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 provided that patient is prepared to take the increased risk of a ICH.
Rationale
This seems like a potentially life changing stroke. No pointers to a stroke mimic and the combination of CTP and clinical findings points towards a lacunar event. This may still respond to treatment. Her previous ICH and microbleeds are relative contraindications to thrombolysis, but she is early in the thrombolysis time window and has potential to benefit from the intervention too. With no LVO, thrombectomy is not an option.
Dr Tracey Baird
Decision
- No BP intervention
- Treat with alteplase 0.9mg/kg
- No thrombectomy
Rationale
The history for acute stroke is fairly strong and the only relative contradiction is previous ICH although that was some time ago so on balance I would lyse although I’d have to accept possibly higher risk as she could have an underlying angiopathy.
There is no vessel occlusion or perfusion deficit so thrombectomy is not required.
Dr Anthony Pereira
Decision
- No BP intervention is needed
- Request CT, CTA & CTP
- No lysis
- No referral for thrombectomy
Rationale
Here the patient has presented approximately two hours after onset. The syndrome is relatively mild but still potentially significant.
The crucial issue is the risk of intra-cerebral haemorrhage. It is essential to try to weight this against the severity of cerebral ischaemia.
Therefore, I would request a CT, CTA and CTP. Here, the CT shows substantial small vessel disease. The CTA looks normal. The CTP is normal. Therefore, the prognosis for this person is very good with no particular intervention.
Dr Shelagh Coutts
Decision
- No BP intervention
- Treat with alteplase 0.9mg/kg
- No thrombectomy
Rationale
This is a patient with a disabling recent deficit. It is suspicious for a lacunar stroke given the pure motor hemiparesis and imaging results (no LVO, normal CTP). The remote ICH would not stop me from giving thrombolysis given the disabling deficit, but I would quote a slightly higher risk of ICH to the family given the small vessel disease that we know she has. I would give thrombolysis with a standard dose. Microbleeds on an MRI are not a contraindication to tPA.
No occlusion so not for EVT.
Dr William Whiteley
Decision
- No BP intervention
- Treat with alteplase 0.9mg/kg
- No thrombectomy
Rationale
Here we have a modestly disabling ischaemic stroke that is probably lacunar. We don’t have any supporting imaging, and a history of ICH – which increases the risk of post alteplase ICH, but also increases the risk of lacunar infarction. Microbleeds are also a risk marker of post alteplase ICH, but the evidence to avoid alteplase in people with microbleeds is weak.
On balance, with a disabling stroke and lack of alternatives I think the known benefit of alteplase is larger than any putative harms.
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