate medical journal

2014 Volume 90, Issue 1065, Page(s) 370–376

Abstract: Background and purpose: Assessment of fitness to drive (FTD) is important after stroke or transient ischaemic attack (TIA) to ensure that neither patients nor public are at risk. This is particularly important in patients with TIAs or minor stroke as ... ...

Abstract	Background and purpose: Assessment of fitness to drive (FTD) is important after stroke or transient ischaemic attack (TIA) to ensure that neither patients nor public are at risk. This is particularly important in patients with TIAs or minor stroke as many are discharged directly from emergency departments by a range of health professionals. We assessed stroke-related FTD knowledge among physicians' and allied health professionals' (AHPs) treating patients with stroke at a hyperacute stroke centre. Methods: Knowledge of FTD restrictions following a stroke or TIA for domestic and commercial use was assessed in 195 physicians and 45 AHPs using a multiple-choice questionnaire between January and December 2009. The effect of discipline, seniority, previous instruction in FTD restrictions and experience in stroke medicine on FTD was assessed. Results: The correct driving restriction following stroke with domestic and commercial license was known to 29% and 73% of physicians, respectively. For AHPs, these figures were 36% and 20%. For TIA with domestic and commercial license, this was 37% and 43% for physicians, and 44% and 11% for AHPs. 25% of physicians and 11% of AHPs believed that no driving restrictions applied after a TIA. The correct office for reporting FTD was known to 180 (92%) doctors and 31 (69%) AHPs (p=0.0001); 160 (82%) physicians and 27 (60%) AHPs correctly identified that reporting was the patients' responsibility (p=0.001). FTD knowledge correlated with post in stroke (OR 3.2 (95% CI 1.6 to 6.2, p=0.001)) but not with seniority or previous FTD education. Conclusions: Health professionals providing stroke care showed limited knowledge of FTD regulations after minor stroke or TIA. Imparting accurate information on driving restrictions is an important but neglected part of stroke management.
MeSH term(s)	Automobile Driving/legislation & jurisprudence ; Data Interpretation, Statistical ; Guideline Adherence ; Guidelines as Topic ; Health Knowledge, Attitudes, Practice ; Humans ; Ischemic Attack, Transient/complications ; Ischemic Attack, Transient/physiopathology ; Licensure ; Patient Discharge/statistics & numerical data ; Physicians ; Prognosis ; Stroke/complications ; Stroke/physiopathology ; Surveys and Questionnaires ; United Kingdom
Language	English
Publishing date	2014-07
Publishing country	England
Document type	Journal Article
ZDB-ID	80325-x
ISSN	1469-0756 ; 0032-5473
ISSN (online)	1469-0756
ISSN	0032-5473
DOI	10.1136/postgradmedj-2012-131395
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Article ; Online: Hereditary hemorrhagic telangiectasia: transient ischemic attacks.

Manawadu, Dulka / Vethanayagam, Dilini / Ahmed, S Nizam

CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne

2009 Volume 180, Issue 8, Page(s) 836–837

MeSH term(s)	Adult ; Blood Chemical Analysis ; Follow-Up Studies ; Humans ; Ischemic Attack, Transient/diagnosis ; Ischemic Attack, Transient/etiology ; Magnetic Resonance Imaging ; Male ; Monitoring, Physiologic ; Risk Assessment ; Severity of Illness Index ; Telangiectasia, Hereditary Hemorrhagic/complications ; Telangiectasia, Hereditary Hemorrhagic/diagnosis ; Tomography, X-Ray Computed
Language	English
Publishing date	2009-04-13
Publishing country	Canada
Document type	Case Reports ; Journal Article
ZDB-ID	215506-0
ISSN	1488-2329 ; 0008-4409 ; 0820-3946
ISSN (online)	1488-2329
ISSN	0008-4409 ; 0820-3946
DOI	10.1503/cmaj.081550
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Article ; Online: An observational study of thrombolysis outcomes in wake-up ischemic stroke patients.

Manawadu, Dulka / Bodla, Shankaranand / Keep, Jeff / Jarosz, Jozef / Kalra, Lalit

Stroke

2013 Volume 44, Issue 2, Page(s) 427–431

Abstract: Background and purpose: Wake-up ischemic stroke (WUIS) patients are not eligible for thrombolysis; the a priori hypothesis was that thrombolysis of selected WUIS patients who meet clinical and imaging criteria for treatment is associated with better ... ...

