The rising cost of code stroke imaging and treatment: A six-year experience at a primary stroke center.

PURPOSE: The increasing cost of acute stroke evaluation has been well documented. Given the expanded use of intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT) in published guidelines, we hypothesized that increasing imaging-associated expenditures would correspond to higher rates of reperfusion therapy. METHODS: A six-year retrospective analysis of all Code Stroke activations at our institution was conducted. For each Code Stroke, data on initial neuroimaging modality ordered and decision to treat with IVT or EVT was documented. Analysis evaluated trends in estimated total imaging cost, number of Code Stroke activations per year, cumulative radiation exposure, and the average imaging cost per treated Code Stroke patient, defined as a case resulting in IVT or EVT treatment. RESULTS: From 2020 to 2025, annual Code Stroke activations and associated imaging expenditures rose nearly three-fold from 133 to 298 cases, driven by an approximately 800% increase in CTA head and neck utilization. Annual imaging expenditure increased from $70,616 to $259,290. Despite the increasing number of Code Stroke activations, the number of patients receiving IVT or EVT has remained stable (19 cases in 2020 vs 16 in 2025), with treatment yield declining from 14.3% to 5.4%. Consequently, the proportion of Code Strokes resulting in reperfusion decreased over time, with the average cost per treated patient increasing over 4-fold from $3717 to $16,205. CONCLUSION: Our findings describe a disproportionate rise in imaging utilization and cost relative to the number of treated Code Strokes. These findings characterize longitudinal trends in imaging utilization and resource use within contemporary stroke evaluation pathways.