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IM18.1-16 | Cerebrovascular Accident — Assignment

CLINICAL SCENARIO

This assignment asks you to analyse a real or simulated stroke case and produce a structured clinical management document covering the full arc from acute triage to secondary prevention and rehabilitation. You will classify the stroke, localise the lesion, apply evidence-based acute management thresholds, design an aetiological workup, plan secondary prevention, coordinate a multidisciplinary rehabilitation plan, and counsel the patient and family. This integrates all five SDL modules in the Cerebrovascular Accident cluster and reflects the competencies expected of a final-year MBBS student who will function as a first-responder and care coordinator in a general medical setting.

Instructions

Write a structured clinical document in the five sections below. Use precise clinical language and cite specific numerical thresholds where relevant (do not use vague terms like 'high BP' — state the exact value). Do not copy SDL text verbatim — integrate and apply the concepts. All management recommendations must reflect current evidence-based guidelines (AHA/ASA, ESO). Word limit: 1,100–1,500 words.

Length: 1,100–1,500 words across all sections

What to Submit

Section 1: Stroke Classification and Lesion Localisation

Guidance: Using the clinical vignette provided (or a case from your clinical posting), classify the stroke as ischaemic or haemorrhagic, and for ischaemic stroke, state the TOAST subtype (large artery atherosclerosis, cardioembolic, small vessel/lacunar, other determined cause, cryptogenic). For haemorrhagic stroke, state the most likely aetiology (hypertensive, amyloid angiopathy, AVM, anticoagulant-related). Then localise the lesion to the correct vascular territory (MCA, ACA, PCA, basilar, PICA, etc.) by linking the observed neurological signs to the expected deficit pattern for that territory. Approximately 250 words.

Section 2: Acute Management Plan

Guidance: Write a structured acute management plan organised by ABCDE priorities. For ischaemic stroke: state whether the patient is eligible for IV thrombolysis (cite the 4.5-hour window, BP threshold of 185/110 mmHg, INR <1.7, and relevant exclusion criteria) and whether large vessel occlusion warrants mechanical thrombectomy (cite standard 6-hour and extended 24-hour criteria). For haemorrhagic stroke: state the BP target (SBP 130-140 mmHg), anticoagulation reversal strategy, and criteria for surgical intervention. Include glucose and temperature management targets. Approximately 300 words.

Section 3: Aetiological Workup and Secondary Prevention

Guidance: List the investigations required to determine stroke aetiology, dividing them into: (a) acute-phase imaging (NCCT, MRI-DWI, CTA), (b) cardiac investigations (ECG, 24-hour Holter, transthoracic or transoesophageal echocardiogram), (c) vascular imaging (carotid Doppler, MRA), and (d) laboratory workup (fasting glucose, HbA1c, lipid profile, thrombophilia screen if young stroke). Then outline secondary prevention: antiplatelet vs anticoagulation (applying CHA2DS2-VASc for AF patients), statin therapy, BP management targets, and lifestyle modifications. For AF-related stroke, state when anticoagulation should be initiated using the 1-3-6-12 rule. Approximately 300 words.

Section 4: Multidisciplinary Rehabilitation Plan

Guidance: Describe the multidisciplinary rehabilitation plan, beginning with the timing of initiation (within 24-48 hours of stroke onset if medically stable). Identify which discipline addresses each deficit: motor weakness (physiotherapy), dysphagia (speech-language pathology from day 1), self-care and ADL (occupational therapy), communication disorders (speech-language pathology), cognitive impairment (neuropsychology), and nutritional support (dietitian). Outline the three phases of rehabilitation — acute inpatient, subacute (hospital or rehabilitation facility), and community-based — with approximate timeframes and goals for each. Approximately 250 words.

