To report successful implementation of a protocol similar to the WAKE-UP trial in a community hospital setting that uses DWI/FLAIR mismatch to possibly treat patients that awaken with stroke symptoms.

Approximately 14 to 25% of ischemic strokes that occur can be considered wake-up strokes. The WAKE-UP trial demonstrated that in patients with a LKN greater than 4.5 hours, IV TPA guided by DWI/FLAIR mismatch resulted in a significantly better functional outcome than placebo at 90 days. In 2019, the American Heart Association updated their stroke guidelines and made a new 2A recommendation which recognized the benefit of using TPA guided by DWI/FLAIR mismatch in patients that awaken with stroke symptoms.

We formulated a protocol which would be activated when a patient presented to the ER with stroke-like symptoms and LKN greater than 4.5 hours. The protocol was proposed to each department to whom would be involved, including EMS, ER, CT, MRI, neurology, and neuroradiology. Once approved by each department, it was presented to hospital leadership for final approval. After it was approved for implementation, a variety of steps including mock alerts were taken to allow for maximum efficiency.

We have been able to treat patients meeting criteria for this modified WAKE-UP protocol in a community hospital setting. The regimented approach with involvement of key departments and hospital administration seemed to be key to successful implementation. Patients treated through the protocol have shown improvement in their functional outcome.