(705) 728-9090 x46320 | 201 Georgian Drive. Barrie, ON L4M 6M2
(705) 728-9090 x46320 | 201 Georgian Drive. Barrie, ON L4M 6M2
This webpage provides an overview of stroke-related resources that support physicians working in or supporting stroke care across the Central East Stroke Network (CESN).
CESN is one of 11 stroke networks across the province. Royal Victoria Regional Health Centre (RVH) is the Enhanced District Stroke Centre (EDSC) – Regional System and is accountable for specialized clinical services and system leadership.
RVH, through the Regional Medical Director, Regional Director, and Regional Coordinators provides leadership, strategic planning, implementation, and coordination of best‑practice stroke care across the continuum for the entire CESN region.
Simcoe: RVH (Enhanced District Stroke Centre)
Muskoka: Huntsville District Memorial Hospital
York: Cortellucci Vaughan Hospital
Durham: Lakeridge Health Oshawa
Haliburton Kawartha Pine Ridge (HKPR): Peterborough Regional Health Centre
To learn more about the stroke services available in each district (i.e. stroke units, community stroke rehab, secondary prevention clinics etc.) and where they are located – click on the link for the CESN Stroke Services Map.
The Canadian Stroke Best Practice Recommendations (CSBPR) provide up-to-date evidence based guidelines for stroke care across the continuum. Not all recommendations will be applicable to all patients in all settings. The CSBPR were first introduced in 2006 and the modules undergo a formal review and update every two to three years.
The Canadian Stroke Consortium is the national professional association for physicians interested in stroke. The Associate Membership is free and provides access to the organization’s educational resources and programs.
CritiCall Ontario is a 24-hr-a-day emergency consultation and referral service to support access to urgent and emergent care in Ontario. It is important to note that the CritiCall Associates are not clinical and are following specific algorithms to connect to the correct service, so they cannot make any clinical judgements.
For ischemic stroke, CritiCall is used to access the Stroke Endovascular Team for patients with suspected LVO who may be eligible for Endovascular Thrombectomy.
Hospitals in CESN that use Telestroke contact the Telestroke neurologist through CritiCall. **Confirm if your site uses Telestroke.
1-800-668-4357 (HELP)
CritiCall is NOT to be used for everyday consults – ONLY urgent/emergent cases.
Ontario uses a Paramedic Prompt Card for the Acute Stroke Bypass Protocol as a quick reference to guide transport to the most appropriate site.
Patients within 6 hours of last known well who present with new onset of at least one of the following may be bypassed to a District Stroke Centre:
Unilateral arm or leg weakness
Slurred speech, inappropriate words, or muteness
Unilateral facial droop
A secondary screen for a Large Vessel Occlusion (LVO) is also conducted using the Los Angeles Motor Scale (LAMS).
Refer to the protocol for additional information and reasons why a patient may not be bypassed.
Repatriation is the process of transferring a recovering stroke patient from a Regional Stroke Centre or EVT site back to a hospital or stroke unit closest to their home once medically stable.
The Provincial Telestroke Program provides access to a standard of care for hyperacute stroke patient assessment and management in Ontario. This resource is staffed 24/7 and uses CritiCall to contact a neurologist.
This service is ONLY available at certain sites within CESN and under specific conditions. This will be further addressed under the District-specific sections.
The National Institutes of Health Stroke Scale (NIHSS) is a standardized, 11-item clinical assessment tool used to measure the severity of a stroke. NIHSS score ranges from 0 (no symptoms) to 42 (severe stroke).
Free training is available through the following links, but you need to create your own account.
Apps available to assist with calculations:
MDCalc (App and website)
NeuroLogic (iPhone users)
Video (13 min): Bedside Neurological Assessment of the Stroke Patient – Dr. Al Jin demonstrates key elements of a bedside assessment
ACT-FAST (Ambulance Clinical Triage for Acute Stroke Treatment) is a 3-step large vessel occlusion (LVO) screening tool used to guide clinical decision making in Stroke Endovascular Thrombectomy (EVT) eligibility. Should be completed if the patient last known well within 4-24 hour window.
Step 1 – Assesses for unilateral arm weakness
Step 2 – Assesses language (right arm weakness) or gaze/shoulder tap (left arm weakness)
Step 3 – If patient screens positive in Step 1 & 2 MD assesses eligibility for EVT consultation
Patients who screen positive need STAT imaging and consultation with a stroke expert to determine if the patient is a possible EVT candidate.
EVT centres for most of Central East Stroke Network are located in Toronto and accessed through CritiCall.
The Canadian Neurological Scale (CNS) is an 8-item tool used to evaluate and monitor the neurological status of stroke patients in the acute phase.
Minimum score is 1.5 (lower scores representative of increasing severity) out of possible score of 11.5
Appropriate for patients who are alert or drowsy. GCS used for stuporous or comatose patients
Note: CNS scores can be reliably converted into NIHSS scores using the following conversion: NIHSS = 23 – (2 x CNS score)
Los Angeles Motor Scale (LAMS) is used by Ontario paramedics as part of their stroke assessment in the first 24 hours from symptom onset.
