What is the optimal management for a patient with a wake-up stroke at 9am, last seen well at 12am, and notified at 1pm?

Management of Wake-Up Stroke Patient

For a wake-up stroke patient last seen well at 12am, discovered at 9am, and with medical notification at 1pm, emergency evaluation for potential advanced imaging and treatment should have been initiated immediately upon discovery at 9am, as this patient falls within the extended time window for potential reperfusion therapies. 1

Initial Assessment and Management

Immediate Actions Upon Discovery (9am)

• Activate emergency medical services (EMS) immediately upon recognition of stroke symptoms 1
• EMS should use validated stroke assessment tools like FAST (Face, Arm, Speech, Time) 1
• Document the last known well time (12am) and time of symptom discovery (9am) 1
• Provide prehospital notification to the receiving hospital to mobilize stroke resources 1

Transport Considerations

• Rapid transport to the nearest appropriate stroke-capable facility 1
• For wake-up strokes, transport to a center with advanced imaging capabilities is crucial 1
• Minimize on-scene time with a target median of 20 minutes or less 1

Hospital Management

Imaging and Evaluation

• Immediate brain imaging upon arrival to exclude hemorrhage 1
• For wake-up strokes discovered within 24 hours of last known well:
  • Advanced imaging (CT perfusion or MRI with diffusion/perfusion) should be performed to assess salvageable brain tissue 1
  • These imaging modalities can identify patients who may benefit from reperfusion therapy despite unknown exact onset time 1

Treatment Options

Reperfusion Therapy Considerations

• Traditional time window for IV thrombolysis is 3-4.5 hours from symptom onset 1
• For wake-up strokes:
  • Patients may be eligible for IV thrombolysis based on advanced imaging showing salvageable tissue 1
  • If large vessel occlusion is identified, endovascular thrombectomy may be considered up to 24 hours from last known well time based on tissue viability 1

Critical Time Points

• The 4-hour delay between discovery (9am) and notification (1pm) represents a critical loss of therapeutic opportunity 1
• Every minute counts in stroke treatment - "Time is Brain" 1

What Should Have Been Done

1. Immediate EMS Activation: Upon discovery at 9am, emergency services should have been called immediately 1
2. Rapid Transport: Patient should have been transported to a comprehensive stroke center with advanced imaging capabilities 1
3. Advanced Imaging: CT/MRI with perfusion studies should have been performed to determine eligibility for treatment despite unknown exact onset time 1
4. Treatment Decision: Based on imaging results:
   • If favorable imaging profile: IV thrombolysis and/or endovascular therapy could have been considered 1
   • If large vessel occlusion with salvageable tissue: endovascular thrombectomy could have been performed up to 24 hours from last known well 1

Common Pitfalls to Avoid

• Misconception: Assuming wake-up strokes are automatically ineligible for reperfusion therapy
  • Modern guidelines support treatment based on tissue status, not just time 1
• Delayed Notification: The 4-hour delay between discovery and medical notification significantly reduced treatment options 1
• Inadequate Triage: Wake-up strokes should be triaged as high priority (Emergency Severity Index level 2) 1
• Failure to Recognize: Family members and caregivers should be educated to recognize stroke symptoms and act immediately 1

The 4-hour delay between stroke discovery and medical notification represents a critical missed opportunity for potentially life-saving and disability-reducing interventions. Current guidelines support evaluation and potential treatment of wake-up strokes based on advanced imaging rather than strict time windows alone.