Select the crosses for each colleagues decision and rationale
Prof Mark Barber
Decision
- No BP intervention
- Treat with tenecteplase
- Refer for thrombectomy
After discussion of risks of bleeding I would thrombolyse. I would also discuss his case with a thrombectomy centre.
Rationale
This man is borderline in a few ways. His INR is on the cut-off for thrombolysis. His NIHSS on the cut-off for many of the thrombectomy trials. However, in his case potentially very disabling. The previous GI bleed would not concern me too much. I would hope that that could be dealt with, with supportive treatment, if he bled again. He is towards the end of the traditional thrombolysis time window, but has CTP that suggests some rescuable tissue. I would discuss with a thrombectomy centre, as well as thrombolysing, but would understand if they felt they couldn’t take him (depending on how accessible they felt the clot was).
Dr Tracey Baird
Decision
- No BP intervention
- No lysis
- No thrombectomy
Rationale
The raised INR largely precludes lysis, in addition there is a disconnect between the plain imaging and the CTP with the plain CT suggesting the time window is longer than 4 hrs – this is not uncommon in non dominant hemisphere strokes.
Although we can see a PCA occlusion this may be more challenging to access interventionally and again the capacity for recovery given the plain CT findings would dissuade me from this.
Dr Anthony Pereira
Decision
- No BP intervention is needed
- Request CT & CTA
- No lysis
- No referral for thrombectomy
Rationale
Here, the patient has significant visual problems but milder limb deficits. The NIHSS is 6. The patient presents four hours from onset and is currently taking warfarin with an elevated INR.
I would request a CT and CTA. The CT shows bilateral occipital infarcts with an older PCA infarct on the right. There is cerebellar infarction. Here, it would be helpful to have a longitudinal view of the vertebral and basilar arteries is to assess their state of disease.
As the patient is taking warfarin, thrombolysis is contraindicated albeit the INR is close to an acceptable risk limit. The artery most likely to be affected here is the right PCA and there is little supporting evidence that endovascular intervention here is appropriate. Therefore, I would not recommend either thrombolysis or referral for thrombectomy.
Dr Shelagh Coutts
Decision
- No BP intervention
- No lysis
- No thrombectomy
Rationale
I wouldn’t thrombolyse this case as the NCCT changes are subacute. The risk of ICH here is high. There are clearly evolving changes. I would wonder whether the time of onset is incorrect, but either way I wouldn’t go ahead in this case.
I would not do EVT for the same reasons.
Dr William Whiteley
Decision
- No BP intervention
- Treat with tenecteplase
- Refer for thrombectomy
Rationale
Here we have a potentially disabling PCA infarct most likely from cardio-embolism. I would start off with tenecteplase (his INR is below the generally recognised threshold for avoiding treatment) and discuss with neurology colleagues to see if they thought that thrombectomy to the PCA was feasible in his case.
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