. however , stroke trials did not include patients with either non - witnessed strokes or wake - up strokes .
patients presenting stroke with symptoms that began at an unknown time represent around 30% of patients with acute stroke , while around 20% of stroke admissions are for wake - up stroke .
although acute reperfusion treatment has not yet been proven effective and safe for wake - up stroke , a large proportion of these patients share similarities with patients admitted within 3 - 6 h of stroke onset when judged by baseline clinical and brain imaging data . some patients with wake - up stroke may thus benefit from recanalization treatments .
however , it is not known how patients with wake - up stroke should best be managed . in this study , we aimed to assess the opinions of stroke experts about the management of patients with wake - up stroke using an international multicenter electronic survey .
this study was an international electronic survey on the treatment of wake - up stroke .
the experts selected included equal portions of stroke neurologists and interventional neuroradiologists who had at least one publication on the acute treatment of ischemic stroke between 2012 and 2015 .
first authors , corresponding authors , authors who had publications in journals with higher impact factors , or authors who had published the most recently were given priority for invitation to participate in the survey .
descriptive statistical analyses were conducted using statistics software ( spss version 20.0 , ibm , chicago , ill .
variables were reported as means , confidence intervals at the 95% confidence level , standard deviations , and standard errors .
this study was an international electronic survey on the treatment of wake - up stroke .
the experts selected included equal portions of stroke neurologists and interventional neuroradiologists who had at least one publication on the acute treatment of ischemic stroke between 2012 and 2015 .
first authors , corresponding authors , authors who had publications in journals with higher impact factors , or authors who had published the most recently were given priority for invitation to participate in the survey .
descriptive statistical analyses were conducted using statistics software ( spss version 20.0 , ibm , chicago , ill .
variables were reported as means , confidence intervals at the 95% confidence level , standard deviations , and standard errors .
fifty - nine invitees started the survey , 4 dropped out of the survey before completing it , and 55 completed the full questionnaire . to complete the 8 questions , participants spent a mean of 3 min .
the 8 questions of the survey and the rates of various responses are listed in table 2 .
around 20% of acute stroke admissions are for patients who wake up with a stroke , and according to international guidelines for the management of acute stroke , patients presenting with wake - up stroke are not eligible to receive revascularization treatments .
there are currently 8 prospective trials enrolling patients to receive recanalization treatments who present with a stroke at an unknown time after the onset of their symptoms or after a stroke where symptoms began more than 4.5 h earlier . in a recent review ,
thomalla and gerloff   described these ongoing trials in detail and discussed emerging perspectives about this subject . in the present study
, we designed a simple questionnaire about the management of wake - up stroke and invited stroke experts , including stroke neurologists and interventional neurologists in equal proportions , to respond .
the positive results obtained in that study for stentrievers and intravenous rtpa for treating large blood vessel occlusions where thus already known to our participants . in the first question , we found that around 70% of participants would recommend a revascularization treatment for patients presenting with wake - up stroke outside a clinical trial .
this finding invites discussion of whether we should recommend nonstandard treatments in our daily practice . a high level of evidence is not always available to guide decisions during daily clinical practice , but doctors must still make these decisions .
although 70% of our survey participants would treat a patient presenting with wake - up stroke outside a trial , this survey did not assess the reasons for this response .
in the second , third , and fourth questions , stroke experts were asked about the best treatment strategies and brain imaging methods for use with wake - up stroke patients .
, we described a common clinical case ; a patient presenting with wake - up stroke due to a distal blood vessel occlusion .
this example represents a patient who would benefit from intravenous treatment with rtpa from the time of the onset of their symptoms up to 4.5 h afterwards . as for the first question of this survey , around 65% of participants would treat the patient . in questions 7 and 8
, we described a case of a patient presenting with wake - up stroke due to a large blood vessel occlusion ( left m1 ) . in this case , around 83% recommended a revascularization treatment . in this study
, the fact that stroke experts agreed in their responses to questions 1 , 5 and 7 indicates that most of them are inclined to treat patients with wake - up strokes .
however , the considerable disagreement among experts in their responses to questions 2 , 3 , 4 , 6 , and 8 showed that stroke experts have not reached consensus on the best brain imaging method and on the best treatment strategy for patients with wake - up stroke . the limitations of the study are the small size of the sample of experts and the limited number of questions asked .
moreover , most of the experts ( 72.5% ) who were invited to participate in the survey did not respond .
the low rate of response obtained on this survey might be due to e - mail spam blockers , because the first 100 invitations were sent collectively and not individually .
in this study , most of stroke experts recommended a recanalization treatment for wake - up stroke .
however , there was considerable disagreement among experts regarding the best brain imaging method and the best recanalization treatment .
 backgroundpatients who wake up having experienced a stroke while asleep represent around 20% of acute stroke admissions . according to international guidelines for the management of acute stroke , patients presenting with wake - up stroke are not currently eligible to receive revascularization treatments . in this study 
 , we aimed to assess the opinions of stroke experts about the management of patients with wake - up stroke by using an international multicenter electronic survey.methodthis study consisted of 8 questions on wake - up stroke treatment.resultstwo hundred invitations to participate in the survey were sent by e - mail . 
 fifty - nine participants started the survey , 4 dropped out before completing it , and 55 completed the full questionnaire . 
 we had 55 participants from 22 countries.conclusionsin this study , most stroke experts recommended a recanalization treatment for wake - up stroke . however , there was considerable disagreement among experts regarding the best brain imaging method and the best recanalization treatment . 
 the results of ongoing randomized trials on wake - up stroke are urgently needed . 
Introduction
Method
Study Design and Selection of Participants
Results
Discussion
Conclusion