Abstract	Background and purpose: Wake-up ischemic stroke (WUIS) patients are not eligible for thrombolysis; the a priori hypothesis was that thrombolysis of selected WUIS patients who meet clinical and imaging criteria for treatment is associated with better outcomes. Methods: The sample consisted of consecutive WUIS patients who fulfilled predefined criteria: (1) were last seen normal >4.5 hours and <12 hours before presentation; (2) National Institute of Health Stroke Scale score ≥ 5; (3) No or early ischemic changes <1/3 middle cerebral artery territory on computed tomography imaging; (4) No absolute contraindications to thrombolysis. The primary outcome measure was the modified Rankin Scale of 0 to 2 at 90 days. Other outcome measures were mortality and symptomatic intracerebral hemorrhage. Results: WUIS patients constituted 10.5% (193/1836) of all stroke admissions. Inclusion criteria were fulfilled by 122 (63%) patients, of whom 68 (56%) were thrombolysed. Thrombolysed and nonthrombolysed patients were comparable for baseline characteristics, but the median baseline National Institute of Health Stroke Scale score was higher in thrombolysed patients (9 versus 11.5; P=0.034). There was no difference in modified Rankin Scale 0 to 2 (25 [37%] versus 14 [26%]; P=0.346), death (10 [15%] versus 14 [26%]; P=0.122), and symptomatic intracerebral hemorrhage (2 versus 0; P=0.204) between thrombolysed and nonthrombolysed patients. After adjusting for age, sex, and baseline National Institute of Health Stroke Scale score thrombolysis was associated with odds ratio of 5.2 (95% confidence interval 1.3-20.3), P=0.017 for modified Rankin Scale 0 to 2 at 90 days and odds ratio of 0.09 (95% confidence interval 0.02-0.44), P=0.003 for death. Conclusions: Thrombolysis in selected WUIS patients is feasible and may have potential of benefit.
MeSH term(s)	Aged ; Aged, 80 and over ; Brain Ischemia/diagnostic imaging ; Brain Ischemia/drug therapy ; Brain Ischemia/epidemiology ; Female ; Follow-Up Studies ; Humans ; Male ; Middle Aged ; Prospective Studies ; Radiography ; Registries ; Stroke/diagnostic imaging ; Stroke/drug therapy ; Stroke/epidemiology ; Thrombolytic Therapy/trends ; Tissue Plasminogen Activator/administration & dosage ; Treatment Outcome ; Wakefulness
Chemical Substances	Tissue Plasminogen Activator (EC 3.4.21.68)
Language	English
Publishing date	2013-02
Publishing country	United States
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	80381-9
ISSN	1524-4628 ; 0039-2499 ; 0749-7954
ISSN (online)	1524-4628
ISSN	0039-2499 ; 0749-7954
DOI	10.1161/STROKEAHA.112.673145
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Article ; Online: A case-controlled comparison of thrombolysis outcomes between wake-up and known time of onset ischemic stroke patients.

Manawadu, Dulka / Bodla, Shankaranand / Jarosz, Jozef / Keep, Jeff / Kalra, Lalit

Stroke

2013 Volume 44, Issue 8, Page(s) 2226–2231

Abstract: Background and purpose: Wake-up ischemic stroke (WUIS) patients are not thrombolysed even if they meet other criteria for treatment. We hypothesized that patients with WUIS showing no or early ischemic changes on brain imaging will have thrombolysis ... ...

Abstract	Background and purpose: Wake-up ischemic stroke (WUIS) patients are not thrombolysed even if they meet other criteria for treatment. We hypothesized that patients with WUIS showing no or early ischemic changes on brain imaging will have thrombolysis outcomes comparable with those with known time of symptom onset. Methods: Consecutive sampling of a prospective registry of patients with stroke between January 2009 and December 2010 identified 394 thrombolysed patients meeting predefined inclusion criteria, 326 presenting within 0 to 4.5 hours of symptom onset (Reference Group) and 68 WUIS patients. Inclusion criteria were last seen normal<12 hours or >4.5 hours (WUIS) or presented <4.5 hours (Reference Group), had National Institutes of Health Stroke Scale score ≥5, and no or early ischemic changes on imaging at presentation. The primary outcome measure was the modified Rankin Scale of 0 to 2 at 90 days measured by trained assessors blinded to patient grouping. Other outcome measures were symptomatic intracerebral hemorrhage, modified Rankin Scale 0 to 1, and mortality at 90 days. Results: The groups were comparable for mean age (72.8 versus 73.9 years; P=0.58) and baseline median National Institutes of Health Stroke Scale score (median 13 versus 12; P=0.34). The proportions of patients with modified Rankin Scale 0 to 2 (38% versus 37%; P=0.89) and modified Rankin Scale 0 to 1 (24% versus 16%; P=0.18) at 90 days, any ICH (20% versus 22%; P=0.42) and symptomatic intracerebral hemorrhage (3.4% versus 2.9%; P=1.0) were comparable after adjusting for age, stroke severity, and imaging changes. Only 9/394 (2%) patients were lost to follow-up. Conclusions: Thrombolysis in selected patients with WUIS is feasible, and its outcomes are comparable with those thrombolysed with 0 to 4.5 hours.
MeSH term(s)	Aged ; Aged, 80 and over ; Brain Ischemia/drug therapy ; Brain Ischemia/mortality ; Case-Control Studies ; Cerebral Hemorrhage/drug therapy ; Cerebral Hemorrhage/mortality ; Female ; Fibrinolytic Agents/therapeutic use ; Humans ; Male ; Middle Aged ; Outcome Assessment (Health Care) ; Prospective Studies ; Registries ; Stroke/drug therapy ; Stroke/mortality ; Thrombolytic Therapy/methods ; Thrombolytic Therapy/standards ; Time Factors ; Tissue Plasminogen Activator/therapeutic use ; Treatment Outcome
Chemical Substances	Fibrinolytic Agents ; Tissue Plasminogen Activator (EC 3.4.21.68)
Language	English
Publishing date	2013-08
Publishing country	United States
Document type	Comparative Study ; Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	80381-9
ISSN	1524-4628 ; 0039-2499 ; 0749-7954
ISSN (online)	1524-4628
ISSN	0039-2499 ; 0749-7954
DOI	10.1161/STROKEAHA.111.000757
Database	MEDical Literature Analysis and Retrieval System OnLINE

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