title: Wake-up stroke and stroke of unknown onset: a critical review.
abstract: Patients, who wake up with an ischemic stroke, account for a large number of the total stroke population, due to circadian morning predominance of stroke. Currently, this subset of patients is excluded from revascularization-therapy since no exact time of onset is known. A large group of these patients might be eligible for therapy. In this review, we assessed the current literature about the hypothesis that wake-up-strokes occur just prior on awakening and if this subgroup differs in characteristics compared to the overall stroke population. We looked at the safety and efficacy of thrombolysis and interventional techniques in the group of patients with unknown stroke-onset. We performed a meta-analysis of the diagnostic accuracy of the diffusion-FLAIR mismatch in identifying stroke within 3 and 4.5 h. The different imaging-selection criteria that can be used to treat these patients are discussed. Additional research on imaging findings associated with recent stroke and penumbral imaging will eventually lead to a shift from a rigid time-frame based therapy to a tissue-based individualized treatment approach.
authors.affiliation: KU Leuven Department of Neurosciences and Experimental Neurology, KU Leuven , Leuven , Belgium ; Department of Neurology, University Hospital Leuven , Leuven , Belgium ; Medical Imaging Research Center, UZ Leuven , Leuven , Belgium.
authors.forename: Anke
authors.initials: A
authors.lastname: Wouters
authors.affiliation: KU Leuven Department of Neurosciences and Experimental Neurology, KU Leuven , Leuven , Belgium ; Department of Neurology, University Hospital Leuven , Leuven , Belgium ; Leuven Research Institute for Neuroscience and Disease (LIND), KU Leuven , Leuven , Belgium ; Laboratory of Neurobiology, Vesalius Research Center , Leuven , Belgium.
authors.forename: Robin
authors.initials: R
authors.lastname: Lemmens
authors.affiliation: Medical Imaging Research Center, UZ Leuven , Leuven , Belgium ; Laboratory for Epilepsy Research, KU Leuven , Leuven , Belgium ; Laboratory for Cognitive Neurology, KU Leuven , Leuven , Belgium.
authors.forename: Patrick
authors.initials: P
authors.lastname: Dupont
authors.affiliation: KU Leuven Department of Neurosciences and Experimental Neurology, KU Leuven , Leuven , Belgium ; Department of Neurology, University Hospital Leuven , Leuven , Belgium ; Leuven Research Institute for Neuroscience and Disease (LIND), KU Leuven , Leuven , Belgium ; Laboratory of Neurobiology, Vesalius Research Center , Leuven , Belgium.
authors.forename: Vincent
authors.initials: V
authors.lastname: Thijs
keywords: circadian rhythm; thrombectomy; thrombolysis; unknown-onset stroke; wake-up-stroke