Question: We are transporting a patient from a small hospital without a CT scanner to a larger hospital with a CT scanner but not a Stroke Centre. Our patient is an obvious stroke patient...slurred speech for over 1 day, but is getting better and no other issues...stable, but still with slurred speech (does not meet Stroke Protocol as onset over 24hrs).

What should we do should this patient become worse enroute to the CT capable hospital? Say his slurred speech becomes worse or he shows other signs and symptoms? Is this considered a "new onset" or a continuation of his current CVA/TIA? If "new onset" I would think he now meets the Stroke Protocol and should be diverted to the Stroke Centre? Could you please clarify?

 Clinically, possibly one of many things is happening: 1) A 2nd embolic event 2) Progression of an original hemorrhagic stroke 3) Conversion of an ischemic stroke to a hemorrhagic stroke 4) Swelling around a space occupying lesion,(tumour or abscess, focal seizure) 5) A unrelated metabolic change (hypoglycemia, hyponatremia, hypoxia etc).

At the end of the day it doesn't matter much for this call.... it is an inter-facility transfer. (The Provincial Stroke Protocol does not apply to inter facility transfers) You should contact the sending physician and the receiving center and alert them of the status change. The findings you have found may change the management. The noncontrast CT head, maybe changed to with and without contrast to help better elucidate the cause, and this may effect final destination. Depending upon findings this patient may need a neurosurgical center, some smaller regional stoke centers do not have neurosurgical capability (Chatham, Stratford, etc).This patient will require stabilization and medical reassesment. They may require further resources for ongoing transport. Communication is essential in these dynamic cases.

It would also be highly unlikely that this patient would qualify for TPA (the ultimate reason behind a proposed diversion to the Stroke Centre) given that the neuro symptoms you are describing have been present for over 24h. The bleeding complications associated with TPA in that scenario would outweigh any possible benefit.

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