Feasibility and Implementation of Wake-Up Stroke Protocol for Treatment of Acute Ischemic Stroke in a Rural Stroke Network of the Midwest

Objectives: The indication for thrombolytic therapy in “wake-up strokes” based on diffusion-positive and FLAIR-negative lesions on MRI has been introduced in the most recent AHA/ASA stroke guidelines. While this protocol is well established in urban centers, rural hospitals often face challenges due to limited resources and the availability of MRI scanners in the emergency department (ED). Here, we report on the successful implementation of the wake-up stroke protocol within our stroke network, highlighting the planning and execution process, its safety, and outcomes. Methods: After 2 months of planning, involving neurology, ED, radiology, and nursing leadership, the “wake-up stroke” protocol was implemented in our rural stroke network system in September 2022. Consecutive patients who received thrombolytics by the protocol were reviewed. For each patient, variables regarding demographics, relevant medical comorbidities and medications, clinical presentation, laboratory values, relevant timing of stroke metrics, complications of thrombolytic therapy, and mRS at 30 days were collected. The group was compared with a randomly severity-matched group of patients who received thrombolytic therapy by standard treatment (within 4.5 h from last known well). Results: Five consecutive acute ischemic stroke patients treated with thrombolytic therapy were identified. Mean age ± SD was 71.2 ± 7.2 years. Of the patients, 60% were males (n = 3). The most common reason for unknown time of symptom onset was nighttime sleep in 60% (n = 3) of the cohort. The median NIHSS (IQR) was 7 (6 to 13). Of the patients, 60% (n = 3) had a M2 occlusion on MR angiogram. The median interval between LKW and needle treatment was 11.68 (IQR: 5.32 to 13.23) hours. Compared with standard treatment, the wake-up stroke group had similar rate of complications (none in each group) and similar rate of mRS <2 at 1 month (60% vs 80%, P = 0.49). Conclusions: The implementation of the wake-up stroke protocol in our network was feasible, with the safety and outcomes of thrombolytics delivered by the protocol comparable to standard treatment. This study supports the utilization of the wake-up stroke protocol in real-world rural practice, highlighting its potential to improve access to high-quality stroke care in underserved areas.