Should wake-up stroke patients be treated as late-window patients?

Wim H. van Zwam, MD, Maastricht University Medical Center, The Netherlands, addresses the issue of timing for reperfusion therapy in wake-up stroke patients. In the MR CLEAN-LATE, DAWN, and DEFUSE 3 trials of thrombectomy for stroke beyond 6 hours, there were a substantial proportion of wake-up patients. The issue with treating these patients is that they are considered to be in the late window. Patients presenting in the early window are normally treated without advanced imaging to prevent unnecessary treatment delay, given the substantial treatment effect and small potential harm of endovascular therapy. In the late time window, advanced imaging-based selection with CT perfusion or collateral scores can be valuable to identify patients most likely to benefit from EVT. The trade-off between obtaining more information and delaying treatment with perfusion imaging remains controversial. Since wake-up patients are considered late-window patients, advanced imaging is generally used as part of their treatment; although, Prof. van Zwam argues that the majority of wake-up patients are actually early-window patients, and that advanced imaging could be wasting time for their treatment. Therefore, more evidence must be obtained in order to change the guidelines for treating wake-up stroke patients. This interview took place at the World Stroke Congress 2022 in Singapore.

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