Before CT: stabilize and keep moving

For an adult with a new focal neurological deficit, activate the stroke pathway and arrange urgent imaging while treating immediate threats. The pre-CT assessment should answer what cannot wait, what affects treatment eligibility, and what can be completed alongside the scan.

I. Activate the pathway

Notify the stroke team and radiology immediately. Allocate airway and monitoring, bedside glucose, history, and transport tasks in parallel. Use telestroke and the regional transfer pathway when local reperfusion expertise is unavailable. Check temperature and look for trauma or a competing emergency while imaging is arranged. Canadian Stroke Best Practices.

II. Protect oxygen delivery

Airway and breathing: assess airway protection, ventilation and oxygenation. Bulbar dysfunction or reduced consciousness may require airway support; intubation depends on clinical failure or anticipated deterioration, not a GCS number alone. If hypoxic, titrate oxygen to SpO₂ >94%; routine oxygen is not a default treatment for a normally saturated pre-CT patient. AHA/ASA 2026.

Circulation: obtain IV access and cardiac monitoring. Investigate hypotension and correct hypovolemia with reassessment. Hypotension compromises cerebral perfusion. Do not delay CT for a second IV or prophylactic defibrillator pads.

III. Reassess during transport

Record the neurological examination and NIHSS, then reassess any change. New pupil asymmetry, worsening consciousness, posturing or respiratory deterioration warrants immediate senior assessment and urgent imaging. Do not wait for hypertension, bradycardia and irregular breathing to appear together. Pupils alone do not reliably identify a herniation subtype. ENLS.

IV. Obtain the history that changes decisions

Record last-known-well separately from symptom discovery and witnessed onset, including wake-up presentations. Establish baseline function and contact a reliable witness. Ask about anticoagulants, the exact last dose, renal disease, recent surgery or trauma, bleeding and previous intracranial hemorrhage. Document the deficit that matters to the patient, not only a numerical score. Canadian recommendations.

V. Treat reversible threats; avoid harmful shortcuts

Blood pressure: avoid reflex normalization before imaging: ischemic perfusion may depend on systemic pressure. Before IV thrombolysis, achieve SBP <185 and DBP <110 mmHg. Severe hypertension or emergencies such as aortic dissection require individualized treatment. Permissive hypertension is not universal for undifferentiated stroke. AHA/ASA 2026.

Glucose: check immediately and correct <60 mg/dL (3.3 mmol/L), then repeat glucose and the examination. Persistent deficits still need the stroke pathway. AHA/ASA 2026. Treat persistent glucose >180 mg/dL with monitoring; intensive targeting of 80–130 mg/dL did not improve outcomes and increased severe hypoglycemia in SHINE.

Swallowing and antithrombotics: give nothing orally, including medicines, until swallowing safety is assessed. The swallow screen must not delay CT. Do not give empiric aspirin or anticoagulation for an ongoing undifferentiated stroke before hemorrhage has been excluded. After imaging, antithrombotic timing depends on the diagnosis and reperfusion treatment. The immediate-aspirin recommendation for suspected TIA is a different pathway. NICE NG128.

VI. Make imaging the next destination

Obtain urgent noncontrast brain CT to identify hemorrhage; an initially normal scan does not exclude ischemia. Arrange head-and-neck CTA promptly when thrombectomy is a possibility. Additional imaging must not delay otherwise indicated IV thrombolysis. Unknown onset or delayed presentation should prompt specialist imaging-based selection, not automatic exclusion. National Clinical Guideline for Stroke.

Draw CBC, electrolytes, creatinine and coagulation tests in parallel. Obtain ECG and troponin as indicated without holding up imaging or reperfusion. Suspected coagulopathy or relevant anticoagulant exposure requires targeted eligibility assessment; “do not wait for routine labs” is not permission to ignore those risks. Canadian recommendations.

VII. Consider mimics without losing the pathway

Hypoglycemia, a postictal deficit and migraine can resemble stroke. Seizure can also accompany stroke: persistent focal findings still require urgent assessment. Avoid reassurance from a negative FAST screen when sudden visual or cerebellar symptoms suggest posterior circulation disease. National Clinical Guideline for Stroke.

At handover

State the timing, disabling deficit, baseline function, glucose response, BP trend, anticoagulant exposure and imaging plan. Escalate deterioration immediately. The aim is a safe route to diagnosis and reperfusion assessment, not completion of a bedside checklist.