07: Experienced colleagues decisions

Prof Mark Barber

Decision

• No BP intervention
• No lysis
• No thrombectomy

Not for any hyperacute stroke interventions.

Rationale

It seems likely, given the brain imaging, that we are dealing with a stroke mimic here.

Dr Tracey Baird

Decision

• No BP intervention
• No lysis
• No thrombectomy

Rationale

I think this is more likely to be a stroke mimic, there are non concordant signs ( L sided weakness and language dysfunction). There is no clear vessel occlusion and the perfusion is unhelpful (possibly suggestive of a more migrainous phenotype).

I would not treat acutely – I would prefer to give a single antiplatelet, review clinically and consider MRI thereafter.

Dr Anthony Pereira

Decision

• No BP intervention is needed
• Request CT, CTA & CTP
• No lysis
• No referral for thrombectomy

Rationale

I would ignore the alcohol history, his recent separation and redundancy to avoid being biased towards thinking that this was a functional presentation. The clinical issue here is that the speech is not clearly dysarthria or dysphasia. There is also a quadriparesis. A proper neurological examination is essential to identify clear-cut signs of an organic or  functional neurological condition.

I would request a CT, CTA and CTP. They are all normal. Therefore, there is no compelling reason to administer thrombolysis or consider thrombectomy.

If from the outset, after a proper clinical assessment unbiased by his social circumstances, I thought that this was functional, I would have asked my radiologists if they could possibly perform an MR brain with DWI.

Dr Shelagh Coutts

Decision

• No BP intervention
• No lysis
• No thrombectomy

Rationale

I think the red blob on the CTA is an artefact

If the weakness is just left sided then I would re-examine the patient.  I get a sense that this is a Todds paresis? Is there something on the exam or history that is helpful?

If I do not have a clear other diagnosis then I would treat with thrombolysis. In this case I am suspicious that this is a mimic. If there is nothing suggestive of a stroke when I re-examine them then I would not thrombolsye and observe the patient.

Dr William Whiteley

Decision

• No BP intervention
• No lysis
• No thrombectomy

Rationale

Here we have a diagnostic conundrum. The signs do not localize to one area of brain, and are not all consistent with the perfusion imaging. Where this is the case, I would not normally consider thrombolysis.

Ischaemic stroke is always possible, but here we would also be thinking of hemiplegic migraine – a condition that I think of as rare, and tends to be overdiagnosed in my opinion – or a functional hemiparesis.

We aren’t told of any functional symptoms or signs here, and this is where face to face examination to look for a Hoover’s sign (https://pubmed.ncbi.nlm.nih.gov/22118379/, https://pn.bmj.com/content/1/1/50) or  functional facial weakness would be helpful.