Treatment of Ischemic Stroke with Unknown Time of Onset or Wake-Up Presentation
When stroke symptoms are first noticed on waking — or the exact onset cannot be determined — the usual time-based treatment window is unavailable. Advanced neuroimaging is used to identify whether brain tissue is still salvageable, opening the door to extended-window intervention.
Clinical Scenario
Acute ischemic stroke where the time of onset is unknown, the patient woke up with symptoms, or 4.5 to 9 hours have elapsed since last known well — and automated perfusion imaging or DWI-FLAIR mismatch confirms the presence of a salvageable ischemic penumbra.
Approach (Partial Overview)
When advanced imaging demonstrates salvageable tissue, extended-window intravenous thrombolysis is the intervention considered in this setting. Selection is guided by specific imaging criteria, and administration is directed by clinicians with expertise in thrombolytic stroke care.
Full regimen details, agent selection, and dosing are in the structured protocol.
References
DOI: 10.1161/STR.0000000000000513
- In patients with AIS who have salvageable ischemic penumbra detected on automated perfusion imaging and who (a) awake with stroke symptoms within 9 hours from the midpoint of sleep or (b) are 4.5–9 hours from last known well, IV thrombolysis may be reasonable to improve functional outcomes.
- In patients with AIS who (a) have unknown time of onset and are within 4.5 hours from symptom recognition and (b) have an MRI-DWI lesion smaller than one-third of the MCA territory and no marked signal change on FLAIR, IVT administered within 4.5 hours of stroke symptom recognition can be beneficial to improve functional outcomes.
- In patients with AIS due to LVO with salvageable ischemic penumbra, presenting within 4.5 to 24 hours from symptom onset or last known well, and who cannot receive EVT, treatment with IVT directed by individuals with expertise in thrombolytic stroke care may be beneficial to improve functional outcomes.
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