Evaluation of stroke related risk factors in wake up and non-wake up stroke patients

  • Elyar Sadeghi-Hokmabadi Neurosciences Research Center (NSRC), Tabriz University of Medical Sciences, Iran, Islamic Republic of.
  • Samad Shams Vahdati Emergency Medicine Research Team, Tabriz University of Medical Sciences, Iran, Islamic Republic of.
  • Reza Rikhtegar Neurosciences Research Center (NSRC), Tabriz University of Medical Sciences, Iran, Islamic Republic of.
  • Nazila Karzad Neurosciences Research Center (NSRC), Tabriz University of Medical Sciences, Iran, Islamic Republic of.
  • Aysa Rezabakhsh | aysapharma.rezabakhsh@gmail.com Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran, Islamic Republic of.


Wake-Up Stroke (WUS) is defined as a stroke with the unclear onset of symptoms and subsequent neurological deficits which perceived upon awakening. WUS patients are often excluded from acute fibrinolytic and reperfusion therapy due to the unknown exact time of symptoms onset. This study aimed to evaluate patients with and without WUS characteristics and associated risk factors at two tertiary hospitals. First, we prospectively evaluated consecutive patients with stroke symptoms and determined stroke sub groups by using Computed Tomography (CT) scan. Next, demographic and clinical characteristics including past medical and drug consumption history as well as cardiac function index (ejection fraction), LDL (mg/dl) level and hematologic parameters: hemoglobin (Hb); hematocrit (Hct); platelet (Plt) were assessed. Results: 510 patients (56.1% men and 43.9% women) with averaged age of 70 and 72 years were studied, respectively. Of 510 patients, 405 (79.4%) had non-WUS stroke (known-onset stroke) and 105 (20.6%) had WUS strokes (unknown-onset stroke). The WUS occurrence most likely was observed in ischemic stroke compared to hemorrhagic one. No significant differences were found between patients from both groups regarding stroke risk factors. However, hypertension and family history were more common in patients with WUS (p>0.05). Moreover, individuals with a previous cerebrovascular accident in WUS group were almost similar to non-WUS counterparts. No differences also detected in case of hematologic characteristics, heart function index and LDL levels between study groups (p>0.05). Together, wake-up stroke occurs in approximately 20% of stroke subjects. In this study, patients with WUS had more hypertension and family history.



PlumX Metrics


Download data is not yet available.


Katan M, Luft A. Global burden of stroke, Seminars in neurology, Thieme Medical Publishers, 2018. pp. 208-211. DOI: https://doi.org/10.1055/s-0038-1649503

Lo AC, Guarino PD, Richards LG, et al. Robot-assisted therapy for long-term upper-limb impairment after stroke. N Engl J Med 2010; 362: 1772-1783. DOI: https://doi.org/10.1056/NEJMoa0911341

Amarenco P, Bogousslavsky J, Caplan L, Donnan G, Hennerici M. Classification of stroke subtypes. Cerebrovasc Dis 2009; 27: 493-501. DOI: https://doi.org/10.1159/000210432

Vos T, Barber RM, Bell B, et al. regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2015; 386: 743-800. DOI: https://doi.org/10.1016/S0140-6736(15)60692-4

S. Omama S, Yoshida Y, Ogawa A, Onoda T, Okayama A. Differences in circadian variation of cerebral infarction, intracerebral haemorrhage and subarachnoid haemorrhage by situation at onset. J Neurol Neurosurg Psychiatry 2006; 77: 1345-1349. DOI: https://doi.org/10.1136/jnnp.2006.090373

Powers WJ, Derdeyn CP, Biller J, et al. 2015 American Heart Association/American Stroke Association focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2015; 46: 3020-3035. DOI: https://doi.org/10.1161/STR.0000000000000074

Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A, San Román L, Serena J, Abilleira S, Ribó M. Thrombectomy within 8 hours after symptom onset in ischemic stroke, N Engl J Med 2015; 372: 2296-2306. DOI: https://doi.org/10.1056/NEJMoa1503780

Cucchiara B, Kasner S, Wolk D, et al. Lack of hemispheric dominance for consciousness in acute ischaemic stroke. J Neurol Neurosurg Psychiatry 2003; 74: 889-892. DOI: https://doi.org/10.1136/jnnp.74.7.889

Kang DW, Kwon JY, Kwon SU, Kim JS. Wake-up or unclear-onset strokes: are they waking up to the world of thrombolysis therapy?. Int J Stroke 2012; 7: 311-320. DOI: https://doi.org/10.1111/j.1747-4949.2012.00779.x

Mackey J, Kleindorfer D, Sucharew H, et al. Population-based study of wake-up strokes. Neurologym 2011; 76: 1662-1667. DOI: https://doi.org/10.1212/WNL.0b013e318219fb30

Atkinson G, Jones H, Ainslie PN. Circadian variation in the circulatory responses to exercise: relevance to the morning peaks in strokes and cardiac events. Eur J Appl Physiol 2010;108 : 15-29. DOI: https://doi.org/10.1007/s00421-009-1243-y

Siniscalchi A, De Sarro G, Pacifici R, et al . Thrombolytic Therapy in Cocaine Users with Ischemic Stroke: A Review of Current Practice. Psychopharmacol Bull. 2019;49:70‐79.

