What focused history questions should I ask a patient found asleep with a possible acute stroke to determine timing, symptom onset, neurological deficits, risk factors, and treatment eligibility?

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Focused History Questions for Wake-Up Stroke Patients

When evaluating a patient found asleep with possible acute stroke, your primary goal is to establish when they were last known to be normal—this defines the therapeutic window and determines treatment eligibility, particularly for thrombolysis and thrombectomy. 1

Critical Timing Questions

Establish "Last Known Normal" Time

  • When did the patient last go to sleep? This becomes the presumed onset time if no other information is available 1
  • When was the patient last seen awake and symptom-free? This is the most critical piece of information 1, 2
  • Did anyone witness the patient going to bed normally? Obtain contact information for witnesses 1

Creative Time Anchors

The American Heart Association emphasizes using creative questioning to establish time anchors that may allow treatment of patients initially labeled "onset time unknown": 1

  • Cell phone use: "Did you use your phone before going to bed or after waking up?" Check call/text timestamps 1, 2
  • Television programming: "What show were you watching before bed? What was on TV when you woke up?" Use program times to narrow the window 1, 2
  • Bathroom/kitchen activity: "Did you get up during the night to use the bathroom or get water? Were you normal then?" 1
  • Alarm clock times: "What time did your alarm go off? Were you already having symptoms?" 2

Symptom Characterization

Preceding Symptoms

  • Did you have any similar symptoms yesterday or in recent days that resolved? If prior symptoms completely resolved, the therapeutic clock resets to when new symptoms began 1
  • How long did any previous symptoms last? Longer-lasting transient deficits increase likelihood of imaging abnormalities 1

Current Neurological Deficits

Document specific deficits to guide localization and severity assessment: 1, 3

  • Weakness: Face, arm, leg—which side and distribution?
  • Speech problems: Slurred speech only (dysarthria) vs. difficulty finding words (aphasia)
  • Vision changes: Loss of vision, double vision, visual field cuts
  • Sensory changes: Numbness, tingling—location and extent
  • Balance/coordination: Dizziness, vertigo, ataxia
  • Level of consciousness: Alert vs. drowsy vs. unresponsive

Stroke Risk Factors and Comorbidities

Vascular Risk Factors

Ask about conditions that inform stroke mechanism and secondary prevention: 1

  • Hypertension history? (suggests small vessel disease/lacunar stroke)
  • Diabetes history? (suggests small vessel disease)
  • Atrial fibrillation or other arrhythmias? (suggests cardioembolic mechanism)
  • Prior stroke or TIA? (suggests recurrent large-artery disease)
  • Myocardial infarction or angina? (suggests atherosclerotic disease)

Treatment Eligibility Factors

These directly impact thrombolysis eligibility: 1

  • Current medications—specifically anticoagulation with warfarin? 1
  • History of recent trauma related to current event? 1
  • History of seizures? (may indicate stroke mimic—Todd's paralysis) 1

Other Potential Stroke Mimics

  • History of migraines? (complicated migraine can mimic TIA/stroke) 1
  • Drug abuse history? (toxicity or CNS abscess risk) 1
  • Recent infection or fever? (CNS abscess consideration) 1
  • Known cancer history? (CNS tumor with acute deterioration) 1
  • Pregnancy status? (in women of childbearing age) 1

Practical Approach Algorithm

For wake-up stroke patients within potential treatment windows:

  1. Establish last known normal time (when went to sleep if no other information) 1
  2. Use creative time anchors to narrow the window (phone, TV, nocturnal activities) 1, 2
  3. Document current deficits using standardized scale (NIHSS) 1
  4. Identify treatment eligibility factors (anticoagulation, recent trauma, seizures) 1
  5. Assess for stroke mimics (hypoglycemia, seizure, migraine) 1
  6. Obtain witness information from family/bystanders—EMS should bring them 1

Critical Pitfall to Avoid

Do not assume wake-up stroke patients are automatically ineligible for treatment. Approximately 20-25% of all ischemic strokes occur during sleep, and advanced imaging (MRI DWI-FLAIR mismatch or CT perfusion) can identify patients eligible for thrombolysis even when onset time is unknown. 2, 4, 5 The WAKE-UP trial demonstrated this approach could increase overall thrombolysis treatment rates by 9%. 4

Time is brain—1.9 million neurons die each minute after stroke onset. 2 While creative history-taking is important, do not delay imaging and stroke team activation to obtain exhaustive history. 1

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Guideline

Timing of Ischemic Stroke Onset

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

3
Guideline

Middle Cerebral Artery Stroke and Lacunar vs Cortical Stroke Differences

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

4
Guideline

Treatment of Wake-Up Strokes and Strokes of Unknown Onset

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

5
Research

Stroke: What's Sleep Got to Do With It?

Journal of clinical neurophysiology : official publication of the American Electroencephalographic Society, 2022

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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