Diagnosing a wake-up stroke by Fernanda Bellolio

1. M. Fernanda Bellolio, MD, MS
Department of Emergency Medicine and Health Sciences Research
Mayo Clinic, United States
Wake-up Stroke

2. • 20% stroke patients awaken with deficits
• 10% have unclear time of symptoms onset
Most therapies not
approved for wake up
strokes

3. Half of wake up strokes within
treatable window

4. Imaging to Guide
• Non contrast CT: ICH or early ischemic signs
• Perfusion–Diffusion MRI or CT: Tissue at risk
• DWI–FLAIR Mismatch: Lesion age
• DWI: 3 mins
• FLAIR: 3-6 hrs

5. Images courtesy of Dr. Alejandro Rabinstein
• Infarcted tissue
DWI or volume
• At-risk tissue
(penumbra)
PWI or flow
• Mismatch

6. Show me the evidence…
• tPA in wake-up stroke
• Endovascular treatment in wake-up stroke
• Clinical approach

7. Ongoing Trials of Stroke of Unknown Onset
Thomalla G and Gerloff C. Stroke. 2015;46:2707-2713.

8. tPA or not tPA?
• Not FDA approved for wake up strokes
• MR WITNESS, WAKE-UP and SAIL-ON single arm, no controls
• Low rates of sICH and “likely” efficacy

9. Endovascular therapy

10. Approach to the patient w/ wake up stroke
• Treat as an emergency
• History, NIHSS, labs
• CT followed by CTA and multiparametric CT or MRI
• Use protocols (pagers, stroke codes, pharmacist, etc.)

11. • No routine therapy can be offered based on available
evidence
• Multiple ongoing trials will guide
• Beware of “hyper-selection” of patients in RCT
Approach to the patient w/ wake up stroke

12. Summary
• Treat as an emergency
• Imaging
• Evidence is growing

13. The future is bright for ischemic stroke treatment
but work remains to be done