Barreto AD, Martin-Schild S, Hallevi H, et al. Thrombolytic therapy for patients who wake-up with stroke. Stroke 2009; 40: 827-832. DOI: https://doi.org/10.1161/STROKEAHA.108.528034

Nadeau JO, Fang J, Kapral MK, Silver FL, Hill MD. Outcome after stroke upon awakening. Can J Neurol Sci 2005; 32: 232-236. DOI: https://doi.org/10.1017/S0317167100004029

Rimmele D, G. Thomalla G. Wake-up stroke: clinical characteristics, imaging findings, and treatment option–an update. Front Neurol 2014; 5: 35. DOI: https://doi.org/10.3389/fneur.2014.00035

Kim BJ, Lee S-H, Shin C-W, et al. Ischemic stroke during sleep: its association with worse early functional outcome. Stroke 2011; 42: 1901-1906. DOI: https://doi.org/10.1161/STROKEAHA.110.602243

Silva GS, Lima FO, Camargo EC, et al. Wake-up stroke: clinical and neuroimaging characteristics. Cerebrovasc Dis 2010; 29: 336-342. DOI: https://doi.org/10.1159/000278929

Béjot Y, Daubail B, Giroud M. Epidemiology of stroke and transient ischemic attacks: Current knowledge and perspectives. Rev Neurol 2016; 172: 59-68. DOI: https://doi.org/10.1016/j.neurol.2015.07.013

Kocer A, Ilhan A, Ince N, Bilge C. The related causes in very early morning onset of stroke, Prog Neuropsychopharmacol Biol Psychiatry 2005; 29: 983-988. DOI: https://doi.org/10.1016/j.pnpbp.2005.06.005

Jiménez-Conde J, Ois A, Rodríguez-Campello A, Gomis M, Roquer J. Does sleep protect against ischemic stroke? Less frequent ischemic strokes but more severe ones. J Neurol 2007; 254: 782-788. DOI: https://doi.org/10.1007/s00415-006-0438-y

Bornstein NM, Gur AY, Fainstein PF, Korczyn AD. Stroke during sleep: epidemiological and clinical features. Cerebrovasc Dis 1999; 9: 320-322. DOI: https://doi.org/10.1159/000016005

Jackson CA, Sudlow CLM, Mishra GD. Education, sex and risk of stroke: a prospective cohort study in New South Wales, Australia. BMJ Open 2018;8:e024070. DOI: https://doi.org/10.1136/bmjopen-2018-024070

Hepburn M, Bollu PC, French B, Sahota P. Sleep Medicine: Stroke and Sleep. Mo Med 2018;115:527‐532.

Khot SP, Morgenstern LB. Sleep and Stroke. Stroke 2019;50:1612–1617 DOI: https://doi.org/10.1161/STROKEAHA.118.023553

Ferrea A, Ribób M, Rodríguez-Lunab D, Romeroa O, Sampolc G, Molinab CA, Álvarez-Sabinb J. Strokes and their relationship with sleep and sleep disorders. Neurología 2013; 28: 103-118.

Seshadri S, Beiser A, Pikula A, et al. Parental occurrence of stroke and risk of stroke in their children: the Framingham study. Circulation. 2010;121(11): 1304. DOI: https://doi.org/10.1161/CIRCULATIONAHA.109.854240

Kubota M, Yamaura A, Ono J-i, et al. Is family history an independent risk factor for stroke?. J Neurol Neurosurg Psychiatry 1997; 62: 66-70. DOI: https://doi.org/10.1136/jnnp.62.1.66

Kapil N, Datta YH, Alakbarova N, et al. Antiplatelet and anticoagulant therapies for prevention of ischemic stroke. Clin Appl Thromb Hemost 2017; 23: 301-318. DOI: https://doi.org/10.1177/1076029616660762

Yilmaz E, Kacar AB, Bozpolat A, et al. The relationship between hematological parameters and prognosis of children with acute ischemic stroke. Childs Nerv Syst 2018; 34: 655-661. DOI: https://doi.org/10.1007/s00381-017-3673-x

Pullicino P, Raynor S. Is low cardiac ejection fraction a risk factor for stroke?. M M J 2013; 25:10-17.

Fidha Rahmayani P, Setyopranoto I. The role of ejection fraction to clinical outcome of acute ischemic stroke patients. J Neurosci Rural Pract 2018; 9: 197–202. DOI: https://doi.org/10.4103/jnrp.jnrp_490_17

Original Articles
Wake Up Stroke, Risk Factors, Familiar History, Hematologic Characteristics
  • Abstract views: 1081

  • PDF: 179
How to Cite
Sadeghi-Hokmabadi, E., Shams Vahdati, S., Rikhtegar, R., Karzad, N., & Rezabakhsh, A. (2020). Evaluation of stroke related risk factors in wake up and non-wake up stroke patients. Emergency Care Journal, 16(2). https://doi.org/10.4081/ecj.2020.8834