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When an unidentified patient who cannot communicate presents with symptoms and signs suggesting an acute stroke, the decision to thrombolyse is a particular challenge. In a time-pressured environment, clinicians need clear thought processes for diagnosis and treatment. Ethical considerations, diagnosis, identity and previous history, contraindications, time of symptom onset (EDICT) can help decision-making in this situation.

A 66-year-old man presented to the emergency department with paraesthesia starting in the first two fingers of his right hand, spreading up his right arm into the right side of his face and mouth over 10 min. During this, his mouth felt numb “like after a dental injection”. He had three further similar episodes in the emergency department. He had a past history of hypothyroidism and irritable bowel syndrome. After a CT scan of head (figure 1), he started treatment with an antiplatelet medication for a presumed transient ischaemic attack (TIA). An MR scan of brain the next day showed a small amount of subarachnoid blood in the left central (rolandic) sulcus (figure 2). We therefore stopped the antiplatelet treatment. Over the next month, he continued having almost daily episodes of tingling and numbness affecting his hand and face, each lasting 20 min. One episode affected his throat, leaving him unable to speak for several minutes (figure 3 and supplementary video on the website). Figure 1 Non-enhanced CT brain shows high attenuation acute subarachnoid blood within the left central sulcus. …