Chapter: Immediate Transfer of Suspected Acute Stroke Patients to a CT‑Capable Facility

Immediate Activation and Transfer

• Activate emergency medical services (EMS) without delay and request direct transport to the nearest stroke‑capable center that has computed tomography (CT) imaging. This recommendation is based on evidence from the American Heart Association guidelines. 1
• Transfer the patient immediately to the closest facility with CT capability while initiating supportive stroke care during transport. The International Stroke Guidelines endorse this approach as a Class I recommendation. 2

Pre‑Transfer Clinical Assessment

• Record the exact time of symptom onset (or last known well) as the single most critical piece of information for determining treatment eligibility. Strong evidence (Class I, Level A) supports this practice. 3
• Perform a rapid neurological assessment using a validated stroke scale (e.g., NIH Stroke Scale or Canadian Neurological Scale) to quantify deficit severity and convey findings to the receiving center. Class I recommendation. 3
• Obtain a finger‑stick glucose measurement immediately; a glucose level < 50 mg/dL contraindicates intravenous thrombolysis. Class I, Level B evidence. 3
• Draw pre‑transfer laboratory samples (complete blood count, electrolytes, creatinine, coagulation studies – INR/aPTT, and random glucose). Evidence supports this without delaying transfer. 2
• Document any anticoagulant (warfarin, direct oral anticoagulants) or recent antiplatelet therapy, as these affect eligibility for reperfusion therapies. Class I recommendation. 3

Blood Pressure Management Prior to Transfer

• For patients who may be eligible for intravenous thrombolysis (≤ 4.5 h from onset), maintain systolic/diastolic blood pressure < 185/110 mm Hg. Class I, Level A. 3
• If blood pressure exceeds the above threshold, administer labetalol 10 mg IV or initiate nicardipine infusion (starting at 5 mg/h, titrated by 2.5 mg/h every 5–15 min, max 15 mg/h). Class I recommendation. 3
• Avoid aggressive blood pressure reduction below target values, as cerebral perfusion may be pressure‑dependent in acute stroke. Class I, Level B. 3
• For patients not candidates for thrombolysis, treat hypertension only if systolic > 220 mm Hg or diastolic > 120 mm Hg; if treatment is required, lower blood pressure by only 15–25 % within the first 24 h. Class I recommendation. 3

Communication and Pre‑Notification

• Provide a detailed pre‑notification to the receiving stroke center, including onset time, current neurological deficits, vital signs, glucose level, anticoagulation status, and estimated arrival time. Evidence from the International Stroke Guidelines emphasizes this as essential for rapid door‑to‑needle times. 4
• For patients presenting within 6 h of onset, specify that CT angiography will be needed to assess for large‑vessel occlusion (LVO) and potential endovascular therapy. Class I recommendation. 2

Imaging and Treatment Prior to Transfer

• If the originating facility has only non‑contrast CT (no CT angiography), perform the scan immediately, administer intravenous alteplase when appropriate (≤ 4.5 h from onset and no contraindications), and then expedite transfer to a comprehensive stroke center for vascular imaging and possible thrombectomy. Class I, Level A evidence. 2
• Do not delay transfer while awaiting the effect of alteplase; mechanical thrombectomy remains highly effective even after thrombolysis. Evidence from recent practice summaries supports this approach. 5

Supportive Care During Transport

• Maintain oxygen saturation > 94 % with supplemental oxygen as needed. Class I recommendation. 1
• Consider airway protection (intubation) if the patient’s Glasgow Coma Scale is < 8 or if bulbar dysfunction prevents airway protection. Class I, Level B. 1
• Treat active seizures with short‑acting benzodiazepines (e.g., intravenous lorazepam). Class I recommendation. 2
• Do not administer prophylactic anticonvulsants; there is no evidence of benefit and potential for harm. Class III recommendation (harm). 2
• Correct hypoglycemia immediately when glucose < 50 mg/dL, as it mimics stroke and contraindicates thrombolysis. Class I, Level A. 3
• Avoid aggressive treatment of mild hyperglycemia during acute transport; focus on preventing severe hyperglycemia. Class IIb recommendation. 1

Time Targets and Expected Outcomes

• Intravenous alteplase is effective when administered within 4.5 h of symptom onset; target door‑to‑needle time is ≤ 30 minutes (90th percentile ≤ 60 minutes) at the receiving facility. Class I, Level A. 4
• Endovascular thrombectomy is effective within 6 h for most LVO patients and up to 24 h for selected patients meeting advanced imaging criteria. Class I, Level A. 2
• Each 15‑minute reduction in door‑to‑needle time is associated with a 5 % decrease in in‑hospital mortality. Class I evidence. 1

Common Pitfalls to Avoid

• Never postpone transfer to obtain imaging at a non‑CT facility; rapid transport supersedes any on‑site intervention without imaging. Class I recommendation. 1
• Do not withhold transfer for “mild” or improving symptoms, as large‑vessel occlusions can present with fluctuating deficits. Class I, Level B evidence. 6
• Avoid over‑treating blood pressure in the pre‑hospital phase unless the specified thresholds are exceeded, to prevent worsening cerebral ischemia. Class I recommendation. 3
• Do not assume patients beyond 4.5 h are ineligible for therapy; endovascular treatment may be offered up to 24 h with appropriate imaging selection. Class I, Level A. 6

