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 but not refer for thrombectomy.
Rationale
Clinically the stroke seem to come before the seizure. Other imaging performed, suggests no role for thrombectomy. Any assessment of the underlying neurological deficits is tricky in the context of seizure, but at the time of decision making there seems to be significant deficits and salvageable brain on the CTP. CTP doesn’t have perfect positive predictive value but the changes there are hard to ignore. With only the CTA I suspect I would have avoided thrombolysis (uncertain diagnosis/uncertain neurological deficits). With the CTP I would go ahead, knowing that the risk of harm is low if this is in fact a stroke mimic.
Dr Tracey Baird
Decision
- No BP intervention
- No lysis
- No thrombectomy
Rationale
Although seizure is a relative contraindication to lysis it is likely to be a symptomatic seizure (rather than a seizure with Todd’s paresis) given the CTP. Lysis could be considered but his varices and raised INR might put me off.
He is not a candidate for thrombectomy.
Dr Anthony Pereira
Decision
- No BP intervention is needed
- Request CT, CTA & CTP
- No lysis
- No referral for thrombectomy
Rationale
The crucial issue here is that he is beyond the three hour NINDS window and into ECASS 3 territory. He has an elevated risk of bleeding and his INR is not normal.
Here I would request a CT, CTA and CTP. This would provide the maximum amount of information. The CTA is normal
In this case, the CTP is consistent with this being a small stroke. Only small volume of brain has been affected and balanced against time and risk of haemorrhage, I would not proceed with thrombolysis in this case.
Dr Shelagh Coutts
Decision
- No BP intervention
- Treat with alteplase 0.9mg/kg
- No thrombectomy
Rationale
This is a tough case. In the original NINDS trial a seizure at onset was an exclusion. Now we can use CTA/CTP to help us confirm that it is indeed a stroke. This was the case here. As long as the deficit is still disabling I would thrombolyse. I would reassess the patient a couple of times to make sure that he isn’t improving dramatically and go ahead with thrombolysis if still disabled. The cirrhosis may increase his risk of bleeding, but with normal platelets and an INR of 1.4 I would go ahead.
Dr William Whiteley
Decision
- No BP intervention
- Treat with alteplase 0.9mg/kg
- No thrombectomy
Rationale
Despite the seizure at onset (which happens after cortical ischaemic stroke, but is not common), he has evidence of a left hemisphere ischaemic stroke, consistent with his symptoms.
It is hard to know how severe the stroke is, because he is post-ictal, but in the acute setting we can’t know the answer to this question.
I would go ahead with thrombolysis with alteplase.
After his stroke he would need to discuss an anticonvulsant and whether he would address his alcohol intake. His varices haven’t bled, and I would probably weigh the benefit greater than the risk here.
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