Neurology · Moderate
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 his family due to sudden-onset weakness in his right arm and speech difficulty that began 2 hours ago. He was previously in his normal state of health. He has a history of primary hypertension and hyperlipidaemia, for which he takes amlodipine and atorvastatin. On examination, he is alert and attentive. Neurological examination reveals right-sided lower facial droop, expressive dysphasia, and reduced muscle power in the right upper extremity (3/5) and right lower extremity (4/5). Sensory examination is intact to light touch. Capillary blood glucose is measured upon arrival.
Vital signs
- HR
- 88 bpm
- BP
- 165/95 mmHg
- RR
- 16/min
- Temp
- 36.8 °C
- SpO₂
- 97%
Examination findings
- Right-sided lower facial palsy with forehead sparing
- Expressive (Broca's) dysphasia
- Right upper limb power 3/5, right lower limb power 4/5
Investigations
| Capillary Blood Glucose | 5.8 mmol/L | reference: 4.0-7.8 |
| Platelet Count | 240 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 diagnostic investigation to perform immediately?
An immediate non-contrast CT head scan is the first-line imaging modality to exclude intracranial haemorrhage prior to considering intravenous thrombolysis. MRI brain is highly sensitive for acute ischaemia but takes longer and is less universally available in hyperacute settings. Carotid Doppler ultrasound and ECG are important secondary investigations to identify cardiac and vascular causes but must not delay primary neuroimaging.
Teaching point: An urgent non-contrast CT head scan is the essential initial investigation in acute stroke to rule out intracranial haemorrhage before administering thrombolysis.
Question 2 of 3
If non-contrast CT head scan excludes intracranial haemorrhage and early ischaemic changes, and no contraindications exist, what is the single most appropriate initial management step?
Intravenous alteplase (recombinant tissue plasminogen activator) is indicated for acute ischaemic stroke within 4.5 hours of symptom onset if intracranial haemorrhage is ruled out and no contraindications exist. Aspirin 300 mg is the standard acute treatment for ischaemic stroke, but it should be delayed for 24 hours post-thrombolysis if alteplase is given. Anticoagulation with heparin is not routinely indicated for acute ischaemic stroke.
Teaching point: Intravenous thrombolysis with alteplase is indicated within 4.5 hours of symptom onset in eligible patients with acute ischaemic stroke once haemorrhage is excluded.
Question 3 of 3
Based on the clinical presentation of right upper-limb predominant weakness, right facial palsy, and expressive dysphasia, which anatomical arterial territory is affected?
The clinical syndrome of contralateral face/arm weakness greater than leg weakness, combined with dominant hemisphere language deficit (expressive dysphasia), points specifically to a dominant (left) middle cerebral artery (MCA) territory stroke (specifically the superior division). Anterior cerebral artery (ACA) strokes characteristically affect the contralateral lower limb more than the arm. Vertebrobasilar strokes cause cerebellar or brainstem symptoms (e.g., ataxia, vertigo, cranial nerve palsies).
Teaching point: A dominant Middle Cerebral Artery (MCA) stroke typically presents with contralateral face and upper limb weakness accompanied by language deficits (aphasia/dysphasia).
Key learning points
- Non-contrast CT head is the urgent first-line neuroimaging modality in suspected hyperacute stroke to exclude intracranial haemorrhage.
- Intravenous thrombolysis with alteplase is indicated within 4.5 hours of symptom onset for acute ischaemic stroke after ruling out haemorrhage and contraindications.
- Dominant MCA territory strokes characteristically manifest with contralateral face and upper-limb-predominant motor deficits and speech dysphasia.
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