Phys Written Answers · neurological
Stroke — Written Clinical Reasoning
DCE long-case preparation: structured written reasoning for acute stroke management, including problem-list synthesis, investigation interpretation, and integrated secondary prevention planning.
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Target exams
SAQ 1 — Acute Stroke Management (15 marks, 20 minutes)
Prompt: Outline your immediate and acute management plan for this patient. Address reperfusion strategy, blood pressure management, and the first 24 hours of stroke unit care. Justify each decision with reference to evidence. [1]
Case vignette: A 76-year-old man with persistent atrial fibrillation on apixaban presents 90 minutes from last-known-well with acute left MCA syndrome (NIHSS 18). CTA shows left M1 occlusion; CT perfusion shows ASPECTS 9, core 15 mL, penumbra 85 mL. BP 168/94. [1]
Model Answer
Immediate assessment and problem identification (2 marks):
- Acute left MCA territory ischaemic stroke, NIHSS 18 — left M1 occlusion on CTA, presenting at 90 minutes from last-known-well
- Persistent atrial fibrillation on apixaban — affects thrombolysis eligibility (DOAC is a contraindication)
- Favourable imaging profile — ASPECTS 9, small core (15 mL), large penumbra (85 mL) — thrombectomy-eligible
- Comorbidities: hypertension, type 2 diabetes, dyslipidaemia — all modifiable risk factors for secondary prevention [1]
Reperfusion strategy (5 marks): [1]
The patient has a large vessel occlusion (M1 MCA) with a favourable imaging profile and is within the thrombectomy window. However, he is on apixaban, which is an absolute contraindication to IV thrombolysis. The anticoagulant effect of a DOAC cannot be reliably excluded by standard coagulation tests, and specific reversal (andexanet alfa) is not fast enough or indicated for the purpose of enabling thrombolysis. [1]
Therefore, IV thrombolysis is withheld, and the patient should proceed directly to mechanical thrombectomy. He is within the 0-6 hour window (90 minutes), has a confirmed LVO, and has a favourable core-to-penumbra ratio (ASPECTS 9, core 15 mL). The HERMES meta-analysis (individual patient data from 5 RCTs) established that thrombectomy within 6 hours of LVO doubles the rate of functional independence, with a number needed to treat of approximately 2.6. The patient does not need imaging-guided selection for the 0-6 hour window (only required for the extended 6-24 hour window per DAWN and DEFUSE-3), but his perfusion profile confirms the favourable mismatch. [1]
Blood pressure management (3 marks): [1]
As the patient is not receiving thrombolysis, permissive hypertension applies — do not treat unless BP exceeds 220/120 mmHg. His BP of 168/94 is appropriate and supports collateral perfusion to the penumbra. Lowering it would risk worsening the ischaemic territory. Post-thrombectomy, the target shifts to below 180/105 mmHg to reduce reperfusion injury and haemorrhagic transformation risk. [1]
First 24 hours of stroke unit care (5 marks): [1]
| Domain | Action | Rationale |
|---|---|---|
| Monitoring | Stroke unit admission; neurological observations every 15 min initially, then hourly. Continuous cardiac monitoring | Detect deterioration (reocclusion, haemorrhage, oedema). Monitor for AF complications |
| Blood glucose | Maintain 4-10 mmol/L with subcutaneous insulin protocol; avoid hypoglycaemia | Hyperglycaemia worsens penumbral injury; hypoglycaemia mimics stroke |
| Temperature | Paracetamol for any fever; active cooling if needed; investigate source | Each 1 degree C fever doubles odds of poor outcome |
| Swallow | Nil by mouth until formal swallow assessment. Bedside screen within 4 hours | Aspiration pneumonia is a leading cause of post-stroke mortality; global aphasia increases risk |
| DVT prophylaxis | Intermittent pneumatic compression immediately; pharmacological prophylaxis deferred until haemorrhagic transformation excluded | Immobile patients have 10-50% VTE risk |
| Imaging | Repeat non-contrast CT at 24 hours to exclude haemorrhagic transformation before starting antiplatelet/anticoagulation | Standard post-reperfusion protocol |
References4ShowHide
- [1]Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke Stroke, 2019.PMID 31662037
- [2]Nogueira RG, Jadhav AP, Haussen DC, et al. Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct N Engl J Med, 2018.PMID 29129157
- [3]Wang Y, Wang Y, Zhao X, et al. Clopidogrel with aspirin in acute minor stroke or transient ischemic attack N Engl J Med, 2013.PMID 23803136
- [4]Barnett HJM, Taylor DW, Eliasziw M, et al. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators N Engl J Med, 1998.PMID 9811916