Prehospital Stroke Care Guidelines

Prehospital Recognition and Activation

• Use a validated FAST screening tool; any positive finding mandates immediate EMS activation and high‑priority transport. 7
• Record the exact time of symptom onset or the last known normal; this single data point determines eligibility for reperfusion therapies. 7
• EMS personnel should perform a second severity assessment with a validated scale to identify potential large‑vessel occlusion candidates (e.g., aphasia, visual‑field deficits, neglect). 7
• Triage patients as Canadian Triage Acuity Scale (CTAS) Level 2 in most cases, upgrading to Level 1 if airway, breathing, or circulation is compromised. 7

On‑Scene Management (Target ≤15 minutes)

• Assess and stabilize airway, breathing, and circulation; check capillary blood glucose; establish IV access with normal saline; and keep on‑scene time ≤15 minutes—do not delay transport for additional interventions. 8
• If capillary glucose is < 60 mg/dL, treat promptly with intravenous dextrose to avoid mistaking hypoglycemia for stroke and to meet thrombolysis eligibility. 8
• Provide supplemental oxygen only when oxygen saturation falls below 94 %; avoid routine high‑flow oxygen. 8
• Use isotonic normal saline for IV fluids and avoid dextrose‑containing solutions in patients who are not hypoglycemic. 8
• Initiate cardiac monitoring on scene to detect arrhythmias that may influence acute management. 8
• Collect blood samples for laboratory testing en route to the hospital whenever feasible. 8
• Do not treat hypertension in the field unless systolic blood pressure is ≥ 220 mmHg and only after consultation with medical command. 8

Transport and Prenotification

• Transport the patient directly to the nearest stroke‑capable center, bypassing non‑stroke hospitals, and provide a detailed prenotification that includes symptom onset time, FAST findings, vital signs, glucose level, and anticoagulation status. 9

Transfer Protocol for Endovascular Therapy

• Apply a “drip‑and‑ship” strategy: administer intravenous alteplase at the primary stroke center and immediately transfer the patient to a comprehensive stroke center for possible mechanical thrombectomy when a large‑vessel occlusion is suspected. 9

Prehospital Management of Suspected Acute Stroke in Patients Found Asleep

Initial Airway, Breathing, and Circulation Assessment

• Airway protection: Intubate the patient if the Glasgow Coma Scale is ≤ 8 or if the patient cannot protect the airway because of impaired consciousness or brain‑stem involvement. 10
• Oxygen therapy: Administer supplemental oxygen only when peripheral oxygen saturation falls below 94 %; routine oxygen in non‑hypoxic patients does not improve outcomes. 10
• Cardiac monitoring: Initiate continuous cardiac monitoring on scene to identify arrhythmias (e.g., atrial fibrillation) that may influence acute stroke management. 11
• Hemodynamic support: Correct hypotension and hypovolemia promptly to maintain systemic perfusion required for organ support. 10

Determining the “Last Known Well” Time

• Definition: The “last known well” (LKW) time is the moment the patient was last observed neurologically normal before falling asleep, not the time they were discovered with symptoms. This single data point drives all subsequent treatment decisions. 12
• Documentation: Record the exact LKW time (typically bedtime). If the precise minute cannot be ascertained within 15 minutes, use standardized time windows (morning, afternoon, evening, overnight). 12
• Source of information: Obtain the LKW time from the patient when possible; otherwise, rely on family members or witnesses who last saw the patient normal. 12

Eligibility for Reperfusion Therapies

• Intravenous thrombolysis: Patients who are ≤ 4.5 hours from known or presumed symptom onset should be prioritized for IV alteplase when no contraindications exist. [13][14]
• Extended‑window thrombolysis: Even when the exact onset time is unknown (e.g., wake‑up strokes), advanced imaging (DWI‑FLAIR mismatch or perfusion studies) can identify candidates for IV thrombolysis beyond traditional windows. 12
• Endovascular thrombectomy: Selected patients may be eligible for mechanical thrombectomy up to 24 hours from LKW when neurovascular imaging demonstrates a favorable profile. [13][10]

On‑Scene Time and Transport Protocol

• Scene time target: Limit on‑scene activities to ≤ 15 minutes; defer non‑essential interventions (IV placement, blood draws) to the transport phase. 14
• Transport destination: Bypass non‑stroke facilities and transport directly to the nearest stroke‑capable center with CT imaging and thrombolysis capability. For suspected large‑vessel occlusion, consider transport to a comprehensive stroke center equipped for endovascular therapy. [14][10]13

Prehospital Notification Content

• LKW time (when the patient went to sleep) – 12
• Time the patient was found with symptoms – 12
• Current neurological deficits and stroke‑scale score (e.g., NIHSS) – (documented per protocol)
• Glasgow Coma Scale score – [13][14]
• Vital signs and oxygen saturation – 11
• Estimated time of arrival at the receiving facility – 14

Expected Outcomes and Time Targets

• Door‑to‑needle time: Aim for a median ≤ 30 minutes and ≤ 60 minutes for the 90th percentile at the receiving hospital. [13][10]
• Thrombectomy efficacy: Mechanical thrombectomy is highly effective when performed within 6 hours of symptom onset for most large‑vessel occlusions and remains beneficial up to 24 hours in patients meeting advanced imaging criteria. 10