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IM18.1-16 | Cerebrovascular Accident — PBL Case

CLINICAL SETTING

It is 9:30 AM at a district government hospital in Tamil Nadu. Dr Kavitha, a final-year MBBS student on her general medicine posting, is the first to see a new arrival in the emergency room. The patient is Mr Rajan, a 64-year-old retired schoolteacher, brought by his wife and son. His wife explains that he was having his morning tea at 8:45 AM when he suddenly dropped the cup, could not move his right hand, and tried to say something but could only produce garbled sounds. They drove 25 minutes to reach the hospital. He has no known medical history and takes no regular medications. On initial observation: he is alert, looking to the LEFT, not following verbal commands. His right arm hangs limp at his side. His face shows a right-sided droop. Vital signs: BP 195/110 mmHg, pulse 88/min irregular, SpO2 96% on room air, blood glucose 8.4 mmol/L, temperature 37.2 C. Dr Kavitha writes in the emergency register: 'Acute onset right hemiplegia + aphasia. Last known well: 08:45. Time now: 09:35. Window: 50 minutes remaining for 4.5 h.'

Trigger 1: The First 15 Minutes — Triage, Examination, and the Clock

Dr Kavitha calls the medical officer on duty, Dr Suresh, who arrives within 3 minutes. He performs a rapid NIHSS assessment: right facial droop (1), right arm plegia — no movement (4), right leg drift — moderate weakness (3), gaze deviation to the left (2), aphasia — global, no words (3), visual field cut right (2). NIHSS = 15. He orders an urgent NCCT brain. While waiting for the CT, he asks Dr Kavitha to verify thrombolysis eligibility. Dr Kavitha pulls out her checklist and notes: time from onset to now = 50 minutes, meeting the <4.5-hour window. BP is 195/110 mmHg — above the 185/110 threshold. She notes the pulse is irregularly irregular. Dr Suresh says: 'The BP needs to come down before we can give alteplase. Two minutes — do you know what to give and to what target?'

DISCUSSION POINTS

  • What is the NIHSS and how does a score of 15 classify this stroke? What does each domain score represent in terms of the patient's deficits?
  • The BP is 195/110 mmHg — what is the exact BP threshold for IV thrombolysis eligibility, and which drug(s) would you use to achieve this threshold rapidly without over-lowering?
  • The pulse is irregularly irregular — what does this suggest, and does the possible underlying cause change the acute management or the choice of secondary prevention later?
Click to reveal Trigger 2: The CT Report — Ischaemia or Haemorrhage? (discuss previous trigger first!)

Trigger 2: The CT Report — Ischaemia or Haemorrhage?

The NCCT brain report arrives (35 minutes after onset): 'No hyperdense lesion to suggest haemorrhage. Subtle loss of grey-white differentiation in the left insular cortex. No midline shift. ASPECTS score 8.' Dr Suresh briefs Mr Rajan's son: 'This is an ischaemic stroke — a blood clot has blocked an artery in the brain. There is no bleeding. We have a treatment — a clot-dissolving drug — but we need to give it within 4.5 hours of onset and we must first bring the blood pressure down to a safe level. I need your consent and your father's assent to proceed.' The son agrees immediately. BP after a single dose of IV labetalol 10 mg is now 182/105 mmHg. Dr Suresh decides to proceed with IV alteplase. He asks Dr Kavitha: 'I want a CTA of the brain and neck — what am I looking for and why does it matter for this patient?'

DISCUSSION POINTS

  • What is the ASPECTS score and what does a score of 8 indicate in terms of infarct extent and thrombolysis risk? At what score is the risk of haemorrhagic transformation considered high?
  • Why is CTA of the brain and intracranial vessels performed in this setting? What finding would change the management from thrombolysis alone to combined thrombolysis and mechanical thrombectomy?
  • The consent process for thrombolysis in a patient who cannot communicate: what are the ethical and practical principles, and who has the authority to consent on behalf of an incapacitated adult in an Indian public hospital?
Click to reveal Trigger 3: Two Hours Later — Deterioration During Infusion (discuss previous trigger first!)

Trigger 3: Two Hours Later — Deterioration During Infusion

IV alteplase (0.9 mg/kg, 90 mg maximum, 10% bolus then infusion over 60 minutes) is commenced at 10:05 AM. At 11:10 AM — 45 minutes into the infusion — the nurse on duty calls Dr Suresh urgently. Mr Rajan's GCS has dropped from 10 to 6. His BP is now 210/120 mmHg. His right pupil is 5 mm and sluggishly reactive. Dr Suresh immediately stops the alteplase infusion and orders a STAT repeat NCCT brain. The report, available 12 minutes later, shows: 'Large hyperdense collection in the left basal ganglia and left MCA territory, consistent with haemorrhagic transformation — parenchymal haemorrhage type 2 (PH-2). Midline shift 7 mm to the right.' Dr Suresh turns to Dr Kavitha and says: 'This is the most serious complication of thrombolysis. What do you give now, and who needs to be called?'

