Code Stroke with Non-Functional CT Scanner
Immediate Action: Transfer to Nearest CT-Capable Facility
When the CT scanner is broken during a code stroke, immediately activate emergency medical services and transfer the patient to the nearest stroke-capable center with functioning CT imaging—do not delay for any on-site interventions, as brain imaging is absolutely mandatory before any reperfusion therapy can be administered. 1, 2
Why CT Cannot Be Bypassed
- Non-contrast CT is the single mandatory imaging study before thrombolysis or thrombectomy—it is required to exclude intracranial hemorrhage, which is an absolute contraindication to alteplase and would fundamentally change management. 1, 2
- No reperfusion therapy (IV alteplase or mechanical thrombectomy) can be initiated without first ruling out hemorrhage on imaging. 1, 2
- Attempting to treat a hemorrhagic stroke with thrombolytics would be catastrophic; the risk of death from unrecognized hemorrhage far outweighs any delay from transfer. 1, 2
Pre-Transfer Stabilization and Preparation
While arranging immediate transfer, complete the following without delaying transport:
Time-Critical Documentation
- Record the exact time of symptom onset (or last known well)—this single data point determines all treatment eligibility and must be communicated to the receiving facility. 2, 3
- Document current time to calculate the remaining treatment window (≤4.5 hours for IV thrombolysis, ≤6–24 hours for thrombectomy depending on imaging). 2
Rapid Clinical Assessment
- Perform a focused neurological examination using the NIH Stroke Scale (NIHSS) to quantify deficit severity—this helps the receiving team prepare for potential large-vessel occlusion requiring thrombectomy. 2, 3
- Assess airway, breathing, and circulation; intubate if Glasgow Coma Scale ≤8 or if airway protection is compromised. 3
Essential Laboratory Work
- Obtain a bedside capillary glucose immediately—hypoglycemia (<50–60 mg/dL) mimics stroke and is an absolute contraindication to thrombolysis; treat with IV dextrose if low. 2, 3
- Draw blood samples for CBC, electrolytes, creatinine, PT/INR, aPTT, and troponin to send with the patient, but do not wait for results before transfer. 2, 3
Blood Pressure Management
- For patients potentially eligible for thrombolysis (within 4.5 hours), lower systolic/diastolic BP to <185/110 mmHg using IV labetalol (10–20 mg over 1–2 minutes) or nicardipine infusion (starting at 5 mg/hr, titrated by 2.5 mg/hr every 5–15 minutes, maximum 15 mg/hr). 1, 2, 3
- Maintain BP <180/105 mmHg if alteplase has already been given elsewhere. 1, 2
- For patients not eligible for thrombolysis, treat hypertension only if systolic >220 mmHg or diastolic >120 mmHg, and lower by only 15–25% over 24 hours to avoid worsening cerebral ischemia. 1, 3
Supportive Care During Transfer
- Provide supplemental oxygen only if oxygen saturation is <94%; avoid routine high-flow oxygen. 2, 3
- Establish IV access with normal saline (avoid dextrose-containing fluids unless hypoglycemic). 3
- Initiate continuous cardiac monitoring to detect atrial fibrillation or other arrhythmias. 3
- Treat active seizures with short-acting benzodiazepines (lorazepam 2–4 mg IV); do not give prophylactic anticonvulsants, as they may impair neural recovery. 1, 2
Pre-Notification to Receiving Facility
Provide a structured "Code Stroke" alert that includes:
- Time of symptom onset (or last known well) 2, 3
- Current NIHSS score and specific deficits (aphasia, visual field cuts, neglect suggest large-vessel occlusion) 3
- Vital signs, including current blood pressure and oxygen saturation 3
- Capillary glucose result 3
- Anticoagulation status (warfarin, direct oral anticoagulants, antiplatelet agents) 3
- Estimated time of arrival 3
- Specify that the patient has not yet had any imaging due to equipment failure 3
Why MRI Is Not a Substitute in This Emergency
- Although MRI with diffusion-weighted imaging (DWI) is more sensitive than CT for detecting acute ischemia (83% vs. 26% sensitivity), MRI is not widely available in the emergency setting and takes significantly longer to complete. 4, 5
- Non-contrast CT remains the preferred first-line modality because it is faster, universally available, and adequately excludes hemorrhage—the single most critical determination before thrombolysis. 1, 2, 6, 4
- MRI may be considered at the receiving facility if CT findings are equivocal or for wake-up strokes requiring DWI-FLAIR mismatch assessment, but it must not delay initial treatment decisions. 1, 2, 6
Expected Outcomes and Time Targets at Receiving Facility
- Door-to-needle time for IV alteplase should be ≤30 minutes (median) and ≤60 minutes (90th percentile). 2, 3
- Each 15-minute reduction in door-to-needle time decreases in-hospital mortality by 5%. 3
- Mechanical thrombectomy is highly effective within 6 hours for most large-vessel occlusions and remains beneficial up to 24 hours in selected patients meeting advanced imaging criteria. 2, 3
Common Pitfalls to Avoid
- Never attempt to "wait and see" if symptoms improve—large-vessel occlusions can present with fluctuating deficits, and every minute of delay increases irreversible brain injury. 3
- Do not delay transfer to obtain "complete" laboratory results—only bedside glucose is required before transport; all other labs can be drawn en route or at the receiving facility. 2, 3
- Avoid over-treating blood pressure below the specified thresholds (<185/110 mmHg for thrombolysis candidates), as cerebral perfusion in acute stroke is pressure-dependent and excessive reduction may worsen ischemia. 1, 2, 3
- Do not assume patients beyond 4.5 hours are ineligible for therapy—endovascular treatment may be offered up to 24 hours with appropriate imaging selection at the receiving center. 2, 3