Stroke — SAQ

Stem

A 72-year-old woman is brought to the emergency department 90 minutes after sudden onset of right-sided weakness and difficulty speaking, witnessed by her family. She has a history of hypertension and atrial fibrillation, for which she takes no regular medication. On examination, she has a dense right hemiparesis, expressive aphasia, and a right homonymous hemianopia. Blood pressure is 178/96 mmHg, blood glucose is 6.2 mmol/L.

Questions

a) What is the most likely diagnosis and vascular territory? What is the most important next investigation? (2 marks)

Most likely diagnosis: left middle cerebral artery (MCA) ischaemic stroke — face/arm-predominant weakness, aphasia (dominant hemisphere), and homonymous hemianopia together localise to the MCA territory (0.5 mark for diagnosis, 0.5 mark for territory reasoning). Given her untreated atrial fibrillation, a cardioembolic mechanism should be suspected (0.5 mark). Most important next investigation: urgent non-contrast CT brain, to exclude haemorrhage before any antithrombotic or thrombolytic therapy (0.5 mark).

b) Her CT brain shows no haemorrhage and no established infarct. She presents within the thrombolysis window. Outline her immediate management, including drug, dose, and any precautions. (3 marks)

• Confirm she is within 4.5 hours of last known well (she is, at ~90 minutes) and check for contraindications (recent surgery/bleeding, anticoagulation with elevated INR, recent MI, large established infarct) (0.5 mark)
• Blood pressure must be under 185/110 mmHg before thrombolysis — hers (178/96) already qualifies, but if it did not, IV labetalol or nicardipine would be required first (0.5 mark)
• Give IV alteplase 0.9 mg/kg (max 90 mg) — 10% as a bolus over 1 minute, the remaining 90% infused over 1 hour (1 mark)
• Also assess for large-vessel occlusion (dense hemiplegia, aphasia, gaze deviation) and obtain urgent CT angiography — she may be a thrombectomy candidate in parallel with thrombolysis (0.5 mark)
• Admit to a dedicated stroke unit for monitoring, including post-thrombolysis BP target under 180/105 mmHg for 24 hours (0.5 mark)

c) She improves significantly after treatment. What secondary prevention would you start, and when? (3 marks)

• Given her atrial fibrillation, this is a cardioembolic stroke — anticoagulation (a DOAC preferred over warfarin) should be started, typically 2–14 days after the event, balancing haemorrhagic-transformation risk against early recurrence risk (1.5 marks)
• High-intensity statin, blood-pressure control, and glycaemic optimisation for all patients (1 mark)
• Smoking cessation counselling if relevant, and referral for multidisciplinary stroke rehabilitation (0.5 mark)

d) List two complications she should be monitored for in the first week, and how each would present. (2 marks)

Any two of (1 mark each):

• Haemorrhagic transformation of the infarct — new neurological deterioration, often with a headache or reduced consciousness
• Cerebral oedema / raised intracranial pressure — deteriorating conscious level, particularly with a large MCA territory infarct (malignant MCA syndrome)
• Aspiration pneumonia — fever, cough, new consolidation; underscores the need for a formal swallow assessment before any oral intake
• Seizures — new focal or generalised seizure activity
• Venous thromboembolism — calf swelling/tenderness (DVT) or acute dyspnoea (PE), particularly relevant given her immobility