SAQ 104 – Stroke – acute ischaemic stroke and disclosure

Question 1. acute ischaemic stroke and disclosure.

a. ROSIER scale

• Emergency department clinical assessment tool for suspected stroke.
• Risk stratifies patients according to likelihood of stroke.
• Validated for ED use after triage.
• Uses clinical information including conscious state, blood glucose, blood pressure, unilateral weakness, speech disturbance, and visual disturbance.
• Widely recommended in ED stroke pathways.

b. Thrombolysis inclusion features

• Age greater than 18 years.
• Treatment can begin within 4.5 hours of symptom onset.
• Clinically definite stroke with new persistent focal neurological deficit.
• Significant measurable deficit, for example NIHSS greater than 4.
• Non-contrast CT brain has excluded intracranial haemorrhage.
• Immediate access to imaging and staff able to interpret it.
• Neurologist or emergency physician authority for thrombolysis.
• Stroke team and post-thrombolysis monitoring pathway available, including blood pressure management.

c. Diagnosis

• Left middle cerebral artery infarction, with hyperdense clot sign.

d. Open disclosure elements

• Apology or expression of regret, including clear words such as I am sorry or we are sorry.
• Factual explanation of what happened.
• Opportunity for the patient or family to describe their experience of the adverse event.
• Discussion of the potential consequences of the adverse event.
• Explanation of steps being taken to manage the event and prevent recurrence.

e. Decompressive craniectomy factors

• Age less than 60 years.
• Reduced conscious state.
• Clinical or radiological features of raised intracranial pressure.
• Large or malignant MCA infarction involving more than 50% of the MCA territory.
• Ability to operate within 48 hours of stroke onset.
• Limited access to thrombolysis or stroke-unit facilities may support the role of surgery in selected settings.