Select the crosses for each colleagues decision and rationale
Prof Mark Barber
Decision
- Lower SBP to <180mmHg before bolus
- No lysis
- Refer for thrombectomy
I would lower the BP and refer for thrombectomy, provided that that could happen very quickly.
Rationale
He has a LVO that would be amenable to lysis and thrombectomy. The evidence for CTP guided late thrombolysis isn’t currently as strong as for CTP guided thrombectomy and does increase the risk of ICH. If thrombectomy can be accessed quickly, then I would refer directly for that. Current European guidelines recommend BP control prior to intervention in this situation, although the evidence base is weak. If there was to be a large delay to thrombectomy then thrombolysis could be considered (using tenecteplase), again after BP control.
Dr Tracey Baird
Decision
- Lower SBP to <180mmHg before bolus
- Treat with alteplase 0.9mg/kg
- Refer for thrombectomy
Rationale
Although the time window here appears outwith the lysis window, the perfusion picture is favourable and essentially this is a Wake-Up stroke.
There is a vessel occlusion and a substantial deficit – I would ensure BP is lowered, offer lysis and strongly consider thrombectomy.
Dr Anthony Pereira
Decision
- Reduce BP
- Request CT, CTA &CTP
- Treat with alteplase 0.9mg/kg (EXTEND)
- Refer for thrombectomy
Rationale
The clinical syndrome here suggests a complete left MCA occlusion. It is potentially attributable to drug use or its associated complications (such as endocarditis).
Here, I would request a CT, CTA and CTP. The CT looks normal. I’m uncertain about the CTA. I think it shows either an MCA occlusion or stenosis. I would want to see other projections and discuss this with my neuroradiology colleagues.
The CTP shows an extensive area of ischaemia with no core. This could be because the time of onset is much shorter than anticipated or possibly a result of vasospasm.
I would bring the blood pressure down.
Using EXTEND criteria, it would be possible to thrombolyse this patient.
If my radiologists agreed that this was thrombosis, I would refer for thrombectomy.
Dr Shelagh Coutts
Decision
- Lower SBP to <180mmHg before bolus
- Treat with alteplase 0.9mg/kg
- Refer for thrombectomy
Rationale
This is a young patient with severe and disabling deficits. He woke up with his deficits and has an M1 occlusion. Perfusion imaging suggests that there is significant penumbra and not much core currently. My practice would depend on how long it will take the patient to get to thrombectomy. If there is a delay or a transfer to another hospital is required then I would thrombolyse the patient. To do this I would bring the BP down to guideline based care first. If I am able to take the patient directly (ie quickly) to thrombectomy then I would let the BP ride high until I got the vessel open.
Dr William Whiteley
Decision
- Lower SBP to <180mmHg before bolus
- Treat with alteplase 0.9mg/kg
- Refer for thrombectomy
Rationale
If there was a perfusion deficit that put him into the ‘favourable’ category I would consider him for alteplase with the EXTEND criteria (<9 hours from midpoint of sleep), before referring to thrombectomy. However, if this was not available, I would refer him for thrombectomy only.
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