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 06, verbatim
Got an unstable posterior circulation case. 70-year-old male, sudden onset diplopia and slurred speech 5 hours ago. Baseline mRS is 2 due to severe knee osteoarthritis. Since arrival, his deficits have been fluctuating wildly; NIHSS was 4 on admission, but is now 16 with bilateral weakness and deteriorating consciousness. CTA shows a high-grade stenosis or subtotal occlusion of the mid-basilar artery. Non-contrast CT is unremarkable. MRI is unavailable until morning. Thrombolysis was not given because he was on therapeutic apixaban for atrial fibrillation, last dose taken 6 hours ago. He is currently intubated for airway protection.
Why this one is hard
Almost every number in this vignette is unstable, starting with the one the trials are anchored to. The positive basilar trials wrote their envelopes around measurable severity — ATTENTION enrolled at NIHSS 10 and above — and this man has been 4 and 16 within the same evening. Which of those is his score? The fluctuation that makes the case frightening also makes it unmeasurable, and now he is intubated and sedated, so the examination that would answer the question has been traded for his airway.
The anatomy hedges too: a high-grade stenosis or subtotal occlusion of the mid-basilar is a different disease depending on which it is — an embolus asks to be removed, an atherosclerotic stenosis raises the question of what keeps the vessel open afterwards — and the imaging that would distinguish them is unavailable until morning. Even his baseline resists the scale: an mRS of 2 earned by knee osteoarthritis is not the biological reserve that score usually encodes, and the basilar envelopes treat prestroke function as a hard criterion. Meanwhile apixaban has already cost him thrombolysis and keeps its thumb on every subsequent risk estimate.
The trials' narrow envelope was built on presentations that hold still long enough to be measured. This one does not, and the honest statement of the evidence is that its central entry criterion cannot even be applied.
Literature anchors
- Tao C, et al. (ATTENTION). N Engl J Med 2022. doi:10.1056/NEJMoa2206317.
- Jovin TG, et al. (BAOCHE). N Engl J Med 2022. doi:10.1056/NEJMoa2207576.
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.