Select the crosses for each colleagues decision and rationale
Prof Mark Barber
Decision
- No BP intervention
- Treat with alteplase 0.9mg/kg
- No thrombectomy
Thrombolyse provided that the patient understands the higher risk of complications with the ankle fracture and is happy to proceed.
Rationale
The history and examination don’t point to any stroke mimics and the CTP is still compatible with a lacunar stroke, which may still respond to thrombolysis. There will be in increased risk of bleeding complications with lysis but, on the other hand, the stroke is potentially very disabling and could impact on her volunteering job and hobbies.
Dr Tracey Baird
Decision
- No BP intervention
- No lysis
- No thrombectomy
Rationale
Given the fall and fracture with normal CTP I’d be reluctant to lyse here.
She is not a thrombectomy candidate.
Dr Anthony Pereira
Decision
- No BP intervention is needed
- Request CT & CTA
- No lysis
- No referral for thrombectomy
Rationale
In this case, the fractured right ankle would put me off giving thrombolysis. Therefore, the only issue is whether there is a proximal artery occlusion. Here, the CT and CTA look normal so I would not recommend further intervention.
Dr Shelagh Coutts
Decision
- No BP intervention
- Treat with alteplase 0.9mg/kg
- No thrombectomy
Rationale
Disabling deficit relatively early from onset. Despite the absence of a LVO or perfusion abnormality I would go ahead and thrombolyse. Disabling deficit in someone with good premorbid function. Clinical acumen is required in the absence of advanced imaging abnormalities.
Dr William Whiteley
Decision
- No BP intervention
- Treat with alteplase 0.9mg/kg
- No thrombectomy
Rationale
This previously well woman has a significant disabling stroke, but no evidence of LAO, or early ischaemic change, but has had an ankle fracture increasing the chance of haemorrhage.
The CTA rules our LAO, but not a distal vessel occlusion that would be consistent with her syndrome.
The ankle fracture is probably compressible, but I would ask an orthopaedic surgeon for their opinion – a displaced fracture would put me off, a non-displaced one less so.
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