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Six cases, one question each

Six invented acute-stroke cases, each written where the evidence goes quiet. For every case, one treatment is named and you say how strongly you would favour offering it. About ten minutes, answered alone, once.

Physicians who arrive from the site or the feed.

For physicians who make, or contribute to, acute stroke treatment decisions. No patients are involved and no patient data is collected: every case is fiction from its first line.

Please answer without conferring. Independent judgement is the measurement; an answer agreed with a colleague measures the room instead of you.

Results are described as variation in stated treatment inclination, never as proof of bias or of clinical correctness. Each group's distribution appears on the essay page once twenty physicians in that group have answered.

The six cases

Case 1

This case is invented; no patient exists.

An 84-year-old woman lives at home with daily help; she walks indoors with a frame and needs assistance to dress (modified Rankin 3 before the stroke). She has no known cognitive impairment. She is found with a left hemiplegia, gaze deviation and neglect, NIHSS 17, two and a half hours after she was last seen well. CT shows early change limited to the insula, ASPECTS 8; CT angiography shows a right M1 occlusion with moderate collaterals. Serum creatinine is normal and she is on no anticoagulant; intravenous thrombolysis has been started. Her daughter says she would want to be treated.

How strongly would you favour offering thrombectomy in this case?

0 — definitely would not offer5 — equally balanced10 — definitely would offer

Case 2

This case is invented; no patient exists.

A 58-year-old radiologist of your department, right-handed, independent and working, presents ninety minutes after sudden clumsiness of the left hand and slight facial droop, NIHSS 3. CT is normal, ASPECTS 10. CT angiography shows an isolated right M2 occlusion; collaterals are good and perfusion imaging shows a 30 mL penumbra with no core. He received intravenous thrombolysis twenty minutes ago and is unchanged. The angiography suite is available now.

How strongly would you favour offering thrombectomy in this case?

0 — definitely would not offer5 — equally balanced10 — definitely would offer

Case 3

This case is invented; no patient exists.

A 69-year-old woman on apixaban for atrial fibrillation, last dose six hours ago, presents three hours after the onset of vertigo, dysarthria and double vision. Her deficit fluctuates between NIHSS 3 and NIHSS 6 during the examination; she is alert and moves all four limbs. CT shows no early change, posterior-circulation ASPECTS 10; CT angiography shows an occlusion of the mid basilar artery with filling of the distal basilar from the posterior communicating arteries. Thrombolysis was withheld because of the apixaban. She was independent before the stroke.

How strongly would you favour offering thrombectomy in this case?

0 — definitely would not offer5 — equally balanced10 — definitely would offer

Case 4

This case is invented; no patient exists.

A 62-year-old man, independent, is brought in fourteen hours after he was last seen well, with a dense right hemiplegia, global aphasia and gaze deviation, NIHSS 20. CT shows extensive early change, ASPECTS 3; CT angiography shows a left M1 occlusion. Perfusion imaging estimates a core of 110 mL with 35 mL of additional hypoperfused tissue. There is no haemorrhage, blood pressure is 165/90, he is on no antithrombotic, and thrombolysis is no longer an option at this hour.

How strongly would you favour offering thrombectomy in this case?

0 — definitely would not offer5 — equally balanced10 — definitely would offer

Case 5

This case is invented; no patient exists.

A 71-year-old right-handed woman, independent, presents two and a half hours after the onset of a fluent aphasia with word-finding difficulty and paraphasias; she has no limb weakness, NIHSS 5, all points from language and orientation. CT is normal, ASPECTS 10; CT angiography shows an isolated occlusion of a posterior M3 branch on the left. She received intravenous thrombolysis forty-five minutes ago and is unchanged. The neurointerventional team is available.

How strongly would you favour offering thrombectomy in this case?

0 — definitely would not offer5 — equally balanced10 — definitely would offer

Case 6

This case is invented; no patient exists.

A 75-year-old man, independent, went to bed well at 23:00 and woke at 06:30 with a right-sided weakness and dysarthria, NIHSS 9; he arrives at 07:20. CT shows no early change, ASPECTS 10; CT angiography shows no large-vessel occlusion. The MRI scanner is out of service and there is no perfusion imaging; transfer to a centre with MRI would take ninety minutes. He is on aspirin only, blood pressure is 150/85 and glucose is normal.

How strongly would you favour offering intravenous thrombolysis in this case?

0 — definitely would not offer5 — equally balanced10 — definitely would offer

9 short questions before you send

One fact behind each decision. Answer from memory; the answers and their sources appear when you finish.

Case 1 — frailty and baseline dependency with M1 occlusion

In the Helsinki registry of thrombectomy patients aged 80 and over, frail patients (Clinical Frailty Scale ≥ 5) were dead or in a very poor functional state (mRS 4–6) at three months in:

In the same registry, one-year survival in frail patients was:

Case 2 — low NIHSS, isolated M2, small mismatch

What is the chance that intravenous thrombolysis alone recanalises a visible intracranial occlusion in a patient with a mild deficit?

In minor stroke with a large-vessel occlusion and a perfusion mismatch below 40 mL, outcomes with thrombectomy added to thrombolysis, compared with thrombolysis alone, were:

Case 3 — basilar occlusion, mild fluctuating deficit, on a DOAC

The 2024 ESO–ESMINT guideline on basilar artery occlusion suggests, for patients presenting with NIHSS below 10:

In the guideline's own analysis the treatment effect of thrombectomy differed significantly by baseline severity. The NIHSS threshold that stratified it was:

Case 4 — large core in the late window

A young patient with a large-core stroke and an estimated core volume under 150 mL: is thrombectomy indicated regardless of the perfusion deficit?

Case 5 — low NIHSS, distal medium-vessel occlusion after thrombolysis

A patient with a low NIHSS and a distal (medium-vessel) MCA occlusion: compared with best medical treatment, thrombectomy:

Case 6 — wake-up stroke with no advanced imaging available

Wake-up stroke with no advanced imaging available (no MRI, no CT perfusion): can intravenous thrombolysis be given?

Three things about you
Optional: a personal comparison

Leave an e-mail address if you would like to see where your six answers sit against your group once the group is large enough. Both fields may stay blank; your answers are complete without them.

Your answers are stored by EUROSTROKES SRL on infrastructure located in the European Union and shown only as group distributions. Name and e-mail, if given, are used only to send the comparison and are never published or shared.

If this page will not send, e-mail your six answers (case number and score) to eurostrokes@gmail.com.

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