Select the crosses for each colleagues decision and rationale
Prof Mark Barber
Decision
- No BP intervention
- No lysis
- Refer for thrombectomy
I would not thrombolyse. Provided that I had quick access to thrombectomy I would consider that, after in depth discussion with the NOK and clarification of exact previous function.
Rationale
We seem to have a good history of him having taken his anticoagulant and I would consider that an absolute contraindication to thrombolysis. Depending on his wife’s wishes, thrombectomy would seem a reasonable potential option. He is still walking the dog. That LVO is proximal and his outcome inevitably poor with no treatment. Thrombectomy gives the possibility of recovery to previous baseline function. I find the CTP confusing and unhelpful, which is probably an experience thing.
Dr Tracey Baird
Decision
- No BP intervention
- No lysis
- Refer for thrombectomy – but I’d want more information about onset time and might try to repeat the perfusion imaging
Rationale
- The apixiban use largely precludes IV lysis.
- The CTA and NHISS suggest a new vessel occlusion.
- I note the history says ‘wife noticed’ – this is first thing in the morning. Are we certain about onset time?
- Thrombectomy would be an option but may require repeat imaging at the hub once arrives
Dr Anthony Pereira
Decision
- No BP intervention is needed
- Request CT & CTA
- No lysis
- No referral for thrombectomy
Rationale
Although only 75 years of age, this gentleman is in a poor state of health. He is beyond the time window of the NINDS study and would have been a poor candidate for ECASS 3. His being on anticoagulation also precludes his being thrombolysed.
His CT brain scan shows quite a bit of atrophy and the CTA suggests a significant, proximal M1 occlusion. However, his poor state of health makes him a poor candidate for thrombectomy.
Dr Shelagh Coutts
Decision
- No BP intervention
- No lysis
- Refer for thrombectomy
Rationale
NO thrombolysis.
Discussion with family regarding treatment options with regards to EVT. In a resource limited environment you may not do EVT, but if after discussion with the family (and patient) there was some quality of life we would take this case for EVT (without thrombolysis). Recent apixaban use is a contraindication to tPA. Not sure that CTP helps you here.
Dr William Whiteley
Decision
- No BP intervention
- No lysis
- Refer for thrombectomy
Rationale
Here is a man with AF on apixaban, who has presented relatively late. Thrombolysis in patients on anticoagulants (apart from warfarin with INR <1.7) is generally not used because of the likely hazard of intracranial haemorrhage. Some have advocated for reversal agents in patients taking a DOAC, although this is still experimental, and should only take place in RCTs.
His minor cognitive impairment doesn’t put me off.
I would refer him for thrombectomy, I think. The CT perfusion is not adequate to make a decision.
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