Circadian variation in stroke onset: Differences between ischemic and hemorrhagic stroke and weekdays versus weekends

Fatima Pariona-Vargas; Katherine T Mun; Eng H Lo; Sidney Starkman; Nerses Sanossian; Mersedeh Bahr Hosseini; Samuel Stratton; Marc Eckstein; Robin A Conwit; David S Liebeskind; Latisha K Sharma; Neal M Rao; Kristina Shkirkova; Gilda Avila; May A Kim-Tenser; Jeffrey L Saver; FAST-MAG Investigators

doi:10.1016/j.jstrokecerebrovasdis.2023.107106

Circadian variation in stroke onset: Differences between ischemic and hemorrhagic stroke and weekdays versus weekends

J Stroke Cerebrovasc Dis. 2023 Jul;32(7):107106. doi: 10.1016/j.jstrokecerebrovasdis.2023.107106. Epub 2023 Apr 26.

Authors

Fatima Pariona-Vargas¹, Katherine T Mun², Eng H Lo³, Sidney Starkman², Nerses Sanossian⁴, Mersedeh Bahr Hosseini², Samuel Stratton², Marc Eckstein⁴, Robin A Conwit⁵, David S Liebeskind², Latisha K Sharma², Neal M Rao², Kristina Shkirkova⁴, Gilda Avila², May A Kim-Tenser⁴, Jeffrey L Saver²; FAST-MAG Investigators

Affiliations

¹ Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, United States. Electronic address: vargasfatima485@gmail.com.
² Department of Neurology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, United States.
³ Department of Neurology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, United States; Department of Radiology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, United States.
⁴ Department of Neurology, University of Southern California, Los Angeles, CA, United States.
⁵ National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States; Department of Neurology, Indiana University, United States.

PMID: 37116446
DOI: 10.1016/j.jstrokecerebrovasdis.2023.107106

Abstract

Objectives: To delineate diurnal variation onset distinguishing ischemic from hemorrhagic stroke, wake from sleep onset, and weekdays from weekends/holidays.

Materials and methods: We analyzed patients enrolled in the FAST-MAG trial of field-initiated neuroprotective agent in patients with hyperacute stroke within 2h of symptoms onset. Stroke onset times were analyzed in 1h, 4h, and 12h time blocks throughout the 24h day-night cycle. Patient demographic, clinical features, stroke severity, and prehospital workflow were evaluated for association with onset times.

Results: Among 1615 acute cerebrovascular disease patients, final diagnoses were acute cerebral ischemia in 76.5% and Intracerebral hemorrhage in 23.5%. Considering all acute cerebrovascular disease patients, frequency of wake onset times showed a bimodal pattern, with peaks on onsets at 09:00-13:59 and 17:00-18:59 and early morning (00:00-05:59) onset in only 3.8%. Circadian rhythmicity differed among stroke subtypes: in acute cerebral ischemia, a single broad plateau of elevated incidences was seen from 10:00-21:59; in Intracerebral hemorrhage, bimodal peaks occurred at 09:00 and 19:00. The ratio of Intracerebral hemorrhage to acute cerebral ischemia occurrence was highest in early morning, 02:00-06:59. Marked weekday vs weekends pattern variation was noted for acute cerebral ischemia, with a broad plateau between 09:00 and 21:59 on weekdays but a unimodal peak at 14:00-15:59 on weekends.

Conclusions: Wake onset of acute cerebrovascular disease showed a marked circadian variation, with distinctive patterns of a broad elevated plateau among acute cerebral ischemia patients; a bimodal peak among intracerebral hemorrhage patients; and a weekend change in acute cerebral ischemia pattern to a unimodal peak.

Keywords: Cerebrovascular; Circadian; FAST-MAG; Hemorrhage; Ischemia; Stroke onset.

MeSH terms

Brain Ischemia*
Cerebral Hemorrhage / epidemiology
Cerebrovascular Disorders* / etiology
Hemorrhagic Stroke* / complications
Hemorrhagic Stroke* / diagnosis
Humans
Stroke* / complications
Stroke* / diagnosis
Stroke* / therapy