Introduction:
In the emergency care of patients with suspected acute stroke, time is brain. Each passing minute can mean the loss of nearly two million neurons. The period between arrival and brain imaging is a golden window that must be maximized to stabilize the patient, gather essential information, and prepare for definitive diagnosis and potential reperfusion therapy. This guide provides a structured, high-yield breakdown for optimizing care before the CT scan.
I. Immediate Triage and System Activation
1. Recognize and Flag Suspected Stroke Early
- Triage should be trained to immediately activate a “Stroke Code” or equivalent pathway.
- Label the case as “Suspected Stroke” and prioritize immediate rooming and evaluation.
2. Notify the Stroke Team
- Simultaneously inform neurology, radiology, and internal stroke response teams.
- Early activation facilitates parallel tasking and imaging preparation.
II. Rapid Assessment – The ABCDE Approach
Pre-imaging assessment must be swift and systematic:
A – Airway
- Assess for patency. Patients with altered consciousness may lose airway protection.
- Prepare for Rapid Sequence Intubation (RSI) if GCS is declining or if respiratory effort is inadequate.
B – Breathing
- Administer oxygen to maintain SpO₂ > 94%.
- Monitor respiratory rate and effort for early signs of brainstem involvement.
C – Circulation
- Establish two large-bore IV lines.
- Attach to a cardiac monitor and defibrillator.
- Obtain stat labs: CBC, electrolytes, renal panel, INR/aPTT, troponin, glucose.
- Perform point-of-care glucose immediately (treat if <60 mg/dL).
D – Disability (Neurologic Evaluation)
- Perform a brief neurological exam with:
- GCS
- Pupillary response (check for anisocoria, sluggish or non-reactive pupils)
- Motor symmetry (look for drift, plegia)
- Use NIHSS or similar scoring tool for standardized baseline documentation.
E – Exposure
- Undress the patient to check for signs of trauma, seizure activity, rashes, or recent procedures.
- Assess for meningeal signs or other findings that could point to alternative diagnoses.
III. Early Signs of Elevated Intracranial Pressure (ICP) and Herniation
Recognizing signs of rising ICP or herniation syndromes can guide pre-CT management decisions:
- Uncal herniation: Dilated, unreactive pupil on the side of the lesion.
- Central herniation: Small, reactive pupils, progressing to fixed pupils and coma.
- Tonsillar herniation: Respiratory arrest, bradycardia, and fixed midline pupils.
Late signs include:
- Cushing’s triad: Hypertension, bradycardia, irregular respirations
- Progressive decline in GCS
- Recurrent vomiting, severe headache
IV. Focused History: SAMPLE + Last Known Well
A concise but directed history informs immediate treatment eligibility:
- S: Symptom onset – Identify Last Known Well (LKW) time precisely.
- A: Allergies – Particularly medication allergies.
- M: Medications – Emphasize anticoagulants, antiplatelets, and thrombolytics.
- P: Past Medical History – Prior stroke, bleeding disorders, surgeries, cardiac history.
- L: Last meal – Important if anesthesia or procedures are anticipated.
- E: Events leading to presentation – Witnessed collapse? Focal deficits?
V. Critical Interventions Before CT
1. Blood Pressure Management
- tPA candidate: Only treat if BP >185/110 mmHg. Preferred agents: Labetalol or Nicardipine.
- Non-candidate: Permissive hypertension allowed unless SBP >220 or DBP >120 mmHg.
2. Glucose Management
- Treat hypoglycemia (<60 mg/dL) immediately with IV dextrose.
- Avoid hyperglycemia (>180 mg/dL) if prolonged – consider insulin.
3. ECG and Cardiac Monitoring
- Obtain a 12-lead ECG to rule out myocardial infarction or arrhythmias (e.g., AFib).
4. NPO Status
- Make the patient NPO due to aspiration risk and possible sedation/intubation needs.
5. Prepare for Imaging
- Remove all metal objects.
- Confirm patient is stable for transport.
- Pre-notify the CT team to ensure no delay on arrival.
VI. Documentation and Communication
- LKW Time: This is the single most critical data point. Document it clearly and time-stamp it.
- NIHSS Score: Baseline score informs both eligibility and prognosis.
- tPA/Thrombectomy Screening: Be prepared to present known contraindications (e.g., bleeding disorders, recent surgery, trauma).
- Begin consent discussion early if patient or family is present and treatment is likely.
VII. Stroke Mimics to Consider
Always keep alternative diagnoses in mind:
- Seizure/postictal state
- Hypoglycemia
- Migraine with aura
- Functional/psychogenic deficits
- Bell’s palsy
A high index of suspicion helps avoid both over- and under-treatment.
Conclusion: Pre-CT Is Prime Time
The moments before brain imaging in a stroke workup are not idle time—they are active, high-stakes minutes that determine diagnostic accuracy, treatment eligibility, and ultimately, patient outcomes.
By executing a well-coordinated, parallel-processing protocol focused on airway, glucose, blood pressure, neurological status, and imaging readiness, emergency providers can compress time-to-treatment and significantly improve neurologic outcomes in acute stroke patients.
Remember: It’s not just what you do after the CT that matters—it’s everything you do before it.
