Select the crosses for each colleagues decision and rationale
Prof Mark Barber
Decision
- No BP intervention
- No lysis
- Refer for thrombectomy
For thrombectomy if can be done quickly and avoid thrombolysis.
Rationale
With the hip fracture I would be concerned about bleeding complications with thrombolysis along with the possibility that it may not be effective with this clot load. Straight to quick thrombectomy would be my preferred route.
Dr Tracey Baird
Decision
- No BP intervention
- No lysis
- Refer for thrombectomy
Rationale
A very similar case to scenario 2 but a more serious fracture, and an obvious vessel occlusion with a favourable CTP suggesting penumbra.
I would not lyse but I would offer thrombectomy.
Dr Anthony Pereira
Decision
- No BP intervention is needed
- Request CT, CTA & CTP
- No lysis
- Refer for thrombectomy
Rationale
In this case, the fractured right femur would put me off giving thrombolysis. The issue, therefore, is whether there is a proximal artery occlusion.
The CT looks normal but the CTA shows a carotid terminus occlusion. I would go back and recheck the NIHSS as I’m surprised it would be so low with a carotid terminus syndrome.
I would request a CTP which in this case shows an unmatched defect, sufficiently large to support intervention. I would refer her for thrombectomy.
Dr Shelagh Coutts
Decision
- No BP intervention
- Treat with alteplase 0.9mg/kg
- Refer for thrombectomy
Rationale
This is a previously healthy woman with good premorbid function.
She has a fractured femur so I would discuss with orthopedics regarding thrombolysis in this setting. Given the large volume of clot I would go ahead with thrombectomy. The decision regarding thrombolysis will depend on what orthopedics think. A fractured femur could potentially be a large source of blood loss and is not really compressible.
Dr William Whiteley
Decision
- No BP intervention
- No lysis
- Refer for thrombectomy
Rationale
Here we have a woman with a fracture that is in a non-compressible site and maybe significant, but also a LAO that is treatable with thrombectomy.
I think, given that thrombectomy is a treatment option here, I would opt for straight to thrombectomy.
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