🧠 MOCK OSCE · FCPS, MCPS, MD PAEDIATRICS ⏱ 10 min · STROKE

Stroke · Short Case

Candidate task: perform focused neurological examination on a child with suspected stroke.
Then discuss differential diagnosis, investigations, management & follow‑up.
Pre‑exam Protocol
⏤ · Wash, Warm, Introduce, Position, Expose, Approach ▾

Standard pre‑examination protocol – must be demonstrated:

🖐 Wash hands with sterilizing solution.
🔥 Warm hands and stethoscope.
👋 Introduce yourself to child & parent.
🧍 Position child: supine, then sitting, then standing for gait.
👕 Exposure — allow full neurological exam.
➡️ Approach from the right side.
✔ CPSP marker: Pre‑exam Protocol is observed and scored.
1. Clinical Examination (≈6 min)
02 General Look (Inspection from end of bed) ▾

Key observations:

  • Posture: hemiplegic posture (flexed arm, extended leg).
  • Gait: circumduction (hemiplegic), ataxic, or unable to walk.
  • Facial asymmetry: lower facial weakness (upper motor neuron).
  • Speech: dysarthria, aphasia (expressive/receptive).
  • Eye signs: visual field defect (hemianopia), gaze deviation.
  • Head size: normal (unless chronic / perinatal).
  • Skin: neurocutaneous stigmata (if syndromic).
  • Dysmorphism: (if associated syndrome).
👁 Red flags: acute onset, altered consciousness, signs of raised ICP, seizure.
03 Focused Neurological Examination ▾

Systematic motor & sensory exam:

  • Cranial nerves: facial weakness (UMN type), visual fields (hemianopia), gaze deviation, dysarthria, dysphagia.
  • Motor: hemiparesis/hemiplegia (upper motor neuron pattern), tone (spasticity or flaccidity), power (MRC scale).
  • Reflexes: brisk on affected side, clonus, extensor plantar (Babinski).
  • Sensory: hemisensory loss (cortical or thalamic).
  • Coordination: ataxia (cerebellar stroke).
  • Gait: hemiplegic gait (circumduction), ataxic gait.
  • Higher functions: aphasia (expressive/receptive), neglect (parietal lobe).
🔍 Key: stroke in children – often subtle; look for focal deficits. Perinatal stroke → early hand preference.
04 General Physical Exam (Hands → Face → Chest → Abdomen → Limbs) ▾

Systematic examination:

  • Hands: clubbing (cyanotic heart disease), splinter haemorrhages (endocarditis).
  • Face: facial asymmetry, dysmorphism.
  • Eyes: fundoscopy (papilledema, retinal emboli, Roth spots).
  • Chest: cardiac murmur (congenital heart disease, endocarditis), respiratory effort.
  • Abdomen: hepatosplenomegaly (sickle cell, storage).
  • Skin: neurocutaneous stigmata (NF, tuberous sclerosis, Sturge‑Weber).
  • Pulses: 4‑limb BP – coarctation, vasculitis.
📏 Anthropometry: weight, height, head circumference – plot on growth charts.
05 Developmental Assessment & Associated Signs ▾

Assess:

  • Motor milestones: delayed (perinatal stroke) or regression (new stroke).
  • Cognitive: intellectual disability (if early/ extensive stroke).
  • Speech: aphasia, dysarthria, language delay.
  • Behaviour: emotional lability, attention deficits.
  • Associated: seizures (post‑stroke epilepsy).
🧠 Red flags: acute deterioration, recurrent strokes (sickle cell, moyamoya).

📋 Case Presentation – (fill in during exam)

This is a _____-year-old _____ child, referred for _____ (sudden weakness / speech difficulty / seizure). On examination, the child appears _____ (well/unwell), with _____ (hemiplegic posture / facial asymmetry). Neurological exam: power _____ (hemiparesis), tone _____ (increased / decreased), reflexes _____ (brisk / absent), plantars _____ (flexor / extensor). Eye findings: visual fields _____ (full / hemianopia), fundi _____ (normal / papilledema). Speech: _____ (normal / dysarthria / aphasia). Growth: weight _____ percentile, height _____ percentile. Associated signs: _____ (cardiac murmur, neurocutaneous stigmata).