Section 5: Patient and Family Counselling

Guidance: Write the key points of a counselling discussion with the patient and family. Cover: (a) explaining the diagnosis in accessible terms, (b) realistic and empathetic prognostic communication (avoid blanket statistics; frame around functional goals), (c) driving restrictions under Indian law (minimum 1 month after stroke, longer if residual deficits), (d) return to work timeline and factors influencing it, (e) importance of medication adherence for secondary prevention, (f) warning signs of recurrent stroke and when to call emergency services, and (g) psychological impact and the importance of screening for post-stroke depression. Approximately 200 words.

Grading Rubric — Acute Stroke Case Analysis Rubric

Criterion	Points	Full-marks descriptor
Stroke Classification and Lesion Localisation (Section 1): Correctly classifies the stroke subtype (ischaemic vs haemorrhagic, TOAST subtype or ICH aetiology) with supporting clinical evidence; accurately localises the lesion to the correct vascular territory using the neurological signs described.	20 pts	Stroke type classified precisely with correct TOAST subtype (for ischaemic) or ICH aetiology; lesion localised to correct vascular territory with named signs supporting each conclusion; correct explanation of crossed or ipsilateral sign logic.
Acute Management Plan (Section 2): Provides a structured, evidence-based acute management plan including supportive care, thrombolysis eligibility assessment (with correct thresholds), and indication or contraindication for thrombectomy; accurately identifies BP targets and monitoring priorities.	25 pts	Supportive care listed in ABCDE framework; thrombolysis eligibility addressed with correct 4.5-hour window, BP threshold (185/110), INR <1.7, glucose, platelet thresholds cited; thrombectomy indication correctly applied with 6-hour standard or 24-hour extended window; BP target for haemorrhagic stroke (130-140 SBP) stated separately.
Aetiological Workup and Secondary Prevention (Section 3): Selects appropriate investigations to determine stroke aetiology; outlines correct secondary prevention strategy including antiplatelet or anticoagulation therapy, BP control, lipid management, and lifestyle modification.	20 pts	Correct aetiological investigations selected (NCCT/MRI, ECG/cardiac monitor, echo, carotid Doppler or CTA, fasting lipids, HbA1c, thrombophilia screen if young); secondary prevention drugs stated with correct agents (DOAC for AF, dual antiplatelet then single for non-cardioembolic, statin, RAAS agent); timing of anticoagulation in AF correctly stated (1-3-6-12 rule or equivalent).
Rehabilitation and Multidisciplinary Plan (Section 4): Outlines an appropriate multidisciplinary rehabilitation plan with correct timing of initiation, relevant disciplines, and phase-based goals; demonstrates understanding that rehabilitation begins acutely.	20 pts	Early mobilisation within 24-48 hours stated; all relevant MDT disciplines identified (PT, OT, SLP, neuropsychology, dietitian, social work); three phases of rehabilitation (acute, subacute, community) with timeframes described; deficit-specific discipline matching (dysphagia to SLP, motor to PT, ADL to OT).
Patient and Family Counselling (Section 5): Demonstrates ability to counsel patient and family on diagnosis, prognosis, driving restrictions, return to work, secondary prevention adherence, and psychosocial support in empathetic, practical terms.	15 pts	Counselling covers: clear diagnosis explanation, realistic but hopeful prognostic framing using functional outcomes rather than statistics alone, driving restriction (minimum 1 month, longer if deficits), return to work timeline based on deficit and job demands, secondary prevention medication adherence, warning signs of recurrent stroke, and psychosocial support including depression screening.

PEER REVIEW

Review your peer's stroke case analysis using the rubric provided. For each section, assign a score and write one specific comment: identify one element that is accurate and well-reasoned, and one element that is missing or imprecise. For Section 2 (Acute Management), verify that exact numerical thresholds are cited — vague descriptions (e.g. 'controlled hypertension') are insufficient. For Section 3 (Secondary Prevention), verify that AF anticoagulation timing is addressed using the 1-3-6-12 rule or equivalent evidence. Complete your review within 72 hours of receiving the submission.