title: Wake-up Stroke and Onset-to-door Duration Delays: Potential Future Indications for Reperfusion Therapy.
abstract: BACKGROUND
  There is limited utilisation of acute stroke reperfusion treatments which have narrow therapeutic windows, with delayed hospital presentation being a major limiting factor in Singapore. Most patients who wake up with symptoms are ineligible for reperfusion treatments as duration from onset time is not known. We studied the profile of wake-up strokes, onset-to-door duration and their associated factors among ischaemic stroke patients in the context of potential new treatments.
  
  
  METHODS
  This is an observational study of consecutive ischaemic stroke patients presenting within 2 weeks of symptom onset to the Singapore General Hospital in 2012.
  
  
  RESULTS
  Of the 642 ischaemic stroke patients studied, 33% of the cases were wake-up strokes [median age 64 years, 88%<80 years; median NIHSS score 4, 98%<20]. The median onset-to-door duration was 14.3 hours (Interquartile range, 4.8 to 38.2 hours), 20% of them arrived <3.5 hours (considering eligibility for intravenous alteplase in the proven 4.5 hours window accounting for a one hour door-to-needle duration), 14%: ≥3.5 to <8 hours, 11%: ≥8 to <12 hours, and 56%: ≥12 hours. Most patients with known stroke risk factors including atrial fibrillation (66%), hypertension (78%) and prior stroke (81%) presented beyond 3.5 hours.
  
  
  CONCLUSIONS
  The one- third proportion of wake-up stroke in this cohort and low prevalence of relative contraindications suggest this is a promising group for emerging thrombolysis indications. With the majority of patients presenting after 8 hours, widening of the therapeutic window with new potential reperfusion treatments would not appreciably increase treatment utilisation. This study reaffirms the urgent need for public education to improve stroke awareness in Singapore.
authors.affiliation: Duke-NUS Graduate Medical School, Singapore.
authors.forename: Melissa S H
authors.initials: MS
authors.lastname: Tan
authors.forename: Elaine S L
authors.initials: ES
authors.lastname: Ang
authors.forename: Shu Swen
authors.initials: SS
authors.lastname: Ho
authors.forename: Szu Chyi
authors.initials: SC
authors.lastname: Ng
authors.forename: Loreto
authors.initials: L
authors.lastname: Talabucon
authors.forename: Fung Peng
authors.initials: FP
authors.lastname: Woon
authors.forename: Deidre Anne
authors.initials: DA
authors.lastname: De Silva
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015995:Prevalence; D011446:Prospective Studies; D015424:Reperfusion; D012846:Singapore; D020521:Stroke / Q000453:epidemiology / Q000601:surgery / Q000628:therapy*; D061665:Time-to-Treatment / Q000706:statistics & numerical data*