2. Viva Discussion (≈4 min)
06 Viva · Differential, Investigations, Management, Follow‑up ▾
🔹 Differential Diagnosis

• Arterial Ischaemic Stroke – thrombosis, embolism
• Cerebral Venous Sinus Thrombosis – venous infarct
• Haemorrhagic Stroke – AVM, aneurysm, trauma
• Moyamoya – progressive stenosis
• Sickle cell disease – vaso‑occlusion
• Migraine with aura – can mimic stroke
• Todd paresis – post‑seizure
• Hypoglycaemia – focal deficit
• ADEM – demyelination
• Functional – non‑organic

🔹 Investigations – Diagnosis

• Brain CT – acute haemorrhage.
• Brain MRI + DWI – acute ischaemia (gold standard).
• MRA / MRV – vascular imaging (stenosis, dissection, venous thrombosis).
• Carotid Doppler – if neck vessel involvement.

🔹 Investigations – Aetiology

• Echocardiography – cardiac source (emboli, PFO, valve lesions).
• Hypercoagulable screen – protein C/S, antithrombin III, Factor V Leiden, prothrombin, MTHFR, lupus anticoagulant.
• Haemoglobin electrophoresis – sickle cell.
• Lipid profile, homocysteine – metabolic.
• Vasculitis screen – ANA, ESR, CRP, ANCA.

🔹 Investigations – Exclude Others

• EEG – Todd paresis, seizure.
• Blood glucose – hypoglycaemia.
• Toxicology screen – drugs.
• CSF – if infection / inflammation.
• Genetic – CADASIL, COL4A1 (if familial).

🔹 Investigations – Rule Out Complications

• Neurological – repeat imaging if deterioration (extension, oedema, haemorrhage).
• EEG – if seizures.
• Swallow study – aspiration risk.
• Rehabilitation – functional assessment (physio, OT, speech).
• Psychosocial – emotional impact, school support.

🔹 Management – Across Organ Systems

Acute

ABCs, antiplatelet/anticoagulation (aspirin, heparin), thrombolysis (if eligible), thrombectomy (large vessel).

Neurological

Seizure control, manage ICP (if large infarct), rehabilitation (physio, OT, speech).

Cardiac

Anticoagulation if cardioembolic (warfarin/DOAC), PFO closure (if indicated).

Haematological

Exchange transfusion (sickle cell), treat hypercoagulable states.

Surgical

Decompressive craniectomy (malignant MCA), AVM/aneurysm intervention.

Rehabilitation

Multidisciplinary: physiotherapy, OT, speech therapy, neuropsychology.

Secondary Prevention

Antiplatelets (aspirin), anticoagulation, blood pressure control, statins, lifestyle.

Psychosocial

Family support, school reintegration, counselling, genetic counselling (if inherited).

📈 Prognosis

  • Neonatal stroke: good; many have normal development.
  • Childhood arterial ischaemic stroke: 50‑80% have residual deficits (hemiparesis, cognitive).
  • CVST: 20‑40% have deficits, some recover fully.
  • Haemorrhagic stroke: higher mortality; depends on lesion.
  • Sickle cell: high recurrence; stroke prevention with transfusion.
  • Moyamoya: progressive; revascularization surgery can improve outcome.

📋 Follow‑up Schedule

  • Neonatal: regular developmental, neurology, ophthalmology.
  • Childhood: neurology 3‑6 monthly, rehabilitation, psychology.
  • Sickle cell: regular TCD, transfusion programme.
  • Moyamoya: annual vascular imaging, revascularization follow‑up.
  • Secondary prevention: BP, lipids, lifestyle.
  • Transition: plan for adult care (coagulation, cardiology).
💡 Examiner expectation: ability to distinguish ischaemic from haemorrhagic, identify aetiology (cardiac, haematological, vascular), and discuss acute management and secondary prevention. Know the red flags: sudden onset, focal deficit, altered consciousness, seizure.
📚 Visit paeds.online for more CPSP resources
Mock OSCE · Stroke · Based on Wyne‑Harris, Nelson & Pediatric Clinical Advisor