Emergency Medicine Journal !exclusive! -

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.

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.

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. emergency medicine journal

Meanwhile, the nurse recorded a blood pressure of 205/110. James recalled the 2024 EMJ guidelines: BP >185/110 is a relative contraindication to IV alteplase unless rapidly controlled. He ordered IV labetalol 10 mg push. As the labetalol took effect (BP 168/94), Mr. Patel suddenly became agitated. His left arm began jerking rhythmically. The monitor showed tachycardia to 120. Junior doctor Sarah shouted, “Seizure?” James shook his head – the movements were focal, but the patient’s eyes were deviated to the left, and he was unresponsive.

“Status epilepticus? Or stroke progression?” James murmured. He gave 2 mg IV lorazepam. The jerking stopped, but the aphasia and hemiparesis remained unchanged. The clock started

The decision was shared with Mr. Patel’s wife, who tearfully agreed to both – “Do everything.”

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. He followed left-sided commands with his eyes

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.”