Select the crosses for each colleagues decision and rationale
Prof Mark Barber
Decision
- No BP intervention
- Treat with alteplase 0.9mg/kg
- No thrombectomy
Thrombolyse and not for thrombectomy. Manage hyperglycaemia.
Rationale
Thrombectomy is not an option as no LVO. Otherwise she is young and has potential to do well with thrombolysis. The level of anaemia is a concern, but probably relates to her renal disease. I would want to check that there had been no acute drop in her haemoglobin before going ahead. She is right at the end of the traditional thrombolysis time window but has a promising CTP in terms of salvageable brain tissue.
Dr Tracey Baird
Decision
- No BP intervention
- No lysis
- No thrombectomy
Rationale
There are markers here for complications if we lyse (high blood glucose, renal failure/dialysis). She is at the tail end of the time window for benefit for IV lysis. In my view this is a tight risk benefit margin. I do however note that overall brain structure on the CT looks quite good for a patient with her co-morbidities, and that she has aphasia so this might be a decision you would also want to involve family in to ensure any expressed pre stroke directives could be followed.
Although her NIHSS is >10 the perfusion deficit is small and there is no major vessel occlusion. She is not a candidate for thrombectomy at the present time.
Dr Anthony Pereira
Decision
- No BP intervention is needed
- Request CT & CTA
- No lysis
- No referral for thrombectomy
Rationale
This lady, in spite of her young age, is in a very poor state of health with uncontrolled diabetes and attendant complications. Her presentation is also more than six hours from onset.
Her CT brain looks normal as does the CTA.
In this case, I would be wary of performing thrombolysis on-time criteria. Her state of health is sufficiently poor that I wouldn’t pursue CTP assess suitability for thrombolysis under the EXTEND criteria.
There is no suitable intracranial target for thrombectomy.
Dr Shelagh Coutts
Decision
- No BP intervention
- Treat with alteplase 0.9mg/kg
- No thrombectomy
Rationale
A good case for thrombolysis. Personally I didn’t need the CTP to make this decision. Disabling deficit. No contraindication so go ahead. CTP just wastes time here. You already know that there is no LVO.
Dr William Whiteley
Decision
- No BP intervention
- Treat with alteplase 0.9mg/kg
- No thrombectomy
Rationale
She has a potentially disabling ischaemic stroke, with a small cortical perfusion deficit. I would go ahead with alteplase – although patients with renal impairment have a higher risk of post alteplase ICH, I think this is the best option here.
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