Neurology · Easy
This case is fictional and exists for study. It describes no real patient.
68 years · male
A 68-year-old male presents to the emergency department with sudden-onset right-sided weakness and difficulty speaking that started 1.5 hours ago. His wife noted that his face drooped on the right side and he was unable to lift his right arm while having breakfast. He has a past medical history of hypertension and type 2 diabetes mellitus, both managed with oral medications. He has no prior history of stroke, head trauma, or bleeding disorders. On neurological examination, he is alert but has expressive aphasia. There is a right upper motor neurone facial palsy and right-sided hemiparesis, with muscle power measured at 2/5 in both the right upper and lower limbs.
Vital signs
- HR
- 88 bpm
- BP
- 165/95 mmHg
- RR
- 16/min
- Temp
- 36.8 °C
- SpO₂
- 98%
Examination findings
- Expressive (motor) aphasia
- Right upper motor neurone facial palsy
- Right upper and lower limb weakness (power 2/5)
- Normal sensation to light touch bilaterally
Investigations
| Capillary Blood Glucose | 6.2 mmol/L | reference: 4.0-7.0 |
| Platelets | 250 10^9/L | reference: 150-400 |
| INR | 1.0 | reference: 0.8-1.2 |
Question 1 of 3
Which of the following is the most appropriate initial investigation to perform?
A non-contrast CT head scan is the essential initial investigation to immediately exclude intracranial haemorrhage before initiating reperfusion therapy. MRI is sensitive for ischaemic change but is more time-consuming and less accessible acutely. Carotid Doppler ultrasound is part of the subacute workup for ischaemic stroke aetiology, not the emergency initial evaluation. Lumbar puncture is used to evaluate suspected subarachnoid haemorrhage or central nervous system infection.
Teaching point: An urgent non-contrast CT head scan must be performed immediately in suspected acute stroke to differentiate ischaemic from haemorrhagic stroke.
Question 2 of 3
Based on the clinical presentation, which is the most likely diagnosis?
The patient exhibits symptoms localized to the dominant (left) cerebral hemisphere: expressive aphasia, right-sided facial weakness, and right hemiparesis, which is characteristic of a left MCA supply distribution. A right MCA stroke would cause left-sided motor deficits and spatial neglect. A TIA is defined by complete resolution of symptoms within 24 hours without evidence of acute infarction. Subdural haematoma typically presents subacutely with fluctuating consciousness and headaches, often following head trauma.
Teaching point: Left middle cerebral artery occlusion presents with expressive/receptive aphasia, right facial droop, and right-sided body weakness.
Question 3 of 3
The urgent non-contrast CT head scan shows no evidence of haemorrhage or early ischaemic changes. What is the most appropriate next step in management?
The patient has an acute ischaemic stroke with a clear time of onset 1.5 hours ago (within the 4.5-hour window) and haemorrhage has been ruled out by non-contrast CT head. Intravenous thrombolysis with alteplase is indicated. Oral aspirin (300 mg) is indicated for acute ischaemic stroke, but when thrombolysis is administered, aspirin is delayed for 24 hours to reduce the risk of haemorrhagic transformation. Anticoagulation with heparin is not indicated acutely for ischaemic stroke. Surgical decompression is reserved for malignant MCA infarction with life-threatening cerebral oedema.
Teaching point: Intravenous alteplase should be administered within 4.5 hours of symptom onset in eligible patients with acute ischaemic stroke once acute haemorrhage is excluded by CT scan.
Key learning points
- Immediate non-contrast head CT is required in acute stroke to rule out haemorrhage prior to thrombolytic therapy.
- Left MCA territory strokes present with language deficits (aphasia) alongside right-sided face, arm, and leg motor weakness.
- Intravenous thrombolysis with alteplase is indicated within 4.5 hours of acute ischaemic stroke onset if contraindications and haemorrhage are ruled out.
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