Neurology · Easy
This case is fictional and exists for study. It describes no real patient.
68 years · male
A 68-year-old male is brought to the emergency department by ambulance following the sudden onset of left-sided body weakness and slurred speech that began 1 hour ago while he was watching television. His wife noted that his face looked drooped on the left side. He has a past medical history of hypertension and hyperlipidaemia, for which he takes amlodipine and atorvastatin. On arrival, he is alert and oriented to time, place, and person. Bedside capillary blood glucose is checked immediately and is within normal limits.
Vital signs
- HR
- 82 bpm
- BP
- 165/95 mmHg
- RR
- 16/min
- Temp
- 36.8 °C
- SpO₂
- 98%
Examination findings
- Left-sided lower facial weakness
- Left upper and lower limb power 2/5
- Dysarthric speech
- Normal sensation to light touch bilaterally
Investigations
| Capillary Blood Glucose | 5.8 mmol/L | reference: 4.0-7.0 |
| Platelets | 220 10^9/L | reference: 150-400 |
| INR | 1.0 | reference: 0.8-1.2 |
Question 1 of 3
Based on the clinical presentation of sudden-onset, persistent focal neurological deficits, what is the most likely diagnosis?
Acute ischaemic stroke presents with sudden-onset focal neurological deficits (e.g., facial droop, limb weakness, dysarthria) that persist. Transient ischaemic attack (TIA) involves neurological deficits that resolve completely within 24 hours (typically within 1 hour). Subdural haematoma usually presents subacutely following head trauma. Todd's paresis is transient neurological weakness occurring after a seizure.
Teaching point: Acute stroke presents with sudden-onset persistent focal neurological deficits, distinguishing it from TIA where deficits resolve rapidly.
Question 2 of 3
What is the single most appropriate initial investigation to perform immediately in the emergency department?
An urgent non-contrast CT head scan is the essential initial imaging modality to rule out intracranial haemorrhage before thrombolysis can be initiated. MRI is highly sensitive for acute ischaemia but is time-consuming and less accessible acutely. Carotid ultrasound and ECG are important secondary investigations to determine stroke aetiology, but they do not take precedence over immediate CT head imaging.
Teaching point: An urgent non-contrast CT head is the first-line investigation to differentiate ischaemic stroke from haemorrhagic stroke.
Question 3 of 3
If non-contrast CT head rules out intracranial haemorrhage and there are no contraindications, what is the next best management step?
Intravenous alteplase (thrombolytic therapy) is indicated for patients with acute ischaemic stroke presenting within 4.5 hours of symptom onset, once intracranial haemorrhage has been excluded by CT scan. Oral aspirin 300 mg is administered 24 hours after thrombolysis or immediately if thrombolysis is contraindicated. Heparin infusion is not recommended routinely for acute ischaemic stroke. Antihypertensives such as labetalol are only required before thrombolysis if blood pressure exceeds 185/110 mmHg.
Teaching point: Intravenous alteplase within 4.5 hours of symptom onset significantly improves functional outcomes in acute ischaemic stroke.
Key learning points
- Always check blood glucose immediately to rule out hypoglycaemia mimicking acute stroke.
- Non-contrast head CT is the definitive initial test to exclude haemorrhage prior to thrombolysis.
- Intravenous thrombolysis with alteplase is indicated within 4.5 hours of onset for acute ischaemic stroke in eligible patients.
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