Case 2

67-year-old man with slurred speech and right-sided weakness

A 67-year-old man is brought to casualty after suddenly developing slurred speech and right-sided weakness 1 hour ago. He was previously normal.

History: Hypertension, type 2 diabetes mellitus, hyperlipidemia
Medications: Amlodipine, metformin, atorvastatin

Vitals: BP 168/94 mmHg, HR 92/min, RR 18/min, SpO₂ 96% RA
Neurological exam: Slurred speech, right facial droop, right arm/leg weakness, decreased pinprick sensation right arm

Move for emergency non-contrast CT head➜ Order urgent MRI brain with diffusion-weighted imaging➜ Perform ABC assessment and check capillary glucose➜ Administer 300 mg aspirin➜

Your fellow resident stops you: ‘Where are you taking him? We don’t have glucose level yet. It might be hypoglycemia.’

Reassessment: Airway intact, breathing no distress, circulation stable, glucose 108 mg/dL
Vitals unchanged: BP 168/94, HR 92, RR 18, SpO₂ 96%

Move for non-contrast CT head➜ Order MRI brain with diffusion-weighted imaging➜ Start aspirin 300 mg now that hypoglycemia ruled out➜ Begin lowering BP aggressively to <140/90➜

Initial assessment complete:
Airway intact, breathing no distress, circulation stable, glucose 108 mg/dL
Vitals unchanged. You activate stroke protocol.

Move for non-contrast CT head➜ Order urgent MRI with diffusion-weighted imaging➜ Begin lowering BP aggressively to <140/90➜ Order CT angiogram head & neck➜

Nurse stops you: ‘No aspirin until we know it’s not a bleed.’ Senior resident steps in. You confirm ABCs stable and glucose 108 mg/dL.

Order MRI with diffusion-weighted imaging➜ Order non-contrast CT head➜ Order labs (CBC, PT/INR, electrolytes) before imaging➜ Give clopidogrel 600 mg loading dose➜

Non-contrast CT head (20 min after arrival):
No intracranial hemorrhage, no mass effect
Subtle early ischemic changes in left MCA territory
Good ASPECTS score

Order CT angiogram head & neck to evaluate for large vessel occlusion➜ Start aspirin now that hemorrhage ruled out➜ Assess eligibility for thrombolysis➜

You send patient for MRI but radiologist calls: ‘Cannot mobilize MRI early enough! Wasting time!’ Senior redirects you.

Send for non-contrast CT head➜ Order CT angiogram head & neck➜

As you open aspirin, nurse stops you: ‘No antiplatelets until we know it’s not a bleed!’ Fellow resident: ‘Don’t stall, need imaging now!’

Start loading dose of clopidogrel 600 mg➜ Send for non-contrast CT head➜ Send for urgent MRI with DWI➜ Order CT angiogram head & neck➜

As you order IV labetalol to lower BP, fellow resident stops you: ‘Why lower pressure? If ischemic stroke, you’ll worsen perfusion!’ Patient unharmed but time lost.

Start aspirin 300 mg urgently➜ Order MRI with diffusion-weighted imaging➜ Order non-contrast CT head➜

You order CT angiogram as first imaging. Radiology calls: ‘Will take time… sure you want this as first-line?’ You realize mistake and cancel.

Cancel CTA and order emergent MRI with DWI➜ Cancel CTA and order emergent non-contrast CT head➜

You order labs first. 12 minutes pass, neurological deficit worsened. Senior: ‘Imaging comes first in stroke. Labs do NOT delay imaging.’

Send immediately for non-contrast CT head➜ Order MRI with diffusion-weighted imaging➜

Finish 1 — Critical Error

You gave clopidogrel before imaging. Patient becomes acutely drowsy, BP spikes, vomits, right pupil dilates.
CT shows large left intracerebral hemorrhage.
Clopidogrel worsened bleeding. Patient intubated, emergency decompression, remains critical.
You’re removed from the team.

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CTA Results: Left M1 occlusion, no carotid dissection, no significant carotid stenosis, moderate collateral flow

Time since onset: ~1 hour 35 minutes
BP 170/96, glucose 108 mg/dL
No contraindications to thrombolysis

Nurse: ‘Should we thrombolyse?’

