Wake-up stroke: Clinical characteristics, sedentary lifestyle, and daytime sleepiness

Wake-up stroke (WUS) is defined when the exact time of the beginning of the symptoms cannot be determined, for the deficits are perceived upon awakening. Sleep alterations are important risk factors for stroke and cardiovascular diseases. This study evaluates the characteristics of patients with and without WUS, the presence of daytime sleepiness, and associated risk factors.

Method:

Patients with ischemic stroke were investigated about the presence of WUS. Clinical and demographic characteristics were evaluated. Stroke severity was studied by the National Institutes of Health Stroke Scale (NIHSS) and the Modified Rankin Scale (MRS), and daytime sleepiness severity was studied by the Epworth Sleepiness Scale (ESS).

Results:

Seventy patients (57.1% men) aged from 32 to 80 years (58.5±13.3) were studied. WUS was observed in 24.3%. Arterial hypertension (67.1%), type 2 diabetes (27.1%), and hyperlipidemia (22.8%) were frequent. Type 2 diabetes and sedentary lifestyle were more common in patients with WUS (p<0.05). Overall, mild, moderate or very few symptoms of stroke (NIHSS<5) were predominant (62.3%). Among all cases, 20% had excessive daytime sleepiness (ESS>10). No differences were found between patients with and without WUS as regards stroke severity or excessive daytime sleepiness. Patients with excessive daytime sleepiness were younger and had more sedentary lifestyle (p<0.05). Individuals with previous history of heavy drinking had more daytime sleepiness (p=0.03).

Conclusion:

Wake-up stroke occurs in approximately 25% of stroke cases. In this study, patients with WUS had more diabetes and sedentary lifestyle. Daytime sleepiness is frequent and is associated with sedentary lifestyle and heavy drinking.

Keywords:
ischemic stroke; sedentary lifestyle; sleep; diabetes; heavy drinking

Clinical and demographic characteristics	All patients (N=70)	Non wake-up (n=53)	Wake-up (n=17)	p-value
Male/female, n %	40/30 57.1/42.9	30/23 56.5/43.4	10/75 8.8/41.2	^a a Fisher exact test; 0.87
Age, range Mean (SD)	32-83 58.5 (13.3)	32-82 58.6 (13.9)	40-83 58.4 (11.6)	^b b Student t test, p<0.05. 0.95
Hypertension (yes/no) %	47/23 67.1/32.9	33/20 62.7/ 37.3	14/3 82.4/17.6	^a a Fisher exact test; 0.15
Diabetes (yes/no) %	19/51 27.1/72.9	11/42 20.8/79.2	8/9 47.1/52.9	^a a Fisher exact test; 0.03
Hyperlipidemia (yes/no) %	16/49 22.8/77.2	12/41 22.6/77.4	5/12 29.4/70.6	^a a Fisher exact test; 0.47
Smoking (yes/no) %	22/48 31.4/68.6	16/37 30.2/69.8	6/11 35.3/64.7	^a a Fisher exact test; 0.69
Heavy drinking (yes/no) %	17/53 26.1/73.9	10/43 18.86/81.14	5/12 29.4/70.6	^a a Fisher exact test; 0.47
Heart disease (yes/no) %	6/61 8.5/91.5	6/47 11.3/88.7	1/16 5.9/94.1	^a a Fisher exact test; 0.68
Sedentary lifestyle (yes/no) %	47/23 67.1/32.9	32/21 60.4/39.6	14/2 82.4/17.6	^a a Fisher exact test; 0.04
Neck circumference, range Mean (SD)	30.0-54.0 39.8 (5.1)	32-52 39.7 (4.6)	30-54 39.9 (6.6)	^b b Student t test, p<0.05. 0.92
BMI, range Mean (SD)	21.4-38.6 27.0 (3.8)	21.4-38.6 27.1 (3.7)		^b b Student t test, p<0.05. 0.74
Waist (cm), range Mean (SD)	65-134 95.5 (12.4)	65-134 95.3 (12.3)	76-128 96.12 (9.9)	0.83
Hip (cm), range Mean (SD)	62-124 97.8 (11.0)	67-124 97.9 (9.9)	62-122 97.5 (14.3)	0.90
Waist-hip ratio, range Mean (SD)	0.75-1.12 0.96 (0.07)	0.80-1.12 0.97 (0.07)	0.75-1.04 0.95 (0.07)	^b b Student t test, p<0.05. 0.51
Behavioral questionnaires
NIH Stroke Scale, range Mean (SD)		0-14 4.8 (4.1)	0-18 6.2 (6.1)	0.58
Modified Rankin Scale, range Mean (SD)		0-5 2.0	1-5 2.5	0.18
OCSP, range Mean (SD)		1-4 2	1-4 3	0.10
Epworth Sleepiness Scale, range Mean (SD)		0-16 6.3 (3.7)	0-12 7.0 (4.1)	0.46

	Without daytime sleepiness n=56	With daytime sleepiness n=14	p-value
Gender (M/F) %	31/25 55.4/44.6	10/4 71.42/28.58	^a a Fisher exact test; 0.33
Age, range Mean (SD)	32-83 60.5 (12.9)	32-78 50.3 (13.2)	^b b Student t test, p<0.05. 0.02
Wake-up stroke (yes/no) %	9/4 516.1/83.9	6/8 42.9/57.1	^a a Fisher exact test; 0.11
Hypertension (yes/no) %	39/15 69.6/30.4	7/7 50/50	^a a Fisher exact test; 0.17
Diabetes (yes/no) %	14/40 25/75	2/10 14.3/85.7	^a a Fisher exact test; 0.71
Hyperlipidemia (yes/no) %	14/42 25/75	5/9 35.7/64.3	^a a Fisher exact test; 0.71
Smoking (yes/no) %	17/39 30.4/69.6	6/8 42.9/57.1	^a a Fisher exact test; 0.49
Heavy drinking (yes/no) %	11/45 19.6/80.4	6/8 42.9/57.1	^a a Fisher exact test; 0.03
Heart disease (yes/no) %	8/48 14.3/85.7	2/12 14.3/85.7	^a a Fisher exact test; 0.36
Sedentary lifestyle (yes/no) %	33/23 58.9/41.1	12/2 85.7/14.3	^a a Fisher exact test; 0.03
Waist (cm), range Mean (SD)	65-134 96.7 (12.3)	77-114 93.4 (12.9)	^b b Student t test, p<0.05. 0.42
Hip (cm), range Mean (SD)	62-124 98.54	85-115 96.27	^b b Student t test, p<0.05. 0.54
Neck circumference (cm), range Mean (SD)	30-54 39.6 (5.4)	33.5-50 41.5 (4.1)	^b b Student t test, p<0.05. 0.25
BMI, range Mean (SD)	21.4-38.6 27.1 (3.6)	23.0-37.6 27.1 (4.9)	^b b Student t test, p<0.05. 0.98
Waist-hip ratio, range Mean (SD)	0.75-1.09 0.97 (0.7)	0.84-1.12 0.97 (0.8)	^a a Fisher exact test; 0.96

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