Select the crosses for each colleagues decision and rationale
Prof Mark Barber
Decisions
- No BP intervention
- Treat with tenecteplase
- Refer for thrombectomy
I would thrombolyse as quickly as possible and refer on to a comprehensive stroke centre for thrombectomy.
Rationale
This lady has a good functional status and a LVO well within the time window for both thrombolysis and thrombectomy, with no obvious contraindication to either. I would use tenecteplase (if it were allowed in Scotland) and refer for thrombectomy.
Dr Tracey Baird
Decisions
- No BP intervention
- Treat with alteplase 0.9 mg/kg
- Refer for thrombectomy – but depends on transfer time, and may need repeat perfusion study when arrives
Rationale
There are no reasons not to thrombolyse here that I can identify.
The decision re thrombectomy may well depend on how long the transfer time window is and family wishes. Age in itself I would not regard as a contraindication. The natural history of this stroke without recanalization will be poor.
Dr Anthony Pereira
Decisions
- No BP intervention is needed
- Request CT, CTA & CTP
- Treat with Alteplase 0.9 mg/kg
- Refer for thrombectomy
Rationale
This lady was independent. She has no definite contraindications for thrombolysis and is well within time for thrombectomy. The contrast CT shows a clear hyperdensity in the left MCA which is likely to be red thrombus. There is vascular change elsewhere but no clear infarction. The CTA shows a distal, left, M1 occlusion. While it is not absolutely necessary to request CTP, I think it adds useful information within the six hour bracket. It shows a substantial mismatch and a small core.
Dr Shelagh Coutts
Decision
- No BP intervention
- Treat with alteplase 0.9mg/kg
- Refer for thrombectomy
This is a perfect thrombectomy case as far as I can see? I would give alteplase and then thrombectomy asap. This is a Calgary centric comment – but I don’t need CTP here. Good scan, bad deficit and LVO….
Rationale
Good scan, early patient. LVO.
The insula changes are pretty subtle. You really need more cuts if you are looking for a proper assessment. Although, we score ASPECTS still we mostly have moved to good, moderate and terrible. And terrible is the discussion point.
Dr William Whiteley
Decision
- No BP intervention
- Treat with tenecteplase
- Refer for thrombectomy
Rationale
This well woman has a lot to lose from a severe ischaemic stroke. I would give tenecteplase as fast I as could (or randomise into a study comparing tenecteplase with another thrombolytic) and then refer directly to a thrombectomy service.
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