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Introduction: One in every four patients with ischemic stroke awakens with the neurologic deficits, a condition named wake-up stroke (WUS). Magnetic resonance imaging (MRI) has been increasingly used in the acute phase of these cases to reliably estimate that the event occurred in less than 4.5 hours, identifying those that could benefit from reperfusion treatment. The aim of this study is to report the first case of WUS treated with alteplase in the Santa Casa of Sao Paulo Hospital and to disseminate this important treatment modality. Case Report: A 73-year-old woman admitted with a complaint of waking-up with a new focal neurologic symptom after going to sleep asymptomatic. On neurologic exam, she presented multiple cranial nerves disfunctions, dysarthria and left ataxia. MRI showed a left pontine lesion with increased signal in diffusion weighted imaging (DWI) sequence and the absence of a corresponding image in fluid-attenuated inversion recovery (FLAIR) sequence, characterizing the DWI-FLAIR mismatch. The patient underwent intravenous thrombolysis with complete resolution of neurologic deficits before hospital discharge. Conclusion: The reported case is common in daily practice; however, MRI-guided thrombolysis is not generally performed. Knowledge that neuroimaging techniques can be used to determine the therapeutic window for thrombolysis is of fundamental importance since it can benefit a substantial group of selected patients by considerably improving their functional outcomes.

Wake-Up Stroke: relato de caso, importância e perspectivas futuras / Wake-Up Stroke: case report, importance and future perspectives