Patient Details: A 52-year-old male who is a cab driver by profession, brought by his brother on 22 February 2024 at 11:00 PM with chief complaints of:

• Sudden loss of consciousness followed by recovery 1 hour back

• F/b acute onset weakness of the right upper and lower limbs

• And complete loss of speech

Immediate Complaint Leading to Emergency Department Visit

The patient was apparently well until 10:00 PM (Last Known Well) when he suddenly developed an episode of loss of consciousness. After regaining consciousness, his brother noticed that he was unable to speak and had weakness of the right side of his body. As the neurological deficits persisted, he was immediately brought to the Emergency Department. The patient arrived within 1 hour of symptom onset, making him a potential candidate for reperfusion therapy.

2. Triage

Stroke Recognition Tool – BEFAST

B – Balance: Unable to assess as pt brought on stretcher due to right-sided weakness

E – Eyes: No obvious visual symptoms elicited initially

F – Face: Right-sided facial deviation suggestive of UMN facial palsy

A – Arm: Right upper limb weakness present

S – Speech: Complete loss of speech (aphasia)

T – Time: Last Known Well 10:00 PM; arrived within 1 hour. Stroke Code activated immediately

 Triage Colour: RED (Resuscitation Category)

Reason: Hyperacute stroke within reperfusion window requires immediate imaging, neurological assessment, and consideration for thrombolysis and/or mechanical thrombectomy

3. Primary Survey

A. Airway & Cervical Spine

• Airway patent

• Patient maintaining airway independently

• Able to protect airway

• No pooling of secretions

• No stridor or gurgling

• No vomiting

• Cervical spine injury not suspected

• Difficult airway cart kept ready considering possible neurological deterioration

B. Breathing

• Respiratory Rate: 14/min

• SpO₂: 99% on room air

• No respiratory distress

• Bilateral equal chest expansion

• Trachea central

• Percussion: Normal note bilaterally

• Auscultation: Bilateral vesicular breath sounds, No wheeze, No crepitations

 C. Circulation

Pulse Rate: 92/min, irregularly irregular, Normal volume and character

• All peripheral pulses palpable equally

• Capillary refill time: <2 seconds, Warm & Dry Extremities

BP: R upper limb: 165/95 mmHg, L upper limb: 164/94 mmHg, Lower limb BP: Not indicated

JVP: Not elevated, Cardiac Auscultation: S1, S2 normal, Rhythm irregularly irregular, No murmurs or gallops

D. Disability

Level of Consciousness: Conscious and alert

GCS: E4 V5 M6 = 15/15

Pupils: Bilaterally equal 3 mm with reactive to light

Neurological Deficit

• Complete aphasia

• Right hemiparesis

• Right UMN facial palsy

NIH Stroke Scale (NIHSS): 15 (formal scoring to be completed)

E. Exposure

• Afebrile

• No external injuries

• No scalp hematoma

• No bleeding

• No skin rash

• No pressure sores

• No obvious deformity

4. Stabilization

• Stroke Code activated immediately

• Two 18G peripheral intravenous cannulas secured

• Continuous ECG, pulse oximetry, and non-invasive BP monitoring initiated

• Head end elevated to 30°

• Patient kept nil per oral (NPO)

• Blood samples sent for urgent investigations

• Thrombolysis checklist completed

• Door-to-CT target <20 minutes

5. Primary Adjuncts

·        RBS: 164 mg/dL

·        Arterial Blood Gas: Normal acid-base status.

·        ECG: Atrial fibrillation with Ventricular rate of 90/min with no acute ischemic ST-T changes

·        NCCT Brain (Emergency): No ICH, No mid line shift, Early loss of gray-white matter differentiation in left MCA territory; ASPECTS: 8

·        Focused POCUS Cardiac: Good LV systolic function, no pericardial effusion, no gross intracardiac thrombus

Secondary Survey

A. Brief Medical History

The patient was apparently well until 10:00 PM, when he suddenly developed an episode of loss of consciousness while at home which was witnessed by his brother. The episode lasted for a brief period, after which he regained consciousness. His brother immediately noticed that the patient was unable to speak and had weakness involving the right upper and lower limbs. There was no history of trauma, seizures, tongue bite, urinary incontinence, headache, vomiting, fever, chest pain, palpitations, or similar episodes in the past. He was brought to the Emergency Department within 1 hour of the Last Known Well.

B. AMPLE History

Allergies: No known drug allergies

Medications:  On T. Telmisartan 40mg OD, T. Amlodipine 5mg OD, T. Metformin + Glimepiride 500/1mg BD. But not compliant, last check-up date Unknown.

Past Medical History:  T2DM & HTN for 8 years, No similar past history

Last Meal: Dinner at approximately 9:00 PM

Events Leading to Illness: Sudden onset neurological deficit at home without preceding trauma

Social History: Chronic smoker, chronic alcohol consumption

C. Detailed Medical Examination

I. Examination of Remaining Systems

General Examination: Conscious, Well-built and nourished, No P I C C L E

II. Central Nervous System

Higher Mental Functions: Conscious and alert with Global aphasia, Unable to obey complex verbal commands

Cranial Nerves

• Right upper motor neuron facial nerve palsy

• Pupils equal and reactive

• Extraocular movements full

• Remaining cranial nerves grossly normal

Motor Examination

Power

Left Upper Limb: 5/5

Left Lower Limb: 5/5

Right Upper Limb: 1/5

Right Lower Limb: 2/5

·        Tone: Increased on the right side

·        Deep Tendon Reflexes: Brisk on the right and normal on the left

·        Plantar Reflex: Right: Extensor, Left: Flexor

Sensory Examination: Decreased sensation over the right side (limited assessment due to aphasia)

Coordination: Right side: NT.  Left side: normal

Meningeal Signs were absent

Cardiovascular System: Pulse irregularly irregular, Variable intensity of S1 S2 normal, No murmurs, Peripheral pulses equal

Respiratory System: Bilateral equal air entry with Vesicular breath sounds, No added sounds

Abdomen: Soft, non-distended, non-tender, no organomegaly, bowel sounds present

Probable Diagnosis: CVA with Right sided hemiparesis with aphasia of acute Left Middle Cerebral Artery (MCA) Territory Ischemic origin, most likely cardioembolic secondary to atrial fibrillation, presenting within window period with Last Known Well time of 1 hour, with h/o T2DM and HTN, eligible for reperfusion therapy.

Differential Diagnosis

1. Acute ischemic stroke due to left MCA large vessel occlusion (most likely)

2. Cardioembolic stroke secondary to atrial fibrillation

3. Post-ictal (Todd's) paralysis

4. Cerebral venous thrombosis

5. Brain tumor

6. Functional neurological disorder (less likely)

Management:

·        Control BP <185/110

·        Prepare thrombolysis check list.

·        Prepare for Thrombolysis along with stroke unit.

·        Send important lab investigations and prepare backup for sICH.

·        Monitor during Thrombolysis: NIHSS and BP.

As an emergency physician my Aim in AIS case is to:

·        Identify and classify the Stroke as Ischemic vs Hemorragic vs TIA

·        Check the window period for thrombolysis or thrombectomy.

·        Evaluate the eligibility for thrombolysis.

·        Activate Stroke unit for thrombolysis or thrombectomy.

·         Do NIHSS and monitor.

·        Evaluate the cause or risk and risk factors.

·        Primary treatment with vital stabilization.

Stroke out of window period: work up and refer to neurology.