Select the crosses for each colleagues decision and rationale
Prof Mark Barber
Decision
- No BP intervention
- No lysis
- Refer for thrombectomy
For thrombectomy ASAP.
Rationale
There probably isn’t an absolute contraindication to thrombolysis here but the recent delivery might cause some issues. More importantly, lysis is very unlikely to have much of an impact on her completely occluded ICA. If thrombectomy can be accessed quickly then I would go straight to that and try to avoid thrombolysis.
Dr Tracey Baird
Decision
- No BP intervention
- No lysis
- Refer for thrombectomy
Rationale
This is a young lady with a presumed post partum dissection. The recent delivery makes IV lysis more challenging – there are case reports where it has been performed successfully but I would prefer to go straight to thrombectomy.
Dr Anthony Pereira
Decision
- No BP intervention is needed
- Request CT, CTA & CTP
- No lysis
- Refer for thrombectomy
Rationale
This is a very young lady who is four days post-partum. The two days of headache and neck pain are suggestive of cervical artery dissection. The clinical presentation is very suggestive of stroke.
I would request a CT, CTA and CTP. The CT doesn’t show any early changes of ischaemia. The CTA is interesting in that it shows a significant narrowing of the internal carotid consistent with the dissection. The carotid artery then occludes and there appears to be no flow in the distal carotid or MCA.
The CTP shows a small core and larger perfusion lesion. Given the risk of haemorrhage from the recent obstetric procedure, I would contraindicate thrombolysis. I would refer for thrombectomy.
Dr Shelagh Coutts
Decision
- No BP intervention
- Treat with alteplase 0.9mg/kg
- Refer for thrombectomy
Rationale
In this case I would call obstetrics and discuss whether they are comfortable with me giving thrombolysis. It may depend on whether there has been any vaginal bleeding post partum. Ideally we would thrombolyse.
Thrombectomy is the best option here. It may be technically challenging to get past the dissection, but not impossible. The terminal ICA/MCA occlusion is unlikely to recanalize with just thrombolysis. I would discuss options with my interventionalist.
Dr William Whiteley
Decision
- No BP intervention
- Treat with tenecteplase
- Refer for thrombectomy
Rationale
There is no direct evidence about thrombolysis in patients with arterial dissection, but there is no reason to think that the primary mechanism of stroke is not thrombotic (unless there arterial occlusion from dissection).
I would therefore try tenecteplase and then ask my neuroradiology colleagues about the feasibility of passing the dissection on the way up to extract the clot or to open any intracranial dissection.
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