Select the crosses for each colleagues decision and rationale
Prof Mark Barber
Decision
- Lower SBP to <180mmHg before bolus
- Treat with alteplase 0.9mg/kg
- No thrombectomy
I would lower blood pressure with labetolol and treat with thrombolysis if achieved. I would not refer for thrombectomy.
Rationale
He has an M2 clot which may respond to thrombolysis provided that his blood pressure can be lowered to a safe level. As far as thrombectomy is concerned, there are at least three relative contraindications. 1. the need for BP control. 2. his previous functional state. 3. it is not a ICA or M1 clot. Adding these three together, I would stick to lysis alone.
Dr Tracey Baird
Decision
- Lower SBP to <180mmHg before bolus
- Treat with alteplase 0.9mg/kg
- No thrombectomy
Rationale
This is clearly a new stroke and I would ensure BP treated then IV lysis.
The decision re thrombectomy is nuanced – he has existing disability and the clot is a little more distal. With a very experienced operator and minimal transfer time it might be feasible but the risk benefit margins are tighter. Again discussion with family re prior expressed wishes would be helpful.
Dr Anthony Pereira
Decision
- No BP intervention is needed
- Request CT & CTA
- No lysis
- No referral for thrombectomy
Rationale
This is a difficult case. The patient is elderly and in poor health. He has had a recent myocardial infarct and a significant right hemisphere cerebral infarct. He is on dual antiplatelet therapy and the blood pressure at presentation is very high.
The CT shows an old infarct. The CTA shows abnormal vessels on the side of the old infarct. In addition, there is an M2 occlusion on the left middle cerebral. The collateral circulation looks quite good.
The patient presents with an timeframe of NINDS. Thrombolysis is feasible but the blood pressure would need to be better controlled. Thrombectomy may be feasible but with an mRS of 3 he is unsuitable.
In this case, regretfully, I would offer no thrombolysis or thrombectomy. I would bring the blood pressure down slowly over the next few days.
Dr Shelagh Coutts
Decision
- Lower SBP to <180mmHg before bolus
- Treat with alteplase 0.9mg/kg
- Refer for thrombectomy
Rationale
Although this is a patient who had a large previous stroke, he has done remarkably well. Has some things that bring enjoyment and has a reasonable quality of life.
I would thrombolyse him after I bring his BP down. I usually wait for the BP to come down. It is very rare that you can’t bring it down.
Given how high the NIHSS is I would go ahead with thrombectomy. There is clearly delayed blood flow in that region. Although it is an M2 occlusion it is clinically acting as an M1.
Dr William Whiteley
Decision
- Lower SBP to <180mmHg before bolus
- Treat with tenecteplase
- Refer for thrombectomy
Rationale
He has a M2 occlusion. Patients like this still benefit from thrombectomy (https://jnis.bmj.com/content/11/11/1065) and is within the time window.
He has a severe deficit and a lot to lose, so I would act as quickly as possible, particularly with the blood pressure lowering.
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