1) A 54-year-old woman presented with sudden onset right-sided weakness and inability to speak, with a history of a prior TIA. Initial assessment found a NIH stroke scale score of 25 and blood glucose of 87 mg/dL. 2) CT scan showed no hemorrhage. CT angiogram then revealed an occlusion of the left middle cerebral artery. The patient received tPA and was taken for mechanical thrombectomy. 3) She was admitted to the neurosciences intensive care unit. She improved significantly with treatment and was discharged with a modified Rankin score of 0 at 90 days.

1. 4th TIME CRITICAL
DIAGNOSIS SUMMIT
Naresh Mullaguri MD
Neurology Resident physician
University of Missouri
Columbia, Missouri
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2. What to do next?
Disclosures :
None
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3. Case
54-year old right handed Caucasian female
LKW – 1550 PM. Symptom onset – 1555 PM
Symptoms: sudden onset right sided weakness and unable to
speak. Also had confusion and agitation. Witnessed by her
daughter and called EMS. She had h/o loose stools for the past
3 days.
PMHx: TIA 10 years ago with similar symptoms of right sided
weakness and inability to speak. Patient not on any antiplatelet
or anticoagulants at home.
She was taken to OSH by EMS at 1635 pm.
Time elapsed –
45min
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4. What is the next appropriate
step?
Send her to CT scan of the Head
Finger stick Blood Glucose
Perform NIH stroke scale
Wait for more history from daughter
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5. What is the next appropriate
step?
Send her to CT scan of the Head
Finger stick Blood Glucose
Perform NIH stroke scale
Wait for more history from daughter
NIHSS - 25
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6. Finger-stick Glucose of 87mg/dl
She was taken to the CT scanner – No
hemorrhage.
What do you do next?
a) Do a CT perfusion scan
b) Mix the t-PA
c) Assess the inclusion and exclusion criteria for t-PA
d) Wait for the daughter to obtain consent for t-PA
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7. What do you do next?
a) Do a CT perfusion scan
b) Mix the t-PA
c) Assess the inclusion and exclusion
criteria for t-PA
d) Wait for the daughter to come to get
consent for t-PA
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8. The ER physician noticed some jerking movements on the
left side of the body on her way back from CT scanner.
Diagnosed as Stroke with possible seizure*.
1mg of Ativan was given and also loaded with 1gm
Keppra. INR – 1.0
Decided to transfer the patient to the University hospital
as he is not a t-PA candidate.
*Seizure at stroke onset is a relative contraindication for t-
PA
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9. She arrived to UH ER via ambulance at 1905 pm.
Time elapsed – 3hr
10min
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10. What do you do next?
a) seizure with post ictal weakness, no acute intervention.
b) Calculate NIH stroke scale.
c) Do a CT and CT Angiogram of the Head and Neck.
d) Admit the patient to the Neurology service.
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11. What do you do next?
a) seizure with post ictal weakness, no acute intervention.
b) Calculate NIH stroke scale.
c) Do a CT and CT Angiogram of the Head and Neck.
d) Admit the patient to the Neurology service.
NIH Stroke scale -
18
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12. CT Angiogram of the Head and Neck was
performed which showed Left sided proximal
MCA occlusion.
What would you do next?
a) Call Interventionist for mechanical
thrombectomy.
b) Start t-PA immediately as she is within
extended window.
c) Order CT perfusion of the Head to assess
penumbra.
d) Call the daughter to explain the situation.
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13. What would you do next?
a) Call interventionist for mechanical thrombectomy.
b) Start t-PA immediately as she is within extended
window*.
c) Order CT perfusion of the Head to assess penumbra.
d) Call the daughter to explain the situation.
*There is no specific history of Seizure and even if there is a focal seizure
with Stroke, it is a relative contraindication and her symptoms do not
correlate with seizure but with occluded left MCA, which is her dominant
hemisphere and might leave her with significant disability if left untreated.
T-PA started at 1930 PM after obtaining verbal consent from husband.
Time elapsed – 3hr 35min 4/8/20174th TCD summit 13

14. What do you do next?
a) Call the interventionist for mechanical thrombectomy
b) Wait for the t-PA to finish and reassess her symptoms
c) Admit the patient to neurosciences intensive care unit for
further care.
d) Call and appreciate outside ER physician for his timely
help.
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15. What do you do next?
a) Call the interventionist for mechanical thrombectomy*.
b) Wait for the t-PA to finish and reassess her symptoms.
c) Admit the patient to neurosciences intensive care unit for
further care.
d) Call and appreciate outside ER physician for his timely
help.
*Left M1 occlusion – within 6hr time window for endovascular
intervention.
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16. She had a successful mechanical
thrombectomy.
She was transferred to the NSICU – she
improved significantly with NIH of 0 at
discharge. She was monitored for A.fib
at discharge with a loop recorder. She
was prescribed Aspirin, Plavix and a
statin.
Modified Rankin Score at 90days is “0”
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17. Thank you
Acknowledgements: Brandi French MD, Arun Kumar MD, Tami Harris SCRN
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