Select the crosses for each colleagues decision and rationale
Prof Mark Barber
Decision
- No BP intervention
- Treat with alteplase 0.9mg/kg
- No thrombectomy
For thrombolysis but not 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. Her CTP is normal but that does not rule out a lacunar infarction or other false negative.
Dr Tracey Baird
Decision
- No BP intervention
- No lysis – but…
- No thrombectomy
Rationale
This is the same scenario as case 3 – but with no perfusion deficit and with a much shorter onset to presentation time.
Again the decision is complex – this may well be a lacunar infarct or a small posterior fossa infarct (assessing for aphasia in acute setting may be challenging) and the more rapid presentation to care means the benefit of lysis may be higher and the overall risk of lysis slightly lower, but stroke mimic presentations in those with ESRF are relatively common and I would still be cautious here.
Dr Anthony Pereira
Decision
- No BP intervention is needed
- Request CT & CTA
- Treat with alteplase 0.9mg/kg
- No referral for thrombectomy
Rationale
In this case, the CT and CTA look normal. The main issues here are the poor state of health of the patient, particularly the uncontrolled diabetes, significant anaemia and renal failure.
That said, the time from onset is very short. Overall, I would be more active in this case. As the CTA is normal, I would simply administer thrombolysis. There is no clear-cut thrombectomy target.
Dr Shelagh Coutts
Decision
- No BP intervention
- Treat with alteplase 0.9mg/kg
- No thrombectomy
Rationale
Disabling deficit. No contraindication. No LVO.
Thrombolysis only. CTP doesn’t help in this case. Deficit may be from a small vessel stroke. Improvement is only minor. This would not stop me from thrombolysing them.
Dr William Whiteley
Decision
- No BP intervention
- Treat with alteplase 0.9mg/kg
- No thrombectomy
Rationale
She has a potentially disabling ischaemic stroke, with no perfusion deficit. This might be due to a small subcortical infarct without a clear perfusion deficit – it isn’t quite clear to me what one would expect with a lacunar infarct.
Patients with lacunar infarcts benefit from alteplase as much as those without, as far as we can tell from the RCTs .
I would go ahead with alteplase – although patient’s renal impairment have a higher risk of post alteplase ICH, I think this is the best option here.
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