Management of Wake-Up Stroke
For patients who wake up with stroke symptoms, IV alteplase administered within 4.5 hours of symptom recognition is beneficial if MRI shows DWI-FLAIR mismatch, and mechanical thrombectomy should be considered for eligible patients within 6-24 hours if they have salvageable brain tissue on advanced imaging. 1
Initial Assessment and Triage
Immediate Actions
- Activate emergency medical services (call 9-1-1) immediately upon recognition of stroke symptoms 1
- EMS should prioritize potential stroke cases and minimize on-scene times 1
- Use validated stroke screening tools like Cincinnati Prehospital Stroke Scale (CPSS) or Los Angeles Prehospital Stroke Screen (LAPSS) 1
- Establish "last known well" time - for wake-up strokes, this is when the patient was last seen normal before sleep 1
Emergency Department Evaluation
- Triage with the same priority as acute myocardial infarction or serious trauma 1
- Stabilize airway, breathing, and circulation (ABCs) 1
- Provide supplemental oxygen to maintain oxygen saturation ≥94% 1
- Perform immediate neurological assessment using a validated stroke severity scale (e.g., NIHSS) 1
- Check capillary blood glucose immediately (treat if <60 mg/dL or 3.3 mmol/L) 1
Urgent Diagnostic Workup
Essential Imaging
- All patients with suspected stroke should undergo immediate brain imaging (CT or MRI) 1
- For wake-up strokes, advanced imaging is crucial:
- Non-invasive angiography (CTA) should be performed in patients with suspected large vessel occlusion (LVO) 1
Laboratory Tests
- Complete blood count, serum electrolytes, creatinine, INR, partial thromboplastin time, and troponin 1
- These tests should not delay reperfusion therapy 1
Treatment Options for Wake-Up Stroke
Intravenous Thrombolysis
- IV alteplase (0.9 mg/kg, maximum 90 mg) is recommended for wake-up stroke patients if:
- Blood pressure should be lowered below 185/110 mmHg before initiating IV thrombolysis 1
Mechanical Thrombectomy
- Consider mechanical thrombectomy for patients with:
- Age ≥18 years
- Pre-stroke mRS score of 0-1
- Causative occlusion of the internal carotid artery or MCA (M1)
- NIHSS score of ≥6
- ASPECTS of ≥6
- Treatment can be initiated within 6-24 hours if there is sizable mismatch between ischemic core and clinical deficits or area of hypoperfusion 1
Important Considerations
Time Window Determination
- Wake-up strokes account for approximately 25% of all acute ischemic strokes 2, 3
- Recent evidence suggests the actual onset time of wake-up stroke is often close to the wake-up time 4
- Studies show wake-up strokes are similar to known-onset morning strokes in severity and outcomes 2
Contraindications and Cautions
- Standard contraindications for IV thrombolysis still apply 1
- Patients with wake-up stroke were historically excluded from thrombolytic therapy due to unknown onset time 2
- Advanced imaging now allows identification of patients with favorable risk-benefit profiles for reperfusion therapy 4
Post-Acute Management
- Implement measures to prevent subacute complications:
- Early mobilization when appropriate
- Prevention of aspiration, malnutrition, pneumonia
- DVT prophylaxis with subcutaneous anticoagulants, intermittent compression devices, or aspirin for immobilized patients 1
- Evaluate for stroke etiology to guide secondary prevention strategies 1
Common Pitfalls to Avoid
- Delaying emergency medical care due to uncertainty about onset time
- Automatically excluding wake-up stroke patients from reperfusion therapy without advanced imaging assessment
- Failing to recognize that wake-up strokes have similar characteristics to known-onset morning strokes
- Waiting for all laboratory results before initiating reperfusion therapy in eligible patients
By following these guidelines, healthcare providers can optimize outcomes for patients who wake up with stroke symptoms through appropriate assessment, imaging selection, and timely reperfusion therapy when indicated.