Wake-up Stroke: New Opportunities for Acute Stroke Treatment



This review summarizes the current science underpinning the treatment of patients with ischemic stroke who awaken with stroke symptoms. This large subset of stroke patients has historically been precluded from treatment with disability-limiting reperfusion therapies such as intravenous thrombolysis. Recent advances in neuroimaging have shifted the paradigm of treatment based upon rigid time-based criteria to treatment guided by evidence of salvageable ischemic penumbra on advanced imaging.

Recent Findings

Several recent randomized controlled trials provide evidence that imaging-guided treatment of wake-up and uncertain onset stroke patients is feasible and effective. Thrombectomy trials have demonstrated dramatic clinical benefit for this treatment modality as many as 24 h from the time patients were last known to be well. Furthermore, appropriately selected wake-up stroke patients beyond 4.5 h from last known well may also benefit from intravenous thrombolysis.


The evaluation and optimal treatment of patients with ischemic stroke is rapidly evolving, creating a moving target for stroke systems of care. Incorporating this new evidence into practice requires re-examination of how patients with stroke symptoms are evaluated and will challenge regional systems to design mechanisms to ensure rapid access to advanced imaging and treatment options.

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Fig. 1


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

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Oostema, J.A., Kahn, M.A. Wake-up Stroke: New Opportunities for Acute Stroke Treatment. Curr Emerg Hosp Med Rep (2020).

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  • Ischemic stroke
  • Wake-up stroke
  • Thrombolysis
  • Mechanical thrombectomy
  • MRI
  • CT perfusion