Case Presentation
Matt Baldwin, a 55-year-old farmer develops left-sided weakness while getting off his quad bike outside the farm homestead, where his teenage son is working on his trail bike. Matt collapses to the ground and his son notices his father has a left-sided facial droop. He calls emergency services who arrive within 30 minutes. Paramedics suspect Matt may have suffered a stroke.
Question 1 [20 minutes]
Q1a. List the major components of assessment for a potential stroke diagnosis.
fast system
- face drooping
- arm weakness
- speech slurred rosier for emergency room
- syncope and seizure discounts seizure
- asymmetric weakness speech disturbance and visual field defects count towards it.
and nihss
Q1b. Matt’s left-sided facial droop affects only the lower half of his face. With reference to innervation by the upper and lower motor neurons supplying the face, explain the pathological basis of Matt’s facial droop. You may choose to support your answer with a diagram.
this is an upper motor neuron affected stroke, this is because the facial motor nucleus has dual innervation by both sides of the body for the upper half of the face, so if one upper motor neuron is dysfunctional, the other one will take over the other upper half of the face. This allows us to distinguish from a lower motor neuron disease, as one whole half of the face would be weak. The likely location of stroke is right sided mca area
Clinical Update
Matt is transferred by ambulance to the nearest hospital with an acute stroke unit. Forty-five minutes later, on arrival to hospital, Matt is reassessed and his GCS documented as 15 [Eyes 4, Verbal 5 and Motor 6]. His dense left hemiparesis, facial droop and left-sided sensory deficits persist. Matt’s son has accompanied him to hospital and reports that his father had numbness and tingling in his limbs on the left side a few days ago, but that this seemed to just go away after a while, so his father didn’t see a doctor about it.
Q1c. Explain the significance of Matt’s previous symptomatic episode that appeared to resolve spontaneously.
possilbe TIA, TIAs markedly increase risk for future stroke in both the short and long term.
Clinical Update
Matt’s blood pressure is recorded as 205/110mmHg. His past medical history includes hypertension and coronary artery disease, for which he has received a coronary stent just three months ago. Matt’s medications include enalapril, bisoprolol, atorvastatin, aspirin and clopidogrel. An urgent head CT confirms signs of a right middle cerebral artery [MCA] infarction, and no evidence of haemorrhage. Matt undergoes intravenous thrombolysis with alteplase 125 minutes after symptom onset.
Q1d. State the optimal timeframe for the delivery of thrombolytic therapy in stroke and outline what additionally needed to be considered for Matt to undergo thrombolysis.
i think under 9 hours? additional medication effect should be considered, as well as general effects of
Clinical Update
A repeat CT scan at 24 hours reveals extensive areas of infarction in the right MCA territory, with slight mass effect. Within 12 hours this picture changes and Matt’s GCS falls to 13 [E3, V4, M6], with a repeat scan showing worsening mass effect. Refer to your GCS handout.
Question 2 [8 minutes]
Q2a. With reference to the Monro-Kellie doctrine, state two [2] pathological consequences of worsening mass effect. 1. 2.
the space inside the cranium is constant, so increase of one means decrease of others, additional csf will be pushed out and blood perfusion will decrease. with larges raises in ICP you can see herniation with structures being pushed on, like the medulla being pressed on by the cerebellum leading to cardiac and respiratory arrest, or higher decrease in perfusion levels of the brain leading to higher ischaemia.
Q2b. The arrow in image [b] overleaf points to the extensive nature of the ischaemic infarct. Describe one [1] pathological consequence of worsening mass effect that can be seen in this head CT, taken at middle cerebral level. (Image [b] provided in original PDF)
- midline deviation?
Clinical Update
Matt undergoes an urgent decompressive hemicraniectomy following multidisciplinary consultation and the gaining of Matt’s consent.
Question 3 [12 minutes]
Q3a. With reference to the ‘RUB’ [Risk for Unacceptable Badness] and the criteria for obtaining informed consent, outline two [2] important considerations that doctors needed to weigh up before proceeding to decompressive hemicraniectomy to save Matt’s life.
What are the risks of this treatment.
is matt okay with the possible risks of this and surviving or would he rather die to this.
Q3b. Explain who, apart from Matt, could have given consent for doctors to proceed with decompressive craniectomy?
someone with the enduring power of attorney, a welfare guardian, or if those are not available, a doctor after acertaining what matt would have wanted.
Document 1: April 9, 2025 Case (Answer Key Version)
Question 1 Q1a. Major components of assessment for a potential stroke diagnosis:
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Primary survey (ABCDE approach) including airway protection and vital signs.
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Neurological assessment using a validated tool (e.g., NIH Stroke Scale) and Glasgow Coma Scale (GCS).
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Point-of-care blood glucose testing to rule out hypoglycemia (a stroke mimic).
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Detailed history establishing the exact “last known well” time and time of symptom onset.
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Urgent non-contrast head CT to distinguish ischemic from hemorrhagic stroke.
Q1b. Pathological basis of Matt’s facial droop:
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The upper face receives bilateral upper motor neuron (UMN) innervation, while the lower face receives unilateral (contralateral) UMN innervation.
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A right-sided MCA infarct causes a right UMN lesion.
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Because the left upper face still receives UMN signals from the intact left hemisphere, it is spared. The left lower face loses its only source of UMN innervation, resulting in a lower facial droop.
Q1c. Significance of Matt’s previous symptomatic episode:
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This represents a Transient Ischemic Attack (TIA).
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It is a critical warning sign that Matt is at a very high imminent risk for a completed stroke, signaling unstable cerebrovascular disease.
Q1d. Optimal timeframe and additional considerations for thrombolysis:
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Optimal timeframe: Within 4.5 hours of symptom onset.
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Additional considerations for Matt: His blood pressure is too high (205/110mmHg) and must be lowered below 185/110mmHg prior to alteplase administration to reduce hemorrhage risk. Furthermore, he recently had a coronary stent and is on dual antiplatelet therapy (aspirin and clopidogrel), which significantly increases his risk of bleeding complications and must be carefully weighed against the benefits.
Question 2 Q2a. Monro-Kellie doctrine pathological consequences:
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Global increase in intracranial pressure (ICP) leading to decreased cerebral perfusion pressure and secondary ischemia.
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Brain herniation syndromes (e.g., subfalcine, uncal, or tonsillar herniation) due to compartmental pressure gradients.
Q2b. Pathological consequence seen on CT:
- Midline shift, evidenced by the displacement of the cerebral structures (like the septum pellucidum) across the center line and effacement of the lateral ventricles.
Question 3 Q3a. Considerations regarding the ‘RUB’ (Risk for Unacceptable Badness):
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Survival vs. Severe Disability: The surgery may save his life, but he might survive with a dense, permanent hemiparesis, severe aphasia, or cognitive deficits that he would consider an unacceptable quality of life.
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Patient Values: Doctors must consider if the projected post-operative functional state aligns with Matt’s previously expressed values, independence as a farmer, and what he would define as “unacceptable badness.”
Q3b. Who could have given consent?
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A legally appointed Welfare Guardian or someone holding an Enduring Power of Attorney (EPoA) for Personal Care and Welfare.
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If neither exists, doctors can proceed under the doctrine of necessity / Right 7(4) of the NZ HDC Code of Rights (acting in the patient’s best interests), relying on clinical consensus and consultation with his family.