Emergency Medicine · Year 3 · from Emergency Medicine

Case 1: Acute Ischemic Stroke - Time is Brain

Patient Demographics

  • Age: 67 years
  • Sex: Male
  • Occupation: Retired accountant

Chief Complaint

"My husband's face looks droopy and he can't lift his right arm."

History of Present Illness

Wife called 911 after noticing her husband suddenly developed right-sided weakness and facial droop while eating breakfast. She reports he was "last seen normal" 45 minutes ago when he went to use the bathroom. On EMS arrival, patient unable to speak clearly and had right arm drift. EMS activated stroke alert en route.

Initial Assessment (Triage and First Impression)

ESI Level: 1 - Immediate life-saving intervention required (stroke alert)

First Impression (Across the Room):

  • Appearance: Alert but frustrated, right facial droop
  • Work of breathing: Normal respiratory effort
  • Circulation: Skin color normal

Vital Signs:

  • Heart rate: 88 bpm, irregularly irregular
  • Blood pressure: 178/96 mmHg
  • Respiratory rate: 16 breaths/min
  • SpO2: 97% on room air
  • Temperature: 37.0C
  • GCS: 14 (E4V4M6)
  • Glucose: 142 mg/dL

Primary Survey (ABCDE)

Airway:

  • Patent, no stridor or obstruction
  • Mild dysarthria noted

Breathing:

  • Normal respiratory effort
  • Clear bilateral breath sounds
  • No accessory muscle use

Circulation:

  • Irregular pulse (atrial fibrillation)
  • Strong peripheral pulses
  • No signs of heart failure

Disability:

  • GCS 14 (E4V4M6 - confused speech)
  • Right facial droop (lower face)
  • Right arm weakness (no antigravity movement)
  • Right leg weakness (drift against gravity)
  • Pupils: 3mm, reactive bilaterally

Exposure:

  • No trauma
  • No rashes

Neurological Assessment

NIH Stroke Scale (NIHSS):

  • 1a. Level of consciousness: 0
  • 1b. LOC questions: 1 (month wrong)
  • 1c. LOC commands: 0
  • 2. Best gaze: 1 (partial gaze palsy)
  • 3. Visual fields: 0
  • 4. Facial palsy: 2 (partial paralysis)
  • 5a. Left arm motor: 0
  • 5b. Right arm motor: 3 (no effort against gravity)
  • 6a. Left leg motor: 0
  • 6b. Right leg motor: 2 (some effort against gravity)
  • 7. Limb ataxia: 0
  • 8. Sensory: 1 (mild-moderate loss)
  • 9. Best language: 1 (mild aphasia)
  • 10. Dysarthria: 2 (severe)
  • 11. Extinction/inattention: 1

Total NIHSS: 14 (moderate stroke)

Last Known Well: 45 minutes ago

Secondary Survey

SAMPLE History:

  • Symptoms: Sudden right-sided weakness, facial droop, slurred speech
  • Allergies: None known
  • Medications: Lisinopril (not taking consistently)
  • PMH: Hypertension, "irregular heartbeat" (never followed up)
  • Last Meal: Eating breakfast when symptoms started
  • Events: Sudden onset while seated

Diagnostic Testing

Immediate:

  • Fingerstick glucose: 142 mg/dL
  • ECG: Atrial fibrillation with RVR (rate 112)

CT Head (door-to-CT: 8 minutes):

  • No hemorrhage
  • No early ischemic changes
  • ASPECTS score: 10

CT Angiography:

  • Left MCA M1 segment occlusion
  • Good collateral circulation

Labs:

  • INR: 1.0
  • Platelets: 234,000
  • Creatinine: 1.1

Management

Time-Critical Interventions:

  1. Door-to-needle time goal: <45 minutes
  2. IV alteplase 0.9 mg/kg (max 90 mg): 10% bolus, remainder over 60 minutes
  3. Blood pressure management: Allow permissive hypertension <185/110 pre-tPA
  4. Neurology and interventional radiology consulted
  5. NPO for swallow evaluation

Thrombectomy Decision:

  • Large vessel occlusion (LVO) confirmed
  • NIHSS 14, good ASPECTS
  • Within time window
  • Emergent mechanical thrombectomy performed

Post-Procedure:

  • Successful recanalization (TICI 2b/3)
  • NIHSS improved to 4
  • Admitted to Neuro ICU
  • Started on anticoagulation for atrial fibrillation (after 24-hour imaging)

Disposition

  • Neuro ICU admission
  • 24-hour follow-up CT
  • Transition to stroke unit
  • Comprehensive stroke workup
  • Anticoagulation planning

Teaching Points

  1. Time is brain: Each minute of untreated large vessel occlusion results in loss of ~1.9 million neurons
  2. Last known well: Document precisely - determines treatment eligibility
  3. NIHSS standardization: Consistent scoring enables treatment decisions and prognostication
  4. Stroke mimics: Always check glucose; consider seizure with Todd's paralysis, complex migraine
  5. Door-to-needle goals: <45 minutes for tPA; door-to-groin <90 minutes for thrombectomy
  6. Atrial fibrillation: Common cause of cardioembolic stroke; often undiagnosed

Clinical Image

Image Description: CT angiography of the brain demonstrating left middle cerebral artery M1 segment occlusion (arrow), with absent flow in the distal MCA territory, consistent with acute large vessel occlusion stroke.

Attribution: Image from Radiopaedia.org, Case courtesy of Dr. Frank Gaillard. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/cases/middle-cerebral-artery-occlusion

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