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Ischemic stroke with unknown onset of symptoms: current scenario and perspectives for the future

Background  Stroke is a major cause of disability worldwide and a neurological emergency. Intravenous thrombolysis and mechanical thrombectomy are effective in the reperfusion of the parenchyma in distress, but the impossibility to determine the exact time of onset was an important cause of exclusio...

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Autores principales: Lopes, Rônney Pinto, Gagliardi, Vivian Dias Baptista, Pacheco, Felipe Torres, Gagliardi, Rubens José
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Thieme Revinter Publicações Ltda. 2022
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10658507/
https://www.ncbi.nlm.nih.gov/pubmed/36580965
http://dx.doi.org/10.1055/s-0042-1755342
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author Lopes, Rônney Pinto
Gagliardi, Vivian Dias Baptista
Pacheco, Felipe Torres
Gagliardi, Rubens José
author_facet Lopes, Rônney Pinto
Gagliardi, Vivian Dias Baptista
Pacheco, Felipe Torres
Gagliardi, Rubens José
author_sort Lopes, Rônney Pinto
collection PubMed
description Background  Stroke is a major cause of disability worldwide and a neurological emergency. Intravenous thrombolysis and mechanical thrombectomy are effective in the reperfusion of the parenchyma in distress, but the impossibility to determine the exact time of onset was an important cause of exclusion from treatment until a few years ago. Objectives  To review the clinical and radiological profile of patients with unknown-onset stroke, the imaging methods to guide the reperfusion treatment, and suggest a protocol for the therapeutic approach. Methods  The different imaging methods were grouped according to current evidence-based treatments. Results  Most studies found no difference between the clinical and imaging characteristics of patients with wake-up stroke and known-onset stroke, suggesting that the ictus, in the first group, occurs just prior to awakening. Regarding the treatment of patients with unknown-onset stroke, four main phase-three trials stand out: WAKE-UP and EXTEND for intravenous thrombolysis, and DAWN and DEFUSE-3 for mechanical thrombectomy. The length of the therapeutic window is based on the diffusion weighted imaging–fluid-attenuated inversion recovery (DWI-FLAIR) mismatch, core-penumbra mismatch, and clinical core mismatch paradigms. The challenges to approach unknown-onset stroke involve extending the length of the time window, the reproducibility of real-world imaging modalities, and the discovery of new methods and therapies for this condition. Conclusion  The advance in the possibilities for the treatment of ischemic stroke, while guided by imaging concepts, has become evident. New studies in this field are essential and needed to structure the health care services for this new scenario.
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spelling pubmed-106585072022-12-01 Ischemic stroke with unknown onset of symptoms: current scenario and perspectives for the future Lopes, Rônney Pinto Gagliardi, Vivian Dias Baptista Pacheco, Felipe Torres Gagliardi, Rubens José Arq Neuropsiquiatr Background  Stroke is a major cause of disability worldwide and a neurological emergency. Intravenous thrombolysis and mechanical thrombectomy are effective in the reperfusion of the parenchyma in distress, but the impossibility to determine the exact time of onset was an important cause of exclusion from treatment until a few years ago. Objectives  To review the clinical and radiological profile of patients with unknown-onset stroke, the imaging methods to guide the reperfusion treatment, and suggest a protocol for the therapeutic approach. Methods  The different imaging methods were grouped according to current evidence-based treatments. Results  Most studies found no difference between the clinical and imaging characteristics of patients with wake-up stroke and known-onset stroke, suggesting that the ictus, in the first group, occurs just prior to awakening. Regarding the treatment of patients with unknown-onset stroke, four main phase-three trials stand out: WAKE-UP and EXTEND for intravenous thrombolysis, and DAWN and DEFUSE-3 for mechanical thrombectomy. The length of the therapeutic window is based on the diffusion weighted imaging–fluid-attenuated inversion recovery (DWI-FLAIR) mismatch, core-penumbra mismatch, and clinical core mismatch paradigms. The challenges to approach unknown-onset stroke involve extending the length of the time window, the reproducibility of real-world imaging modalities, and the discovery of new methods and therapies for this condition. Conclusion  The advance in the possibilities for the treatment of ischemic stroke, while guided by imaging concepts, has become evident. New studies in this field are essential and needed to structure the health care services for this new scenario. Thieme Revinter Publicações Ltda. 2022-12-29 /pmc/articles/PMC10658507/ /pubmed/36580965 http://dx.doi.org/10.1055/s-0042-1755342 Text en Academia Brasileira de Neurologia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution 4.0 International License, permitting copying and reproduction so long as the original work is given appropriate credit ( https://creativecommons.org/licenses/by/4.0/ ) https://creativecommons.org/licenses/by/4.0/This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
spellingShingle Lopes, Rônney Pinto
Gagliardi, Vivian Dias Baptista
Pacheco, Felipe Torres
Gagliardi, Rubens José
Ischemic stroke with unknown onset of symptoms: current scenario and perspectives for the future
title Ischemic stroke with unknown onset of symptoms: current scenario and perspectives for the future
title_full Ischemic stroke with unknown onset of symptoms: current scenario and perspectives for the future
title_fullStr Ischemic stroke with unknown onset of symptoms: current scenario and perspectives for the future
title_full_unstemmed Ischemic stroke with unknown onset of symptoms: current scenario and perspectives for the future
title_short Ischemic stroke with unknown onset of symptoms: current scenario and perspectives for the future
title_sort ischemic stroke with unknown onset of symptoms: current scenario and perspectives for the future
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10658507/
https://www.ncbi.nlm.nih.gov/pubmed/36580965
http://dx.doi.org/10.1055/s-0042-1755342
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