Proceed with IV thrombolysis with alteplase 0.9 mg/kg➜ First correct BP to <140/90, then reperfusion therapy➜ Send for mechanical thrombectomy (more effective for LVO)➜ Do not give thrombolysis - ischemic brain at hemorrhage risk➜

You realize aspirin can’t reopen blocked artery. Need to assess thrombolysis eligibility first.

Time since onset: ~1 hour 35 minutes
BP 168/94, glucose 108 mg/dL
No contraindications

Proceed with IV thrombolysis with alteplase➜ First correct BP to <140/90, then reperfusion➜ Send for mechanical thrombectomy instead➜ Do not give thrombolysis - ischemic brain at risk➜

Assessing for IV thrombolysis:
Time since onset: ~1 hour 35 minutes
NCCT: no hemorrhage
BP 168/94, glucose 108 mg/dL
No contraindications, good ASPECTS

Proceed with IV thrombolysis with alteplase➜ First correct BP to <140/90, then reperfusion➜ Send for mechanical thrombectomy instead➜ Do not give thrombolysis - ischemic brain at risk➜

You order CTA but realize mistake, order NCCT instead.

NCCT Findings: No hemorrhage, subtle early ischemic changes left MCA, good ASPECTS

Order CT angiogram head & neck now➜ Start aspirin now that hemorrhage ruled out➜ Assess eligibility for thrombolysis➜

You initiate IV alteplase. Bolus given, infusion running smoothly. Resident: ‘Good. Now what? Alteplase alone might not suffice for LVO.’

Start dual antiplatelet therapy with aspirin + clopidogrel➜ Repeat CTA, go for thrombectomy if occlusion persistent➜ Arrange mechanical thrombectomy regardless (confirmed LVO)➜

You lower BP before thrombolysis, then realize BP doesn’t need to be this low - tPA only requires <185/110 mmHg.

Proceed with IV thrombolysis➜ Send for mechanical thrombectomy instead➜ Do not give thrombolysis - ischemic brain at risk➜

You prioritize mechanical thrombectomy for M1 occlusion. IR team: ‘Giving IV thrombolysis first? We can do drip-and-ship.’

Start IV alteplase while prepping for thrombectomy➜ Don't give thrombolysis - LVO won't respond➜

You skip thrombolysis due to hemorrhage risk. Senior: ‘Inside 4.5-hour window, no contraindications, good ASPECTS. Can’t deny reperfusion!’

Proceed with IV thrombolysis with alteplase➜ Send for mechanical thrombectomy instead➜ Lower BP to <140/90 before deciding➜

You proceed with IV alteplase. CTA shows proximal left M1 occlusion.
Senior: ‘Alteplase alone has limited efficacy in LVO.’

Continue alteplase alone and wait for improvement➜ Arrange transfer for thrombectomy while continuing alteplase➜ Stop alteplase and send for thrombectomy➜

You lower BP before reperfusion, then realize mistake - tPA only requires <185/110 mmHg.

Proceed with IV thrombolysis➜ Send for mechanical thrombectomy instead➜ Do not give thrombolysis - ischemic brain at risk➜

You prioritize thrombectomy but realize guidelines require thrombolysis first. You give alteplase. CTA shows M1 occlusion.
Senior: ‘Alteplase alone limited in LVO.’

Continue alteplase alone and wait➜ Arrange transfer for thrombectomy while continuing alteplase➜ Stop alteplase and send for thrombectomy➜

You skip thrombolysis due to hemorrhage risk. Senior: ‘Inside 4.5-hour window, no contraindications. Can’t deny reperfusion!’

Proceed with IV thrombolysis with alteplase➜ Send for mechanical thrombectomy instead➜ Lower BP to <140/90 before deciding➜

You prescribe aspirin + clopidogrel. Resident: ‘Antiplatelets don’t recanalize M1 clot, increase hemorrhage risk after alteplase!’

Repeat CTA, go for thrombectomy if occlusion persistent➜ Arrange mechanical thrombectomy regardless (confirmed LVO)➜

You try to repeat CTA. Resident: ‘Why waste time? We know there’s LVO - that’s why thrombectomy exists!’

Thrombectomy successful: Clot retrieved from left M1, complete flow restoration
Speech improving, right-sided weakness improving
No hemorrhagic transformation

Senior: ‘Great job! Now figure out why he had stroke to prevent next one.’

