Wake-Up Stroke, Large Vessel Occlusion, and a Spoke Hospital Without Thrombectomy
At 06:40 a 74-year-old right-handed man is brought in by his wife, who found him on the floor beside the bed. She last spoke with him at 22:30 the previous night, when he was completely normal. He now has dense right hemiplegia, global aphasia, and right gaze deviation; NIHSS 19. Fingerstick glucose 118 mg/dL. Blood pressure 188/106 mmHg, heart rate 88 and irregular. Noncontrast CT shows no hemorrhage, ASPECTS 8. CTA shows a left M1 occlusion; CT perfusion shows core 18 mL and Tmax>6 s volume 96 mL. Last known well was 8 hours 10 minutes ago; the wife says he 'went to bed around 11.' Your hospital has no thrombectomy capability. The nearest thrombectomy center is 55 minutes by ground or 22 minutes by air. Telestroke is available now.
1. What reperfusion strategy do you pursue, in what order, and why?
Read the worked answer
The decisive therapy is endovascular thrombectomy, and transfer must start immediately.
Reasoning:
- He is outside the 4.5-hour window for standard intravenous thrombolysis (LKW 8 h 10 min ago).
- He meets late-window thrombectomy criteria by both major trials: NIHSS ≥10 with core <31 mL (DAWN-type clinical-core mismatch) and, at 8 hours, core <70 mL with mismatch ratio >1.8 and penumbra ≥15 mL (DEFUSE-3-type). ASPECTS 8 does not exclude him.
- IV thrombolysis in the 4.5–9-hour window is only a Class IIb, protocol-dependent option requiring advanced imaging selection (DWI-FLAIR mismatch on MRI, which you do not have, or a perfusion-mismatch strategy such as EXTEND-style criteria, which he would meet). It is reasonable to discuss with the receiving center, but it must never delay transfer, and it obligates a BP <185/110 before the bolus.
- Practical sequence: confirm no hemorrhage, check glucose and coagulation history, activate air transfer (22 vs 55 minutes matters when 8 hours have already elapsed), send CTA images ahead, hold antihypertensives unless BP exceeds the threshold, keep NPO, protect the airway, and document the exact last-known-well and the wife's account.
- Do not wait for MRI, sedation, or a full laboratory panel before moving him.
2. The bedside nurse asks whether to give labetalol for the BP of 188/106. How do you answer, and what is your BP plan for the next several hours?
Read the worked answer
Treat - but modestly and with a specific target, not reflexively.
- If fibrinolysis is given, BP must be <185/110 mmHg before the bolus and kept <180/105 afterward. If the receiving center wants to consider late-window lysis, you must bring him below 185/110 first.
- Even without lysis, pre-procedure BP <185/110 is the standard before thrombectomy, so 188/106 is over threshold and warrants treatment.
- Give a small titratable dose (labetalol 10–20 mg IV, or nicardipine infusion) and reassess in 5–10 minutes. The goal is to get under the threshold, not to normalize the pressure.
- Avoid overshoot. His penumbra is pressure-dependent, hypertension is chronic, and a systolic in the 120s during a 55-minute road or 22-minute air transfer risks infarct extension. Hold further doses once below ~180 systolic.
- After reperfusion, target <180/105 for at least 24 hours, avoid hypotension, and watch for blood pressure lability during transport.
3. CT perfusion software is down and cannot be repeated before the aircraft arrives. Do you still transfer? Explain.
Read the worked answer
Yes - transfer now. Perfusion imaging is a selection tool, not a gatekeeper.
- Thrombectomy in the 6–24-hour window can be selected on clinical-core mismatch alone (age, NIHSS, and noncontrast CT core/ASPECTS), which is exactly how the DAWN population was enrolled. With NIHSS 19, ASPECTS 8, and a documented M1 occlusion, he is a plausible candidate without a perfusion map.
- Canceled or delayed transfer to obtain a perfusion scan is a well-recognized source of harm; time is the dominant modifiable variable at 8 hours.
- Communicate to the receiving center that CTP is unavailable and that the clinical-core assessment plus CTA is the basis for transfer; they can repeat imaging on arrival if they need it.
- Do not send him by ground to save a scan; document the imaging limitation clearly in the transfer note so the accepting neurointerventionalist can factor it in.