„Wake-up Stroke”: Übersicht zu diagnostischen und therapeutischen Optionen des aus dem Schlaf heraus aufgetretenen ischämischen Schlaganfalls

Zusammenfassung

Bis zu 25 % aller ischämischen Schlaganfälle treten während des Schlafes auf („Wake-up Stroke” [WUS]). Aufgrund des unklaren Zeitfensters werden diese Patienten üblicherweise nicht in Akutstudien zur Schlaganfalltherapie eingeschlossen und auch im klinischen Alltag erfolgt nur selten eine spezifische Therapie. Aktuell besteht keine zugelassene Therapie für diese Patienten. Im Rahmen dieser Arbeit möchten wir einen Überblick über die bisher zum Thema publizierte Literatur geben. Informationen zu Patientencharakteristika und zu den derzeit verfügbaren diagnostischen und therapeutischen Möglichkeiten bei Patienten mit WUS werden dargestellt und bewertet. Bezüglich klinischer, ätiopathologischer und radiologischer Befunde und der Patientencharakteristika unterscheiden sich Patienten mit WUS und solche mit bekanntem Beginn der Schlaganfallsymptome nicht wesentlich voneinander. Auch wenn derzeit noch kein diagnostischer Goldstandard besteht, so erscheinen moderne Bildgebungsverfahren, insbesondere die multiparametrische MRT, geeignet für die Indikationsstellung einer Thrombolysetherapie bei WUS-Patienten. Erste Pilotstudien zeigen, dass ein Teil dieser Patienten erfolgreich mit Thrombolyse behandelt werden kann. Größere, prospektive, randomisierte, kontrollierte Studien müssen folgen, um sowohl die Wirksamkeit und Sicherheit der Therapie als auch den Nutzen der modernen Bildgebungsverfahren in dieser Patientengruppe weiter zu untersuchen. Die bisher vorliegenden ersten Ergebnisse sollten Eingang finden in die Planung solcher zukünftigen Studien.

Abstract

Up to 25 % of all acute ischemic strokes (AIS) occur during sleep with the patients or relatives becoming aware of their neurological deficits as they wake up. Because of the unclear time of stroke onset patients with stroke on awakening are usually not considered for acute therapies and excluded from most treatment trials. We give an overview of the published data regarding ischemic wake up strokes (WUS). In particular we focused on baseline characteristics, imaging methods and therapy strategies. Comparing WUS patients and patients with known stroke onset there were no major differences found regarding patient characteristics, etiology, clinical and radiological characteristics. Even though there is no existing gold standard multiparametric neuroimaging (CT; MRI) appears to be helpful for decision making whether to treat a WUS patient with thrombolysis or not. Especially multiparametric MRI which proved to be safe in patients within an extended time window might serve as an adequate diagnostic tool. The results of first pilot studies analyzing treatment of WUS demonstrate that a substantial number of these patients can be treated with IV thrombolysis (IVT) successfully. Large randomized, controlled, prospective clinical trials for patients with WUS are needed to test safety and efficacy of IVT and to evaluate the assumed benefit of multiparametric neuroimaging techniques in this patient group. The results of first pilot studies may be instrumental to help plan and design such trials.

Schlüsselwörter

Erwachen - ischämisch - Schlaf - Schlaganfall - MRT-basierte Thrombolyse

Key words

awakening - ischemic - sleep - stroke - MRI based thrombolysis

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