To encourage health care systems to implement these stroke treatment guidelines, the Brain Attack Coalition (BAC) of voluntary patient advocate groups and professional organizations has published recommendations for the establishment of primary and comprehensive stroke centers to receive and treat patients with acute stroke. These recommendations have been implemented in the United States by the Joint Commission that certifies hospitals and health care organizations [19–21].

Potential stroke victims must be identified and treated as early as possible. Ideally, bystanders and witnesses will learn to recognize strokes through education efforts by large voluntary health organizations such as the American Stroke Association and National Stroke Association, to enhance public awareness. Although some worry that the complexity of stroke symptoms will never be fully appreciated by the lay public, others (Brain Attack Coalition, National Stroke Association, American Heart Association) have cooperated to develop simplified lists of stroke signs that improve the likelihood that bystanders will recognize a stroke and know to call for emergency help.

Patients may be examined first by pre-hospital providers (Paramedics and Emergency Medical Technicians), and considerable advance work should be done by them (see Chap. 14) [22]. Patients will arrive in the hospital Emergency Department by ambulance or by private vehicle with family or other witnesses. By whichever route, the next step should be activation of the Code Stroke system. In some communities, this could include radio activation of the Stroke Team by medics from the field. The Stroke Team must be prepared at all times to respond immediately to the Emergency Department. In busy Neurology practices this preparedness will mandate an on-call schedule with reduced clinic schedules to facilitate immediate response. In Medical Centers with hospitalists, it may be better for the Neurologists to train Emergency Department or hospitalist physicians to handle the early phases of the Code Stroke. Prior to arrival of the Code Team, department staff should begin the Code Stroke protocol. This process is facilitated by standing orders that can be initiated by department nursing staff without MD authorization.

The first step is to establish the time of onset of the stroke. This is critical because thrombolysis for stroke is much more likely to be effective within the first 3 h from the start of symptoms [23, 24]. The physician should be suspicious of any second-hand estimates of onset time; it is critical to obtain corroboration from other witnesses. In many cases, the Code Team physician should telephone the home or scene and try to obtain information from a direct witness. When did this happen? What did you first notice? If you returned from an errand to find the victim symptomatic, when was the last time you knew the victim was symptom free? Often using a “time anchor”, a term coined by the Cincinnati Stroke Team, is useful: find an event with a known time, such as a television program or the time the call was made to 911, and relate the stroke onset to that event [25]. If the patient awoke with symptoms, the onset time is pushed back to the bedtime or last time the victim was known to be at baseline.

While it is important to carefully set the onset time, there is a risk in over-emphasizing some statements from well-meaning friends and family. It is human nature to revisit memory, and try to “explain” a tragedy: often witness will embellish with statements like “well, now that you mention it, he was feeling poorly last evening.” We have frequently encountered a version of “She seemed different last night.” These statements must be vigorously pursued: Was there weakness? Was there speech or language deficits? Unless a relatively clear-cut description of definite neurologic impairments can be elicited, such vague statements should not be used to set the onset time.

After setting the onset time, a brief past medical history is needed. A thorough history and review-of-symptoms will be obtained after the Code is over; at this early point the focus is on stroke risk factors, emphasizing potential sources of cardiac embolism. Knowledge of the medications is essential, especially anti-thrombotics such as warfarin and aspirin. Next, a brief but thorough examination must be done to elicit focal neurologic findings consistent with acute stroke. Until later, one avoids time consuming assessments such as a detailed mental status assessment or a prolonged sensory examination. At this point, the sole purpose is to confirm the presence of focal findings and perform enough examination to preliminarily localize the occluded artery.

In parallel, specific laboratory studies must be drawn to search for conditions that mimic stroke, such as hypoglycemia, or that may confound therapy, such as a prolonged prothrombin time. The full list of tests is included in the standard orders, Tables 14.2, 14.3, and 14.4. A 12-lead EKG must be done to rule out a simultaneous myocardial infarction, which is present in about 5 % of all stroke patients [16]. Finally, the patient must be taken to the Imaging Department for a brain CT or MRI scan to rule out hemorrhage.

Since time is critical, the above sequence must be amended as needed to maintain speed. The Physician in charge of the Code Stroke must ask for status updates, and amend the sequence of events accordingly. For example, if the CT scanner is ready for the patient, but the EKG has not been done, it would be better to go the scanner first and get the EKG upon returning from CT. A frequent source of delay is the transportation of the specimens or the patient. Neurologists are not generally accustomed to worrying about such details, but in the course of analyzing stroke teams at many medical centers, we have found this area problematic. The physician must specify that the STAT specimens from the Code Stroke must be walked over the laboratory specifically, even in hospitals that have an established Code Stroke system. Similarly, medical center policy usually mandates the use of escorts to physically transport a patient to Imaging for a brain CT scan; this delays the scan. In our experience, quicker results will obtain if the Stroke Team members personally move the patient.