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Management of a wake-up stroke
  1. Xuya Huang1,
  2. Vafa Alakbarzade1,2,
  3. Nader Khandanpour1,
  4. Anthony C Pereira1
  1. 1 Department of Neurology, St. George's University Hospitals NHS Foundation Trust, London, UK
  2. 2 Royal Cornwall Hospitals NHS Trust, Truro, UK
  1. Correspondence to Dr Xuya Huang, Neurology, St George's Hospital, London SW17 0QT, UK; xuya.huang{at}


Current national guidelines advocate intravenous thrombolysis to treat patients with acute ischaemic stroke presenting within 4.5 hours from symptom onset, and thrombectomy for patients with anterior circulation ischaemic stroke from large vessel occlusion presenting within 6 hours from onset. However, a substantial group of patients presents with acute ischaemic stroke beyond these time windows or has an unknown time of onset. Recent studies are set to revolutionise treatment for these patients. Using MRI diffusion/FLAIR (fluid-attenuated inversion recovery) mismatch, it is possible to identify patients within 4.5 hours from onset and safely deliver thrombolysis. Using CT perfusion imaging, it is possible to identify subjects with a middle cerebral artery syndrome who have an extensive area of ischaemic brain but as yet have only a small area of infarction who may benefit from urgent thrombectomy in up to 24 hours. Here, we highlight the recent advances in late window stroke treatment and their potential contribution to clinical practice.

  • wake up stroke
  • stroke with unknown time of onset
  • thrombolysis
  • thrombectomy
  • CT perfusion
  • DWI-FLAIR mismatch

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  • Contributors XH wrote the first draft and did subsequent revision. VA and NK reviewed the article, provided comments and revisions. ACP oversaw the writing process, the organisation and the direction of the paper and provided revision of the paper.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Commissioned. Externally peer reviewed by Tom Hughes, Cardiff, UK.

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  • Editors’ commentary
    Phil E M Smith Geraint N Fuller

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