Stroke Training and Awareness Resources (STARs)


08: Experienced colleagues decisions

Select the crosses for each colleagues decision and rationale

Prof Mark Barber

Decision

  • No BP intervention
  • No lysis
  • No thrombectomy

Not for any hyperacute stroke treatments. Active palliative interventions may become appropriate.

Rationale

Given this background function, I would not consider thrombolysis or thrombectomy. She would be at high risk of complications and is not the kind of patient that would have contributed to the data for any of the thrombolysis or thrombectomy trials. With a M1 occlusion she is unlikely to do well with thrombolysis in any case and active palliation and early return to her home, if possible, would be options that I would consider first.

Dr Tracey Baird

Decision

  • No BP intervention
  • No lysis / Treat with alteplase 0.9mg/kg – consider after d/w family
  • No thrombectomy

Rationale

This is complex – age in itself is not a disbar to lysis but preexisting disability and age might well deter me from thrombectomy. I note the anaemia which might make me worry about the risks of lysis/bowel cancer recurrence .

I would discuss with the  family as to whether they feel lysis is appropriate – if no family available I might err on the side of caution here.

Dr Anthony Pereira

Decision

  • No BP intervention is needed
  • Request CT & CTA
  • No lysis
  • No referral for thrombectomy

Rationale

This is elderly lady is in a very poor state of health. She has presented within 90 minutes However, the fact she was unaware of their syndrome does raise the possibility that the time of onset may not be secure.

I would request a CT and CTA. Here the CT shows a dense vessel and I think there is evidence of early ischaemic change. There is also an occlusion of the right middle cerebral artery and probably also the right terminal carotid.

The prospect of success here is rather remote. Assuming, that when assessed in person this lady is very frail indeed, I would be inclined not to proceed with either thrombolysis or thrombectomy. It is not possible to make everyone better in medicine but it is possible to make everyone worse.

Dr Shelagh Coutts

Decision

  • No BP intervention
  • Treat with alteplase 0.9mg/kg
  • No thrombectomy

Rationale

The treatment of the super elderly is tough. The super elderly do badly with big strokes in general. The trial data doesn’t suggest that we should withhold treatment in this situation, but the effect size does appear to be lower. My personal experience is that most of the super elderly patients do badly despite thrombectomy.

After discussion with the family regarding thrombolysis I would go ahead if they felt that is what she would want.

I would consider thrombectomy in a perfect patient, but not with the pre-morbid deficits described here.

Dr William Whiteley

Decision

  • No BP intervention
  • Treat with tenecteplase
  • Refer for thrombectomy

Rationale

The controversies here are her low Hb and functional status.

If there is evidence of recent active bleeding, I would be cautious about thrombolysis, but here there isn’t any, and her stroke is life-threatening in a woman of this age, so I would go ahead with tenecteplase planning for thrombectomy

My view on prior disability is to consider treatment in patients who would consider active treatment and have something to gain. This lady, although 96 and impaired does take part in her own self care, and seems to participate, so I would at least open a discussion with my thrombectomy colleagues.

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