Start dual antiplatelet therapy, schedule outpatient workup➜ Order TTE with bubble study + continuous cardiac monitoring➜ Test for hypercoagulability (Factor V Leiden, protein C/S, etc)➜

Thrombectomy successful: Clot retrieved from left M1, complete flow restoration
Speech improving, right-sided weakness improving
No hemorrhagic transformation

Senior: ‘Great job! Now figure out why he had stroke to prevent next one.’

Start dual antiplatelet therapy, schedule outpatient workup➜ Order TTE with bubble study + continuous cardiac monitoring➜ Test for hypercoagulability (Factor V Leiden, protein C/S, etc)➜

You initiate IV alteplase and notify IR for ‘drip-and-ship’

Thrombectomy successful: Clot retrieved from left M1, complete flow restoration
Speech improving, right-sided weakness improving
No hemorrhagic transformation

Senior: ‘Great job! Now figure out why he had stroke to prevent next one.’

Start dual antiplatelet therapy, schedule outpatient workup➜ Order TTE with bubble study + continuous cardiac monitoring➜ Test for hypercoagulability (Factor V Leiden, protein C/S, etc)➜

IR team: ‘Patient has no contraindications. Drip-and-ship improves outcomes even with LVO.’ You admit mistake and give alteplase.

Thrombectomy successful: Clot retrieved from left M1, complete flow restoration
Speech improving, right-sided weakness improving
No hemorrhagic transformation

Senior: ‘Great job! Now figure out why he had stroke to prevent next one.’

Start dual antiplatelet therapy, schedule outpatient workup➜ Order TTE with bubble study + continuous cardiac monitoring➜ Test for hypercoagulability (Factor V Leiden, protein C/S, etc)➜

You lower BP before reperfusion, then realize mistake - tPA only requires <185/110 mmHg, current BP 168/94.

Proceed with IV thrombolysis with alteplase➜ Send for mechanical thrombectomy instead➜

You wait to see if alteplase works alone. Senior: ‘Why waiting? LVO rarely recanalizes with alteplase alone!’

Arrange transfer for thrombectomy while continuing alteplase➜ Stop alteplase and send for thrombectomy➜

You stop alteplase for thrombectomy. IR informs you: ‘Wasn’t necessary - keep infusion running during transfer.’ You restart.

Thrombectomy successful: Clot retrieved from left M1, complete flow restoration
Speech improving, right-sided weakness improving
No hemorrhagic transformation

Senior: ‘Great job! Now figure out why he had stroke to prevent next one.’

Start dual antiplatelet therapy, schedule outpatient workup➜ Order TTE with bubble study + continuous cardiac monitoring➜ Test for hypercoagulability (Factor V Leiden, protein C/S, etc)➜

You lower BP before reperfusion, then realize mistake - tPA only requires <185/110 mmHg.

Proceed with IV thrombolysis➜ Send for mechanical thrombectomy instead➜

You start dual antiplatelet therapy. Senior: ‘That was major LVO! Can’t just wait for OPD workup! Patient could be back tomorrow!’

Order TTE with bubble study + continuous cardiac monitoring➜ Test for hypercoagulability➜

Morning after thrombectomy: Speech clearer, right-sided power 4+/5
Cardiac monitoring: Episode of atrial fibrillation lasting 40 seconds
Echo: No structural heart disease, normal LV function, no thrombus, bubble study negative

Wait for new CT scan, give heparin meantime➜ Wait for new CT scan before initiating therapy, no heparin➜ Prescribe oral anticoagulant (post-thrombectomy CT showed no hemorrhage)➜ Order prolonged Holter monitoring to confirm etiology➜

You order hypercoagulability tests. Senior: ‘67-year-old with HTN, DM, hyperlipidemia - common stroke reasons! Rule out common causes first.’

Cancel hypercoag tests, order cardiac monitoring + echo➜ Keep hypercoag panel but add cardiac monitoring + echo➜

Finish 2 — Fatal Error

You start heparin before new CT. Patient becomes drowsy, unequal pupils.
CT shows large intraparenchymal hemorrhage with mass effect and brain herniation.
Patient deteriorates rapidly, arrests. Resuscitation unsuccessful.
Removed from team.

