To describe the role of neuroimaging in guiding thrombolytic treatment in patients with wake-up stroke (WUS).

WUS accounts for 14% to 29.6% of all ischemic strokes. Management of WUS is complicated by its narrow therapeutic time window which can affect the safety and efficacy of administering intravenous (IV) tissue plasminogen activator (t-PA). Therefore, many studies have targeted neuroimaging to approximate WUS time of onset and potentially select patients for thrombolytic treatment.

The authors used PubMed to search for the term “Wake-Up Stroke” cross-referenced with “pathophysiology,” “pathology,” “computed topography,” “magnetic resonance imaging,” or “treatment.” English language Papers were reviewed. Also reviewed were pertinent papers from the reference list of the above-matched manuscripts.

Studies leveraged the ability of different neuroimaging modalities, such as computed topography-perfusion (CTP) and magnetic resonance imaging (MRI), to estimate time of onset in WUS and subsequently select WUS patients appropriate for thrombolytic therapy. MRI mismatch concepts (perfusion weighted imaging (PWI)–diffusion-weighted imaging (DWI) mismatch and DWI–fluid attenuated inversion recovery (FLAIR) mismatch) were able to estimate time of onset and using these techniques helped select patient for thrombolytic therapy. Based on this, a few clinical trials were conducted using CTP and/or MRI to guide thrombolytic therapy in WUS and the results showed both favorable outcomes (modified Rankin scale of 0-2) and comparable safety of alteplase use in WUS to that of standard care.