Phys Written Answers · neurological
Stroke — Written Clinical Reasoning
DCE long-case preparation: structured written reasoning for acute stroke management, including problem-list synthesis, investigation interpretation, and integrated secondary prevention planning.
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Target exams
SAQ 1 — Acute Stroke Management (15 marks, 20 minutes)
Prompt: Outline your immediate and acute management plan for this patient. Address reperfusion strategy, blood pressure management, and the first 24 hours of stroke unit care. Justify each decision with reference to evidence. [1]
Model Answer
Immediate assessment and problem identification (2 marks):
- Acute left MCA territory ischaemic stroke, NIHSS 18 — left M1 occlusion on CTA, presenting at 90 minutes from last-known-well
- Persistent atrial fibrillation on apixaban — affects thrombolysis eligibility (DOAC is a contraindication)
- Favourable imaging profile — ASPECTS 9, small core (15 mL), large penumbra (85 mL) — thrombectomy-eligible
- Comorbidities: hypertension, type 2 diabetes, dyslipidaemia — all modifiable risk factors for secondary prevention [1]
Reperfusion strategy (5 marks): [1]
The patient has a large vessel occlusion (M1 MCA) with a favourable imaging profile and is within the thrombectomy window. However, he is on apixaban, which is an absolute contraindication to IV thrombolysis. The anticoagulant effect of a DOAC cannot be reliably excluded by standard coagulation tests, and specific reversal (andexanet alfa) is not fast enough or indicated for the purpose of enabling thrombolysis. [1]
Therefore, IV thrombolysis is withheld, and the patient should proceed directly to mechanical thrombectomy. He is within the 0-6 hour window (90 minutes), has a confirmed LVO, and has a favourable core-to-penumbra ratio (ASPECTS 9, core 15 mL). The HERMES meta-analysis (individual patient data from 5 RCTs) established that thrombectomy within 6 hours of LVO doubles the rate of functional independence, with a number needed to treat of approximately 2.6. The patient does not need imaging-guided selection for the 0-6 hour window (only required for the extended 6-24 hour window per DAWN and DEFUSE-3), but his perfusion profile confirms the favourable mismatch. [1]
Blood pressure management (3 marks): [1]
As the patient is not receiving thrombolysis, permissive hypertension applies — do not treat unless BP exceeds 220/120 mmHg. His BP of 168/94 is appropriate and supports collateral perfusion to the penumbra. Lowering it would risk worsening the ischaemic territory. Post-thrombectomy, the target shifts to below 180/105 mmHg to reduce reperfusion injury and haemorrhagic transformation risk. [1]
First 24 hours of stroke unit care (5 marks): [1]
| Domain | Action | Rationale |
|---|---|---|
| Monitoring | Stroke unit admission; neurological observations every 15 min initially, then hourly. Continuous cardiac monitoring | Detect deterioration (reocclusion, haemorrhage, oedema). Monitor for AF complications |
| Blood glucose | Maintain 4-10 mmol/L with subcutaneous insulin protocol; avoid hypoglycaemia | Hyperglycaemia worsens penumbral injury; hypoglycaemia mimics stroke |
| Temperature | Paracetamol for any fever; active cooling if needed; investigate source | Each 1 degree C fever doubles odds of poor outcome |
| Swallow | Nil by mouth until formal swallow assessment. Bedside screen within 4 hours | Aspiration pneumonia is a leading cause of post-stroke mortality; global aphasia increases risk |
| DVT prophylaxis | Intermittent pneumatic compression immediately; pharmacological prophylaxis deferred until haemorrhagic transformation excluded | Immobile patients have 10-50% VTE risk |
| Imaging | Repeat non-contrast CT at 24 hours to exclude haemorrhagic transformation before starting antiplatelet/anticoagulation | Standard post-reperfusion protocol |
SAQ 2 — Secondary Prevention and Integrated Care (10 marks, 15 minutes)
Prompt: The patient's 24-hour CT shows successful reperfusion with no haemorrhagic transformation. His NIHSS has improved to 8. Carotid Doppler shows no significant carotid stenosis. Outline your integrated secondary prevention and rehabilitation plan. [1]
Model Answer
Problem list (2 marks):
- Cardioembolic stroke from persistent AF — on apixaban (was protective but stroke occurred despite it; reassess dose and adherence)
- Residual neurological deficit (NIHSS 8) — aphasia, right hemiparesis — rehabilitation required
- Hypertension — needs long-term BP target under 130/80
- Type 2 diabetes (HbA1c 68) — needs optimisation
- Dysphagia risk — formal swallow assessment before oral intake
- Post-stroke depression risk — screen at 1 month [1]
Anticoagulation management (3 marks): [1]
The patient was on apixaban when his stroke occurred. This is a treatment failure that requires investigation:
- Confirm adherence and dosing (apixaban 5 mg BD is the standard dose; dose reduction to 2.5 mg BD applies if any two of: age 80+, weight under 60 kg, creatinine over 133 — he is 76, likely does not meet dose-reduction criteria)
- Continue apixaban 5 mg BD. As his stroke is moderate (NIHSS 8) and repeat CT shows no haemorrhagic transformation, anticoagulation can be resumed approximately 3-6 days post-stroke (the 1-3-6-12 rule: moderate stroke NIHSS 8-16, start at approximately day 6). In practice, he was already on apixaban; it was held during the acute phase. Resume after confirming no haemorrhagic transformation.
- Antiplatelets are NOT indicated — this is a cardioembolic stroke. Adding an antiplatelet to a DOAC increases bleeding without reducing stroke risk (unless there is a separate indication such as coronary stent). [1]
Risk factor optimisation (3 marks): [1]
| Risk factor | Target | Intervention |
|---|---|---|
| Blood pressure | Under 130/80 | Up-titrate perindopril; add thiazide or amlodipine if needed. PROGRESS trial: perindopril +/- indapamate reduced recurrent stroke by 28% |
| Lipids | LDL reduction over 50% from baseline | Continue atorvastatin, increase to 80 mg. SPARCL: atorvastatin 80 mg reduced recurrent stroke |
| Diabetes | HbA1c under 53 mmol/mol | Add SGLT2 inhibitor (renal and cardiovascular benefit; does not lower stroke risk directly but addresses cardiometabolic risk). Continue metformin |
| Smoking/alcohol | Smoking cessation; alcohol moderation | Brief intervention; nicotine replacement therapy if needed |
Rehabilitation and follow-up (2 marks): [1]
- Early, intensive multidisciplinary rehabilitation: physiotherapy (gait and motor relearning), occupational therapy (activities of daily living, cognitive assessment), speech pathology (aphasia therapy, swallow assessment), dietitian
- Constraint-induced movement therapy for the right upper limb if eligible
- Screen for post-stroke depression at 1 month (PHQ-9); treat with SSRI (sertraline) if positive
- Early supported discharge planning with community rehab team when medically stable
- Medication reconciliation and patient education on apixaban adherence
- Address advance care planning and goals of rehabilitation with the patient and family [1]
References
- [1]Hacke W, et al. Pancreatic fibrosis correlates with exocrine pancreatic insufficiency after pancreatoduodenectomy Dig Surg, 2008.PMID 18818498
- [2]Nogueira RG, et al. Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct N Engl J Med, 2018.PMID 29129157
- [3]Wang Y, et al. Clopidogrel with aspirin in acute minor stroke or transient ischemic attack N Engl J Med, 2013.PMID 23803136
- [4]Barnett HJM, et al. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators N Engl J Med, 1998.PMID 9811916