What criteria should I use to decide whether to refer a patient with suspected stroke for immediate imaging?

Refer a patient with suspected acute stroke for immediate brain imaging if any of the following criteria are present:

• Indications for thrombolysis or thrombectomy treatment.
• Current anticoagulant treatment or known bleeding tendency.
• Depressed level of consciousness, defined as Glasgow Coma Score below 13.
• Unexplained progressive or fluctuating neurological symptoms.
• Signs suggestive of raised intracranial pressure such as papilloedema, neck stiffness, or fever.
• Severe headache at onset of stroke symptoms.

In these cases, perform urgent non-enhanced CT brain scanning immediately to exclude intracranial haemorrhage before initiating treatments like alteplase.

If thrombectomy is considered, follow initial CT with CT angiography and possibly CT perfusion imaging if beyond 6 hours of symptom onset.

For patients with suspected acute stroke but without these immediate imaging indications, brain imaging should still be performed as soon as possible and within 24 hours of symptom onset.

Always exclude hypoglycaemia as a cause of neurological symptoms before imaging.

Patients with suspected stroke should be admitted directly to a specialist acute stroke unit after initial assessment.