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Repeat head CT (24h post-thrombectomy): No hemorrhagic transformation

Senior: ‘Good. Now start secondary prevention for AF-related cardioembolic stroke.’
Patient alert, improving, BP 138/84, glucose controlled
No contraindications to anticoagulation

Start direct oral anticoagulant (DOAC) today as long-term➜ Begin aspirin + clopidogrel dual antiplatelet therapy➜ Delay anticoagulation 2-3 days, continue aspirin alone➜

Finish 3 — Fatal Error

You start anticoagulation immediately. Patient becomes drowsy, GCS drops to 10.
CT shows large left-sided intracerebral hemorrhage with mass effect.
Initial scan only ruled out procedural bleeding - delayed hemorrhagic transformation risk.
Anticoagulation accelerated hemorrhage. Neurosurgery called but hemorrhage massive.
Patient deteriorates into herniation, pronounced dead.

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You order prolonged Holter monitoring. Senior: ‘We already have documented paroxysmal AF. Don’t need more evidence.’

Wait for new CT scan, give heparin meantime➜ Wait for new CT scan before initiating therapy, no heparin➜ Prescribe oral anticoagulant➜

Senior: ‘Hypercoag tests waste money and delay diagnosis. For patient with risk factors, not required!’

Cardiac monitoring: Episode of atrial fibrillation
Echo: No structural heart disease, normal LV function, no thrombus

Wait for new CT scan, give heparin meantime➜ Wait for new CT scan before initiating therapy, no heparin➜ Prescribe oral anticoagulant➜ Order prolonged Holter monitoring to confirm etiology➜

You start apixaban 5 mg twice daily for AF-related cardioembolic stroke.
Patient improving steadily, neurologically stable, BP controlled, ready for discharge.

Senior: ‘Good work! Finalize secondary prevention - lifelong anticoagulation, aggressive risk-factor control.’

Which discharge plan most appropriate?

Plan A: Apixaban, amlodipine, losartan, atorvastatin 80mg, metformin, physio+speech therapy, cardiology follow-up➜ Plan B: Apixaban, amlodipine, atorvastatin, metformin, DAPT (aspirin+clopidogrel), physio+speech therapy, cardiology follow-up➜ Plan C: Apixaban, amlodipine, losartan, atorvastatin, metformin, cardiology follow-up (no rehab)➜

You decide to start aspirin and clopidogrel instead of anticoagulation, but your senior immediately stops you.

‘This is a cardioembolic stroke from atrial fibrillation. AF doesn’t form platelet-rich clots like the ones seen in arteries, it forms fibrin-rich, coagulation-driven thrombi inside the left atrium!’ He cancels the order and waits for your corrected decision.

Start direct oral anticoagulant (DOAC) today as long-term anticoagulation➜ Delay anticoagulation for another 2-3 days to be safe, continue aspirin alone for now➜

You decide to wait another 2-3 days before starting anticoagulation and continue aspirin alone to be safe. Your senior immediately corrects you.

‘Why are you waiting? We already have a 24-hour CT showing no hemorrhage. This is the exact moment to begin anticoagulation. The longer you delay, the more you risk a recurrent stroke!’

You start the patient on apixaban, 5 mg twice daily for AF-related cardioembolic stroke, and discontinue aspirin. His condition is improving steadily. He’s neurologically stable, BP is controlled, and he’s medically ready for discharge planning.

Senior: ‘Good work! Finalize secondary prevention - lifelong anticoagulation, and aggressive risk-factor control.’

Which discharge plan most appropriate?

Finish 4 — Perfect Outcome

Discharge plan perfect: anticoagulation for AF, high-intensity statins, BP control, diabetes management, rehab.
Senior presents your orders to team: ‘This is exactly how secondary prevention should look!’
Patient’s gait improving, proper counseling for long-term adherence.
Discharged home with family support and clear follow-up.

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Finish 5 — Good but Flawed

Senior pauses at DAPT: ‘With atrial fibrillation, anticoagulation alone is treatment. Adding aspirin+clopidogrel increases bleeding risk - GI, intracranial, no benefit.’
Deletes DAPT before discharge.
Overall management decent but introduced unnecessary hazard.
Patient improves rapidly, discharged home safely.

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Finish 6 — Good but Incomplete

Senior: ‘Medications fine but skipped rehab. After MCA stroke, need structured physiotherapy, gait training, speech therapy to prevent long-term disability.’
Adds rehab referrals.
Patient remains stable, discharged safely but plan lacked key pillar of post-stroke care.

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