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MSGM Case discussion June 2024

Prepared by Dr Wong YL

Supervised by Dr Gordon Pang (Hospital Queen Elizabeth)

Mrs AJ, a 78 years old lady


  • Atrial fibrillation

  • history of stroke with left hemiparesis in 2020 Presented with left sided body weakness noted at 6am associated with difficulty in talking Last seen well at 9pm before going to sleep Arrived in ED at 7.59am

Further history

  • Fall in sitting position when trying to stand up from bed upon awakening

  • Complained of pain over right hip and unable to ambulate


  • T.Warfarin 3mg OD (last taken 2 days prior to admission)

  • T.Bisoprolol 5mg OD

  • T.Atorvastatin 40mg ON


  • Moderate frailty (Clinical Frailty scale 6)

  • ambulate with walking frame

Social history

  • Married with 8 children

  • Lives with daughter and son in law in single storey landed house with sitting toilet

  • Does not smoke or consume alcohol

Physical examination

Glasgow Coma Scale E4V2M5

Blood pressure 129/96mmHg Pulse rate 118 beats per minute Temperature 36.7◦C Oxygen saturation 100% on NPO2 2L/min Dxt 8.8

Neurological examination

  • Tone hypertonia left U/L and L/L

  • Power 4 for right upper limb, 1 for left upper and lower limb(unable to assess power of right lower limb due to pain)

  • Reflexes hyperreflexia left upper and lower limb

  • Barbinski upgoing left side • Unable to assess sensation NIHSS more than 15 Right lower limb

  • Bruises over right thigh

  • Tenderness over right hip

  • Dorsalis pedis pulse palpable


  • ECG Atrial fibrillation

  • Chest Xray clear lungs field

  • MRI Brain- Hyperacute infarcts seen at right frontal and right side of pons, acute infarct seen at right cerebellum. Right parietooccipital and left frontotemporal encephalomalacia

  • MRA brain - Vessel occlusion at distal basilar artery and M4 segment right MCA

  • Pelvic xray- right neck of femur fracture

Pelvic X-Ray

MRI Brain

Blood investigations

  • Full blood count - WCC 6.55 Hb 7.1 Plt 296

  • Renal Profile - Urea 7.7 Creat 94.9 Na 139 K 4.1

  • Liver Function - Test Alb 36 ALP 74 ALT 16

  • Coagulation profile - INR 1.26


  1. Should the patient be considered for thrombolysis ?

  2. With concomitant acute stroke and hip fracture, should the patient be offered operative management for the hip fracture?

  3. If yes, what is the appropriate timing for the surgery?

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3 commentaires

Patient will benefit from perfusion imaging to determine whether this wake-up stroke will benefit from thrombolysis/thrombectomy if expertise is available. NIHSS still within limits to reap benefit. INR not high to be contradicted as well. There is also a Japanese study stating benefit from reduced dose alteplase with borderline high NIHSS.

This article also talking about thrombolysis in those on DOAC

Will need at least 48hours if thrombolysed to assess situation--> if develop complications eg ICB--> would not advocate for hip surgery --> palliate

if improving and has potential to ambulate--> may then consider emergency op with high risk consent and ICU backup. However, this should be a MDT and shared decision making process after family conference.


Well done on finding such a clinical dilemma. In view of the use of warfarin and hip fracture and the size of the stroke, thrombolysis will be contraindication, particularly as this is a wake up stroke, last awake 9 hours prior. Hip fracture surgery in this case would also be a major issue, and one would question the wisdom on not thrombolysing but operating. The prognosis for this patient is guarded, and it would require around 24 hours of stabilization, can shared decision making with regards to surgery. Palliative care should be considered if her clinical condition does not improve.


The data on IVT in posterior circulation stroke is limited, her premorbid condition suggests that she is frail. The role of thrombolysis in her condition is limited. Given the previous insults to her brain, any neurological recovery if at all might be small with high risk of ICH.

In cases of acute stroke and hip fracture, a multidisciplinary team involvement is necessary. Careful discussion with anaesthetist and surgeon and family is needed. Surgery will be deemed high risk with ICU back up.

Elective surgery post thrombolysis should be delayed at least 6 months. Emergency surgery should be done if needed.

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