Value of CT perfusion imaging in wake-up strokes – a comparative study of patients qualifying for thrombolysis vs those not suitable for thrombolysis

Background and purpose: Stroke remains a major global health concern, contributing significantly to worldwide morbidity and mortality. Despite advances in stroke management, wake-up strokes pose unique challenges for the Emergency Physician due to the uncertain timing of symptom onset, often resulting in limited treatment options. A significant knowledge gap concerning the diagnostic challenges, optimal management and outcomes associated with wake-up strokes remains, particularly in low- and middle-income countries. This study compares outcomes between patients with wake-up strokes who received thrombolysis and those who did not, based on advanced imaging. Methods: We used a retrospective review of patient records for all wake-up strokes between January 2022 and July 2024 from a Johannesburg, South Africa hospital. Data collected included demographics, risk factors, initial National Institute of Health Stroke Scale and modified Rankin Scale, radiological characteristics, interventions and discharge information. We utilised the RAPID-AI software to aid in analysis of the CT perfusion studies. Results: Some 57 patients fulfilled the inclusion criteria (51% females), with 22 patients receiving thrombolytic therapy and showed a 65% reduction (median of 12 on admission to 4 on discharge) in median National Institute of Health Stroke Scale score compared to a 45% reduction (median of 11 on admission to 6 on discharge) in those who did not receive thrombolytic therapy (p=0.01). Post-lytic intracerebral haemorrhage without clinical deterioration occurred in one patient. There were 7 mortalities, with 2 in the thrombolytic cohort unrelated to thrombolysis. Conclusion: In patients presenting with wake-up strokes, computed tomography perfusion can be used successfully to help determine eligibility for thrombolytic therapy. Furthermore, thrombolysed patients had a higher rate of functional recovery.