Determine the utility of urgent non-contrast head computed tomography (CT) after downgrading a code stroke.

“Downgrading” a code stroke based on clinical history and physical examination postpones urgent head imaging for patients who do not qualify for urgent intervention (thrombolysis, mechanical thrombectomy). Pathologies like intracranial hemorrhage (ICH) may have a delay in diagnosis due to this downgrade stalling urgent interventions such as controlling blood pressure and reversing coagulopathies. Our institution implemented an urgent non-contrast head CT scan for downgraded code stroke patients before the delayed brain magnetic resonance imaging (MRI) to determine if this intervention would aid in identifying missed ICHs requiring urgent intervention.

This was a retrospective study of downgraded code stroke patients who later got a brain MRI and magnetic resonance angiography and presented to the Barrow Neurological Institute from January 2024 to September 2025. Patients were assessed if delayed head imaging affected patient care compared to if urgent head imaging was obtained. From January 2024 to January 2025, patients who were downgraded received only delayed brain MRI imaging. In February 2025, an urgent non-contrast CT head was implemented before the delayed brain MRI to see if this would improve ICH detection.    

A total of 125 downgraded code stroke patients were included in the study. 85 patients did not receive an urgent non-contrast head CT. 40 patients had an urgent non-contrast head CT after downgrading. Of the 85 patients that did not receive a CT head, 2/85 (2.35%) had ICHs that were later seen on brain MRI and of the 40 patients who received an urgent CT head, 0/40 (0%) patients had intracranial pathology that required urgent intervention.

Urgent non-contrast head CT after downgraded strokes, did not change management compared to delayed imaging. Future studies are needed given the small sample size in the intervention arm.