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 05, verbatim
I have a 55-year-old male in ED, onset of mild left arm weakness and slurred speech 2 hours ago. Fully independent baseline, mRS 0. NIHSS is low, only 5, but CTA shows a complex lesion: there is a proximal right internal carotid artery occlusion at the bulb, and also a distal right M1 occlusion. Non-contrast CT is normal with an ASPECT score of 10. We have initiated intravenous thrombolysis given the early timeframe, and the infusion is running now. He has no medical contraindications. The concern is the tandem nature of the block despite the low clinical score.
Why this one is hard
The referring physician has named the problem exactly: the deficit is mild and the anatomy is not. Every pivotal thrombectomy trial set its floor above this man's score, so the strongest evidence in stroke medicine simply does not reach him. What the observational record adds is uncomfortable in both directions. Patients like him deteriorate early and often — in the largest minor-stroke LVO cohort, roughly one in eight worsened under thrombolysis alone, and a more proximal occlusion predicted it — and a tandem carotid-plus-M1 lesion is close to the definition of proximal.
But going to the suite now has its own published cost. Our meta-analysis of eleven observational cohorts in mild deficits found no functional advantage for thrombectomy over best medical management and a symptomatic haemorrhage rate more than tripled — with all the selection that observational treatment data carry, in both directions. The two honest readings of the same literature disagree: one says treat the vessel before the deficit declares itself, the other says the deficit is the outcome that matters and the knife has a price. A randomised answer for exactly this patient does not yet exist; the trials that would provide one are registered and unreported.
So the case sits where the vignette leaves it: infusion running, angiography suite twenty metres away, and two literatures pointing in opposite directions across a mild deficit.
Literature anchors
- Seners P, et al. (MINOR-STROKE collaboration, early neurological deterioration). JAMA Neurol 2021. doi:10.1001/jamaneurol.2020.4557.
- Safouris A, et al. (meta-analysis, EVT in mild deficits). Stroke 2023. PMID 37526011 · doi:10.1161/STROKEAHA.123.043937.
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.