What is the management for a patient with suspected ischemic stroke who declines a computed tomography (CT) scan?

Management of Suspected Ischemic Stroke When Patient Declines CT Scan

If a patient with suspected ischemic stroke refuses CT imaging, you cannot administer thrombolytic therapy (rtPA), and management must focus on supportive care, risk factor modification, and secondary stroke prevention while continuing to advocate for imaging.

Critical Limitation Without Imaging

Brain imaging is absolutely required to guide acute stroke intervention, as it is essential to exclude hemorrhage before any antithrombotic therapy can be safely administered 1. Without CT or MRI, you cannot:

• Differentiate ischemic stroke from hemorrhagic stroke 1
• Rule out stroke mimics such as brain tumor, abscess, or other non-vascular pathology 1
• Safely administer rtPA or any anticoagulation 1
• Assess for early ischemic changes or hemorrhagic transformation risk 1

Immediate Supportive Management

Airway and Oxygenation

• Assess and secure airway, breathing, and circulation immediately 1, 2
• Monitor oxygen saturation continuously and provide supplemental oxygen if saturation falls below 94% 2
• Be particularly vigilant for respiratory compromise, as 63% of hemiparetic patients develop hypoxia within 48 hours 1

Vital Sign Monitoring

• Check vital signs at least every 30 minutes during initial evaluation 2, 3
• Treat hyperthermia (temperature >99.6°F) aggressively, as it is associated with poor stroke outcomes 2, 3
• Monitor cardiac rhythm continuously, as cardiac arrhythmias commonly accompany acute stroke 1, 3

Blood Pressure Management

• Do NOT routinely treat hypertension unless blood pressure exceeds 220/120 mmHg 2
• Avoid rapid or excessive blood pressure lowering, as this may exacerbate cerebral ischemia 2
• Without the ability to give thrombolytics, permissive hypertension is appropriate to maintain cerebral perfusion 2

Essential Laboratory and Diagnostic Studies

Proceed with all non-imaging diagnostic tests that would normally be obtained 1, 2:

Immediate Blood Tests

• Blood glucose measurement to rule out hypoglycemia as a stroke mimic 2, 3
• Complete blood count with platelet count 1, 2
• Prothrombin time/INR and activated partial thromboplastin time 1, 2
• Basic metabolic panel (electrolytes, renal function) 1, 2
• Lipid profile (fasting or non-fasting) 1
• HbA1c for diabetes screening 1
• Cardiac troponin 1, 2

Cardiac Evaluation

• Obtain 12-lead ECG immediately to screen for atrial fibrillation, atrial flutter, and other cardiac conditions 1, 3
• Consider echocardiography (with or without contrast) to evaluate for cardiac sources of embolism, though this may be deferred to inpatient setting 1

Neurological Assessment and Documentation

• Perform standardized neurological assessment using the National Institutes of Health Stroke Scale (NIHSS) to document baseline severity 2, 3
• Document the exact time the patient was last known to be well, as this remains critical for future decision-making if the patient changes their mind about imaging 2, 3
• Assess for stroke mimics through focused history and examination 2, 3

Secondary Prevention Measures

Without imaging to confirm ischemic stroke and exclude hemorrhage, you cannot safely initiate:

• Antiplatelet therapy (aspirin, clopidogrel)
• Anticoagulation
• Any acute reperfusion therapy 1

However, you can begin:

• Risk factor counseling and education 1
• Smoking cessation counseling if applicable 1
• Planning for outpatient vascular imaging once patient agrees to diagnostic workup 1

General Supportive Care

• Position head of bed at 25-30 degrees 2, 3
• Keep patient NPO (nothing by mouth) until swallowing can be assessed 2
• Avoid prophylactic anticonvulsant medications, which are not recommended and may impair neural recovery 2

Critical Pitfall to Avoid

The most important pitfall is accepting the patient's refusal without adequate informed consent discussion. You must clearly explain:

• That without imaging, you cannot determine if this is a hemorrhagic or ischemic stroke 1
• That potentially life-saving treatments (rtPA, mechanical thrombectomy) cannot be administered without imaging 1
• That even basic stroke medications cannot be safely given without excluding hemorrhage 1
• That the time window for effective treatment is rapidly closing (ideally within 3-4.5 hours for rtPA) 1

Ongoing Advocacy for Imaging

Continue to advocate for imaging throughout the patient's care, as clinical circumstances may change and the patient may reconsider 1, 3. If the patient later agrees to imaging, brain CT or MRI should be obtained immediately, though the window for acute reperfusion therapy may have closed 1.