What is the recommended management for a patient presenting with an acute neurological deficit suggestive of stroke at a facility without computed tomography capability?

Management of Stroke at a Non-CT Center

Immediately transfer the patient to the nearest facility with CT capability while initiating supportive care and stroke protocols during transport. 1, 2

Immediate Actions Before Transfer

Initial Assessment and Stabilization

• Activate emergency medical services (EMS) immediately and request transport to the nearest stroke-capable center with CT imaging 1
• Document the exact time of symptom onset (or time last known well) as this determines treatment eligibility—this is the single most critical piece of information 1
• Perform rapid neurological assessment using a validated stroke scale (NIHSS or Canadian Neurological Scale) to quantify deficit severity and communicate findings to the receiving facility 1
• Obtain fingerstick glucose immediately to exclude hypoglycemia as a stroke mimic, as glucose <50 mg/dL is a contraindication to thrombolysis 1

Critical Pre-Hospital Blood Work

• Draw blood samples before transfer including: complete blood count, electrolytes, creatinine, coagulation studies (INR, aPTT), and random glucose 1
• Do not delay transfer waiting for laboratory results—send samples with the patient or have results called to the receiving facility 1
• Specifically document anticoagulant use (warfarin, direct oral anticoagulants) and recent antiplatelet therapy, as these affect treatment eligibility 1, 2

Blood Pressure Management During Transfer

For Potential Thrombolysis Candidates (Within 4.5 Hours)

• Target blood pressure <185/110 mm Hg if the patient may be eligible for IV thrombolysis based on time from onset 1
• Use labetalol 10 mg IV or nicardipine IV 5 mg/h (titrate by 2.5 mg/h every 5-15 minutes, maximum 15 mg/h) if blood pressure exceeds these thresholds 1
• Avoid aggressive blood pressure reduction below these targets, as cerebral perfusion may be pressure-dependent in acute stroke 1

For Non-Thrombolysis Candidates

• Only treat blood pressure if systolic >220 mm Hg or diastolic >120 mm Hg, as permissive hypertension maintains cerebral perfusion 1
• Lower blood pressure by only 15-25% within the first day if treatment is required 1

Transfer Protocols and Communication

Pre-Notification Requirements

• EMS should bypass non-CT facilities and transport directly to the closest stroke center with imaging capability 1, 2
• Provide detailed pre-notification to the receiving facility including: time of symptom onset, current neurological deficits, vital signs, glucose level, anticoagulation status, and estimated arrival time 1
• For patients within 6 hours of onset, specify that CT angiography will be needed to evaluate for large vessel occlusion eligible for endovascular therapy 1, 2

Primary Stroke Centers Without CT Angiography

• If your facility has basic CT but no CT angiography capability, complete non-contrast CT immediately, administer IV alteplase if appropriate (within 4.5 hours and no contraindications), then rapidly transfer to a comprehensive stroke center for vascular imaging and potential endovascular therapy 1, 2
• Do not delay transfer waiting to see if alteplase works—mechanical thrombectomy remains highly effective even after thrombolysis, and time is critical 2

Supportive Care During Transfer

Airway and Oxygenation

• Maintain oxygen saturation >94% with supplemental oxygen as needed 1
• Consider airway protection if Glasgow Coma Scale <8 or inability to protect airway due to bulbar dysfunction 1

Seizure Management

• Treat active seizures with short-acting benzodiazepines (lorazepam IV) if they occur during transport 1
• Do not administer prophylactic anticonvulsants—there is no evidence of benefit and potential harm to neural recovery 1

Glucose Management

• Treat hypoglycemia immediately if glucose <50 mg/dL, as this is a stroke mimic and thrombolysis contraindication 1
• Avoid hyperglycemia but do not aggressively treat mild elevations during acute transport 1

Critical Time Targets

Treatment Windows

• IV thrombolysis (alteplase) is effective within 4.5 hours of symptom onset, with target door-to-needle time of 30 minutes (90th percentile 60 minutes) at the receiving facility 1
• Endovascular thrombectomy is effective within 6 hours for most patients with large vessel occlusion, and up to 24 hours for select patients meeting advanced imaging criteria 1, 2
• Every 15-minute reduction in door-to-needle time reduces in-hospital mortality by 5%, emphasizing the urgency of rapid transfer 1

Common Pitfalls to Avoid

• Never delay transfer to obtain imaging at a non-CT facility—transport time to a stroke center is more valuable than any intervention you can provide without imaging 1, 2
• Do not withhold transfer for "mild" or "improving" symptoms—large vessel occlusions can present with fluctuating deficits, and early improvement does not exclude need for intervention 1
• Avoid over-treating blood pressure in the pre-hospital phase unless specific thresholds are exceeded, as this can worsen cerebral ischemia 1
• Do not assume patients beyond 4.5 hours are not treatment candidates—endovascular therapy extends to 24 hours with appropriate imaging selection 1, 2