The stroke consultant, Dr. Khan, arrived. “This is a large vessel occlusion. Thrombolysis alone may not recanalise. We need mechanical thrombectomy, but our nearest centre is 45 minutes away by ambulance.”
“Status epilepticus? Or stroke progression?” James murmured. He gave 2 mg IV lorazepam. The jerking stopped, but the aphasia and hemiparesis remained unchanged. emergency medicine journal
The clock started. Dr. James Cooper, the emergency medicine registrar, met the patient in Resus 4. Mr. Patel was awake but unable to raise his right arm or leg. His speech was dense, global aphasia – not just slurred, but absent. He followed left-sided commands with his eyes. The face showed a pronounced right lower facial droop. The stroke consultant, Dr
James ran through the ROSIER score: 5 out of 10 – high probability of acute stroke. Crucially, the wife confirmed symptom onset exactly 52 minutes ago. That put Mr. Patel within the 4.5-hour window for thrombolysis, but only if the CT head was clear of haemorrhage and the team moved fast. The stroke team was paged. But the radiology department had just called a “red alarm” – the sole CT scanner was occupied by a major trauma patient with a possible pelvic fracture, and the next slot was 20 minutes away. James faced a decision: wait for CT or consider transfer to a neighbouring hyperacute stroke unit 12 miles away. Thrombolysis alone may not recanalise
The decision was shared with Mr. Patel’s wife, who tearfully agreed to both – “Do everything.”
Author: Dr. A. Rivers, Emergency Department, City General Hospital
James calculated: Door-to-needle time would be 82 minutes if they gave alteplase now. But giving thrombolysis before transfer to thrombectomy carries bleeding risk if the clot doesn’t move.
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