Synthetic cases. These are fictional teaching vignettes, model-generated for testing clinical-reasoning systems. No real patients are described on these pages.
The vignette — bank Case 02, verbatim
Got a tough one in bay six. 91-year-old male, sudden left-sided weakness witnessed by care home staff 3 hours ago. Baseline is poor, advanced vascular dementia, mRS 4, needs assist of two for all transfers. Current NIHSS is 18, completely neglected on the left, eyes turned to the right. Non-contrast CT shows loss of insular ribbon on the right. CTA shows a dense right M1 segment occlusion. Thrombolysis was withheld given his advanced baseline dependency and family preferences. The family is here now and wants to understand what else can be done for him.
Why this one is hard
Every pivotal thrombectomy trial in the anterior circulation asked for functional independence before the stroke; a baseline mRS of 4 was excluded by design, so there is no randomised estimate for this man at all. What makes the case hard is that the exclusion was never a finding — it was a choice — and age, taken alone, points the other way: in the HERMES pooled analysis the treatment effect was intact at 80 and beyond. The variable that actually carries this decision is not the year of birth but reserve, and reserve is precisely what the trials filtered out before they started counting.
The observational data that do exist describe the gap without closing it. In the MR CLEAN Registry, prestroke-dependent patients reached a favourable outcome — mRS 0–2 or no worsening from baseline — less than half as often as independent ones, with similar safety, and the association did not survive adjustment. A frailty cohort of thrombectomy-treated patients aged 80 and over found very poor outcome in four of five frail patients against half of the non-frail. Neither of those is a randomised answer, and both are anterior-circulation cohorts standing in for evidence the trials chose not to generate.
And the vignette's last sentence is the actual case: the family is in the room and wants to understand. What has to be explained is a decision for which the honest evidence statement is "he was excluded from every trial that would tell us" — which is a different sentence, and a harder one to say, than either "it would help" or "it would not."
Literature anchors
- Goyal M, et al. (HERMES). Lancet 2016. doi:10.1016/S0140-6736(16)00163-X.
- Goldhoorn RB, et al. (MR CLEAN Registry, prestroke dependency). Stroke 2018. doi:10.1161/STROKEAHA.118.022352.
- Tiainen M, et al. (frailty, thrombectomy ≥80). J Stroke Cerebrovasc Dis 2022. doi:10.1016/j.jstrokecerebrovasdis.2022.106816.
Break the demo — send a case
For stroke physicians and vascular neurologists only. This is not a route for personal medical questions; if you are a patient or a relative, do not use this address. The demo does not run anonymously, and it is not a clinical service. Every case is reviewed and approved by the administrator before it runs; responses may take several days. Never use this for a live clinical decision — for acute stroke, follow your local pathway.
Your case must contain no images and no patient-identifying data, and it must be retrospective — not an active patient awaiting a decision. A case may appear on this site anonymously, as a constructed teaching case; you are named only if you ask to be.