title: Intravenous Tissue Plasminogen Activator for Wake-Up Stroke: A Propensity Score-Matched Analysis.
abstract: OBJECTIVE
  To evaluate the safety and efficacy of intravenous (IV) tissue plasminogen activator (tPA) in the treatment of wake-up stroke (WUS) using propensity score (PS) analysis.
  
  
  METHODS
  Consecutive acute ischemic stroke patients meeting inclusion criteria were retrospectively identified from our stroke registry between July 2008 and May 2014, and classified as stroke onset less than or equal to 4.5 hours treated with tPA (control; n = 369), tPA-treated WUS (n = 46), or nontreated WUS (n = 154). The primary outcome of interest for safety was symptomatic intracerebral hemorrhage (sICH), defined as parenchymal hemorrhage associated with a greater than or equal to 4-point increase in National Institutes of Health Stroke Scale (NIHSS) score. Multivariate logistic regression with adjustment for confounders and PS for receiving IV tPA assessed outcomes, along with PS-matched average treatment effect on the treated (ATT).
  
  
  RESULTS
  No significant difference was found in rates of sICH between tPA-treated WUS, nontreated WUS, and controls (2.2%, .7%, and 3%, respectively), or in the odds of sICH between tPA-treated WUS and controls (OR = .53, 95% CI = .06-4.60, P = .568). Among WUS patients, tPA treatment was significantly associated with higher odds of good functional outcome in fully adjusted analyses (OR = 7.22, 95% CI = 2.28-22.88, P = .001). The ATT of tPA for WUS patients demonstrated a significantly greater decrease in NIHSS score at discharge when compared to nontreated WUS patients (-4.32 versus -.34, P = .032).
  
  
  CONCLUSIONS
  Comparable rates of sICH between treated WUS and stroke onset less than or equal to 4.5 hours treated with tPA suggest that tPA may be safely used to treat WUS. Superior outcomes for tPA-treated versus nontreated WUS subjects may suggest clinical efficacy of the treatment.
authors.affiliation: Stroke Program, Department of Neurology, Tulane University School of Medicine, New Orleans, Louisiana.
authors.forename: James E
authors.initials: JE
authors.lastname: Anaissie
authors.affiliation: Stroke Program, Department of Neurology, Tulane University School of Medicine, New Orleans, Louisiana.
authors.forename: Dominique J
authors.initials: DJ
authors.lastname: Monlezun
authors.affiliation: Stroke Program, Department of Neurology, Tulane University School of Medicine, New Orleans, Louisiana.
authors.forename: James E
authors.initials: JE
authors.lastname: Siegler
authors.affiliation: Stroke Program, Department of Neurology, Tulane University School of Medicine, New Orleans, Louisiana.
authors.forename: Elizabeth D
authors.initials: ED
authors.lastname: Waring
authors.affiliation: Stroke Program, Department of Neurology, Tulane University School of Medicine, New Orleans, Louisiana.
authors.forename: Lauren N
authors.initials: LN
authors.lastname: Dowell
authors.affiliation: Stroke Program, Department of Neurology, Tulane University School of Medicine, New Orleans, Louisiana.
authors.forename: Alyana A
authors.initials: AA
authors.lastname: Samai
authors.affiliation: Stroke Program, Department of Neurology, Tulane University School of Medicine, New Orleans, Louisiana.
authors.forename: Alexander J
authors.initials: AJ
authors.lastname: George
authors.affiliation: Stroke Program, Department of Neurology, Tulane University School of Medicine, New Orleans, Louisiana.
authors.forename: Tara
authors.initials: T
authors.lastname: Kimbrough
authors.affiliation: Stroke Program, Department of Neurology, Tulane University School of Medicine, New Orleans, Louisiana.
authors.forename: Jimmy
authors.initials: J
authors.lastname: Berthaud
authors.affiliation: Stroke Program, Department of Neurology, Tulane University School of Medicine, New Orleans, Louisiana. Electronic address: smartin2@tulane.edu.
authors.forename: Sheryl
authors.initials: S
authors.lastname: Martin-Schild
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000175:diagnosis / Q000188:drug therapy* / Q000503:physiopathology; D002543:Cerebral Hemorrhage / Q000139:chemically induced; D016009:Chi-Square Distribution; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage* / Q000009:adverse effects; D006801:Humans; D007262:Infusions, Intravenous; D016015:Logistic Models; D008145:Louisiana; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D057216:Propensity Score; D012042:Registries; D012189:Retrospective Studies; D012307:Risk Factors; D020521:Stroke / Q000175:diagnosis / Q000188:drug therapy* / Q000503:physiopathology; D015912:Thrombolytic Therapy / Q000009:adverse effects; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage* / Q000009:adverse effects; D016896:Treatment Outcome; D014851:Wakefulness; D055815:Young Adult
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
keywords: Acute ischemic stroke; stroke; tPA; treatment; wake-up stroke