Scale assesses facial droop, arm drift and grip strength to generate a total score from 0-5. A score of 4 or greater indicates a higher likelihood of a large vessel occlusion. Paramedics should be reporting in their prenotification if the patient screens LVO positive.
Facial droop: Absent=0 Present=1
Arm Drift: Absent=0 Drifts down=1 Falls rapidly=2
Grip Strength: Normal=0 Weak grip=1 No grip=2
Ontario Health CorHealth Ontario has outlined a standard imaging protocol for hyperacute stroke care when determining if a patient is a candidate for Endovascular Treatment (EVT)
The imaging selection criteria requires both a non-contrast CT (NCCT), and Multiphase Computed Tomography Angiography (mCTA).
Where available, CT Perfusion should also be completed in the late window (i.e., 6-24 from time last known well), and may be completed in the early time window (i.e., 0-6 from time last known well).
Check with your site if you have CT Perfusion available and how to order your Acute Stroke Protocol imaging.
The ASPECTS (Alberta Stroke Program Early Computed Tomography Score) is a 10-point quantitative scoring system used on non-contrast CT scans to evaluate early signs of brain damage in patients with acute ischemic stroke. It is primarily used to assess the middle cerebral artery (MCA) territory to guide treatment decisions
ASPECT Score in Acute Stroke (University of Calgary) site is Let’s Get Proof
Alberta stroke programme early CT score (Radiopaedia updated March 2026)
MD Calc – calculator for ASPECTS Score
Automated CT perfusion imaging software which supports the post-processing of data and the analysis of brain images using artificial intelligence in a standardized way. Supports decision making for hyperacute therapies in a more timely manner.
Some of the District Stroke Centres in CESN have this software. Please check with your site if is available and how to sign up for the appropriate training.
Perfusion imaging is particularly helpful when the exact last known well is unclear, patient awakens with symptoms, symptoms are vague or fluctuating, non-contrast CT does not show any obvious changes.
Each district with CESN has an Acute Stroke Protocol that supports non-thrombolytic sites and guides decision making in the 0-24hr window from symptom onset. The protocol includes patients presenting to the ED , non-admitted patients and inpatients who experience a stroke.
District Stroke Centres have their own acute stroke protocols for patients in the ED and inpatient code strokes.
Thrombolysis delivery sites in CESN use Tenecteplase (TNK) for disabling ischemic stroke. TNK is a tissue plasminogen activator (tPA) that has been approved by Health Canada for stroke and added to the Canadian Stroke Best Practice Recommendations.
Key Points about Administration:
Within 4.5 hours of stroke symptom onset or last known well time
TNK has a longer half-life than alteplase allowing it to be administered as a single intravenous bolus over 5 seconds
As soon as possible after brain imaging with a target median door-to-needle time (DTN) of ≤ 30 minutes
Monitoring is required for the first 24 hours after administration of thrombolytic.
Please refer to your organization’s order sets for eligibility criteria, contraindications and dosing. ***Note that the dosing is NOT the same as for myocardial infarction or pulmonary embolism.
A minimally invasive procedure to remove a blood clot from a blocked large vessel in the anterior circulation or basilar artery.
EVT may be indicated in patients who have received intravenous thrombolysis as well as those who are not eligible for thrombolysis.
Currently CESN does not have any EVT centres and so patients are transferred to Sunnybrook, Toronto Western or St. Michael’s. The receiving site is based on a rotating call schedule through CritiCall. The only exception is Campbellford who transfers to Kingston.
Contacts:
Regional Medical Director: Dr. Shubhdeep Ahden
Regional Director: Donelda Sooley Email: cesn@rvh.on.ca
District Medical Director: Dr. Alex Jahangirvand
Clinical Nurse Specialist: Claire Ortwein
Sites:
Enhanced District Stroke Centre: Royal Victoria Regional Health Centre
To learn more about the stroke services available in Simcoe and each district (i.e. stroke units, community stroke rehab, secondary prevention clinics etc.) and where they are located – click on the link for the CESN Stroke Services Map.
Accordion Content
Accordion Content
Accordion Content
Follow the Simcoe District Acute Stroke Protocol for patients presenting in the 0-24hr window from symptom onset/last known to be at baseline
Follow the RVH stroke protocols for patients presenting within the 0-24hr window.
Monitoring post thrombolysis…..
Stroke Prevention 2026: emphasis on a stepwise approach to investigations for etiology (15Jan26)
Presenter: Dr. Andrew Demchuk
Recording link: https://youtu.be/gi4hUeF6s70
Acute Stroke: Recognition & Management (10Feb26) – Focused on early recognition, rapid neuro assessment, hyperacute therapies and the Acute Stroke Protocol in the 0-4 & 4-24hr window
Presenter: Dr. Shubhdeep Ahden, Vascular Neurologist at Royal Victoria Regional Health Centre
Recording link: https://youtu.be/gLuzyGKc3SQ
Stroke Mimics & Chameleons (21April26) – Focused on navigating diagnostic uncertainty in acute stroke
Presenter: Dr. Simon Beshara, Adjunct Professor, Queens University & Neurologist at Lakeridge Health
Recording link: https://youtu.be/KkqotEJwP1o
