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.
“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 – Narrative Case Series Presentation It was a Tuesday afternoon in a busy UK district general hospital. The department was in its usual post-lunch chaos when triage flagged a 58-year-old man, Mr. Patel, as “priority 2 – possible stroke.” The paramedic handover was clipped: “Found by his wife at home, last known well 45 minutes ago. Sudden right-sided weakness, slurred speech, and facial droop. GCS 14. BP 185/100, HR 88, SpO₂ 97% on air. Blood glucose 6.2 mmol/L.” emergency medicine journal
The decision was shared with Mr. Patel’s wife, who tearfully agreed to both – “Do everything.”
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. James calculated: Door-to-needle time would be 82 minutes
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.”
Just then, the trauma patient was moved. The CT slot opened. CT head was performed at 67 minutes from onset: No haemorrhage. No early ischaemic changes on ASPECTS. CT angiography showed a proximal left middle cerebral artery (M1) occlusion with good collaterals. Or stroke progression
Author: Dr. A. Rivers, Emergency Department, City General Hospital
