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WSC 2022 | Should wake-up stroke patients be treated as late-window patients?

Wim H. van Zwam, MD, Maastricht University Medical Center, The Netherlands, addresses the issue of timing for reperfusion therapy in wake-up stroke patients. In the MR CLEAN-LATE, DAWN, and DEFUSE 3 trials of thrombectomy for stroke beyond 6 hours, there were a substantial proportion of wake-up patients. The issue with treating these patients is that they are considered to be in the late window. Patients presenting in the early window are normally treated without advanced imaging to prevent unnecessary treatment delay, given the substantial treatment effect and small potential harm of endovascular therapy. In the late time window, advanced imaging-based selection with CT perfusion or collateral scores can be valuable to identify patients most likely to benefit from EVT. The trade-off between obtaining more information and delaying treatment with perfusion imaging remains controversial. Since wake-up patients are considered late-window patients, advanced imaging is generally used as part of their treatment; although, Prof. van Zwam argues that the majority of wake-up patients are actually early-window patients, and that advanced imaging could be wasting time for their treatment. Therefore, more evidence must be obtained in order to change the guidelines for treating wake-up stroke patients. This interview took place at the World Stroke Congress 2022 in Singapore.

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Transcript (edited for clarity)

We have seen, also in our trial, that there are quite some wake up patients. And also in the DAWN and DEFUSE 3 trial, there are quite some wake up patients. I even think that in the general stroke or endovascular treated patients, we have up to 20% wake up patients. And what my argument is, or my, how should I say, my frustration, is that patients that arrive when they wake up with a stroke are considered late window patients...

We have seen, also in our trial, that there are quite some wake up patients. And also in the DAWN and DEFUSE 3 trial, there are quite some wake up patients. I even think that in the general stroke or endovascular treated patients, we have up to 20% wake up patients. And what my argument is, or my, how should I say, my frustration, is that patients that arrive when they wake up with a stroke are considered late window patients.

Now I’ve started that presentation with why do we treat patients in the early window without advance imaging? And we touched on that already in the beginning of this interview. We do that because we don’t want to lose any time. And although there are probably some patients, fast progressors, that will not have a benefit, we don’t care about that so much because the majority in the early window will benefit. And we don’t want to, as I said, lose time.

Second, in the early time window, to do additional advanced imaging is less reliable. Patients may have a ghost core. So it seems that they have a large score, but in reality it that’s not the case. There have been a few publications about it. So in the early time window, I think we should not do any advanced imaging, just go as fast as possible to open the vessel.
In the later time window, there is reason to select either CT perfusion or what we have shown now with collaterals. That takes extra time. Of course, it takes time to take the decision. But we know that in the late time window, the very fast progressors are already out… well, they are already dead, or are in such a bad condition that you don’t treat them anymore. So you have the slower progressors in the late time window that you have a little bit more time. And if you would treat all patients in the late time window, it’ll be very inefficient. Because there are many patients already that will probably not fulfill the criteria, and treating them all is inefficient. So I said there is good reason to treat patients in the early window without advanced imaging, and to treat patients in the late window with advanced imaging.

Now the question is how do you consider wake up patients? At the moment, they are considered late window. So we do all the advanced imaging. That takes time. And in my opinion, they are all, or nearly all, early window patients. And we should not do this advanced imaging. We should go as fast as possible. There are quite some fast progressors in this cohort. And losing time, looking at collaterals, looking at CT perfusion, et cetera, will be damaging for those patients.

That’s my argument. And the thing is that you should have it in the guidelines to have things changed. I completely agree that in the first- or second-year resident on the emergency department will look at the guidelines and behave following the guidelines. So she or he will ask, “What time did you go to bed?” And then it was the evening before. So then they consider them as late window. And I hope that we can change that one day. But we need, in fact, we need real evidence. We now have secondary evidence, in fact, but not the real evidence.

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Disclosures

Prof. van Zwam reports the following disclosures: speaker fees from Cerenovus, Stryker and Nicolab and consulting fees from Philips, all paid to institution.