DISCUSSION POINTS

  • What is symptomatic intracranial haemorrhage (sICH) after thrombolysis, what is its approximate incidence, and what are the risk factors that increase its likelihood?
  • The alteplase infusion is stopped. What is the immediate pharmacological reversal strategy for thrombolysis-induced haemorrhage — specifically, what blood products are used and why?
  • With a midline shift of 7 mm and deteriorating GCS, what are the indications for neurosurgical intervention, and what are the realistic surgical options for a left MCA territory haemorrhagic transformation?
Click to reveal Trigger 4: Recovery, AF, and the Anticoagulation Decision (discuss previous trigger first!)

Trigger 4: Recovery, AF, and the Anticoagulation Decision

Mr Rajan survives the acute crisis after neurosurgical consultation (conservative management — midline shift improved to 3 mm on day 3 NCCT with osmotherapy and BP control). By day 10, he is awake, follows simple commands, has partial right arm movement (NIHSS now 8), and has word-finding but no global aphasia. The cardiologist confirms permanent atrial fibrillation on 24-hour Holter; transthoracic echo shows moderate left atrial dilatation and no structural valve disease. The team gathers for a ward round discussion. The registrar asks: 'CHA2DS2-VASc for this patient — calculate it, and when do we start anticoagulation given that he had a haemorrhagic transformation?' The family is present in the corridor, asking Dr Kavitha: 'Doctor, will he walk again? Can he go home? Will this happen again?'

DISCUSSION POINTS

  • Calculate Mr Rajan's CHA2DS2-VASc score from the available clinical information. What score does a prior stroke or TIA contribute, and what is the recommended treatment at his score?
  • Given that he had a haemorrhagic transformation (PH-2) after thrombolysis, when should anticoagulation for AF be initiated? Apply the 1-3-6-12 rule and justify the timing for this specific scenario.
  • How would you counsel Mr Rajan's family about prognosis — what do you say about walking, going home, recurrence risk, and the role of rehabilitation? What specific markers of recovery predict a better functional outcome at 6 months?

Group Task Assignments

  • Using Mr Rajan's clinical data, construct a complete stroke triage checklist covering: NIHSS assessment, thrombolysis inclusion and exclusion criteria (with exact numerical thresholds), BP management algorithm, and the criteria for requesting CT angiography in addition to plain NCCT.
  • Draft the consent and information sheet for a patient's family before IV thrombolysis in a patient who cannot communicate, addressing: what the drug does, the 6% risk of sICH, the alternative of no treatment, and the role of mechanical thrombectomy as a complementary option.
  • Design a discharge summary for Mr Rajan at day 14 covering: stroke classification (TOAST subtype), secondary prevention medications (with doses and evidence), driving restriction, rehabilitation referral plan, and the CHA2DS2-VASc-guided anticoagulation plan including the specific timing of initiation.
  • Debate the following clinical question: 'For a patient with AF-related ischaemic stroke who develops haemorrhagic transformation on thrombolysis, should long-term anticoagulation still be prescribed?' What is the evidence for and against, and what factors tilt the decision?

Learning Issues

Research these questions and bring your findings to the discussion.

  1. [IM18.11] What are the inclusion and exclusion criteria for IV thrombolysis in acute ischaemic stroke, including the exact BP threshold, time window, INR threshold, and platelet count threshold?
  2. [IM18.8] What is the ASPECTS score, how is it calculated on NCCT brain, and how does it influence thrombolysis eligibility and haemorrhagic transformation risk?
  3. [IM18.13] What is the management of haemorrhagic transformation after IV thrombolysis — including the blood product reversal strategy and the criteria for neurosurgical intervention?
  4. [IM18.12] What is the CHA2DS2-VASc score, how is it calculated, and what is the correct timing of anticoagulation initiation in AF-related ischaemic stroke using the 1-3-6-12 rule?
  5. [IM18.15] What are the phases, disciplines, timing, and deficit-matched goals of a multidisciplinary stroke rehabilitation programme?
  6. [IM18.16] How do you counsel a stroke patient's family about prognosis, recurrence risk, driving restrictions, secondary prevention, and the psychological impact of stroke?