A 75 year old man is admitted to your unit from the Emergency Department following admission for dysphagia, dysphonia and fluctuating consciousness.
During a period of drowsiness, he was said to have had a seizure and aspirated, following which he was intubated and ventilated.
On arrival in the intensive care unit, he is noted to be afebrile, blood pressure 190/120, pulse rate 80/min. Oxygen saturation is 98%, he is ventilated with an FIO2 of 0.5.
“Initial examination and investigations are unremarkable. What is your differential diagnosis and initial plan?” was the original follow-up question. The original viva clearly must have taken things in the direction of meningoencephalitis, because the examiner comments are "Areas that were poorly covered included post-seizure management, and the potential for CNS infection. Eleven out of sixteen candidates passed this section". However, that would be boring. So, I have removed a part of the stem which reported a normal CT brain, and used the rest to fashion a viva about endovascular clot retrieval.
To score marks with their answer for the first part of the question, the candidate should:
Negative symptoms:
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Positive symptoms:
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An urgent CT now becomes the priority. Ideally, they should ask for a perfusion study, as this will yield more diagnostic information than a plan non-contrast scan (which may not reveal a stroke in the hyperacute phase)
The candidate should be pivoting towards thrombolysis at this stage.
Disclaimer: the viva stem above may be an original CICM stem, acquired from their publicly available past papers. Or, perhaps it is a slightly altered version of the original CICM stem. Or, it is a completely original viva stem, concocted by the monstrously amoral author of Deranged Physiology for nothing more than his own personal amusement. In either case, because the college do not make the main viva text or marking criteria available, almost everything here has been confabulated. It might sound like a plausible viva and it could be used for the purpose of practice, but all should be aware that it does not represent the "true" canonical CICM viva station.
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Silva, Gisele S., and Raul G. Nogueira. "Endovascular Treatment of Acute Ischemic Stroke." CONTINUUM: Lifelong Learning in Neurology 26.2 (2020): 310-331.
Brinjikji, Waleed, et al. "Patient outcomes with endovascular embolectomy therapy for acute ischemic stroke a study of the national inpatient sample: 2006 to 2008." Stroke 42.6 (2011): 1648-1652.
Kidwell, Chelsea S., et al. "Design and rationale of the mechanical retrieval and recanalization of stroke clots using embolectomy (mr rescue) trial."International Journal of Stroke 9.1 (2014): 110-116.
Jansen, Olav, et al. "Neurothrombectomy for the treatment of acute ischemic stroke: results from the TREVO study." Cerebrovascular Diseases 36.3 (2013): 218-225.
Furlan, Anthony, et al. "Intra-arterial prourokinase for acute ischemic stroke: the PROACT II study: a randomized controlled trial." Jama 282.21 (1999): 2003-2011.
Ma, Alice, Gerard Moynihan, and Lachlan H. Donaldson. "Intensive Care Management Following Endovascular Clot Retrieval for Acute Stroke: A Systematic Review of the Literature." Journal of Clinical Interventional Radiology ISVIR (2019).
Rodrigues, Filipe Brogueira, et al. "Endovascular treatment versus medical care alone for ischaemic stroke: systematic review and meta-analysis." bmj 353 (2016): i1754.
Hao, Yonggang, et al. "Risk of intracranial hemorrhage after endovascular treatment for acute ischemic stroke: systematic review and meta-analysis." Interventional neurology 6.1-2 (2017): 57-64.
Nogueira, Raul G., et al. "Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct." New England Journal of Medicine 378.1 (2018): 11-21.
Albers, Gregory W., et al. "Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging." New England Journal of Medicine 378.8 (2018): 708-718.