Abstract TP034: Toward a Unified Strategy for Stroke of Unknown Onset

Introduction: Advanced treatment options now exist that are available for some ischemic strokes who arrive with unknown onset time; commonly called wake-up stroke (W-S). When triaging these patients with W-S, concerns regarding thrombolytic therapy eligibility arise due to unknown onset time. We analyzed current hospital level practices and thrombolytic treatment considerations for W-S stroke in in Texas (TX) and Louisiana (LA) with high prevalence of acute ischemic stroke. Methods: Potential hospitals included stroke centers identified affiliated with a research consortium in Texas (TX), or as affiliated with a health system in Louisiana (LA). This data included hospitals characteristics, structural capacity and annual metrics, and current procedures for W-S patients at these institutions. Additionally, via the survey, the hospital’s stroke team was assessed on their knowledge regarding W-S. The survey was developed by a multidisciplinary collaborative of stroke specialists and hosted on a REDCap platform. Data analysis was completed using SAS v9.4. Results: Data were received from 54 (98.2%) of 55 hospitals contacted in LA (29) and TX (25). Survey responses were collected between 9/1/2024 and 3/31/2025. The 39 (72.2%) hospitals that reported using a standardized W-S protocol included all 29 health system hospitals in LA, and 10 hospitals in TX. 48 (96.0%) stated less than ¼ of patients received thrombolytics for W-S. Hospitals with a wake-up stroke (W-S) protocol were significantly associated with fewer stroke beds (P = .0092), fewer called stroke codes (P = .0040), physician-dependent transfer decisions (P = .0002), higher thrombolytic eligibility (P <.0001). Conversely, hospitals with more stroke admissions were less likely to have a W-S protocol (P = .0072), indicating that higher patient volume may influence protocol utilization. Conclusion: There is significant variability in which stroke centers follow a W-S protocol. While large Comprehensive Stroke Centers are more equipped with advanced imaging and specialized expertise necessary to evaluate patients with unknown time of onset, they demonstrated a lower frequency of endorsing a W-S protocol than smaller hospitals. Requiring CSCs to identify their W-S process of care may improve access and delivery of acute stroke therapy to patients who present with unknown onset times.