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 with patients permission, knowing that any functional gains may be small.
Rationale
Despite time frame, advanced imaging suggests little to gain from thrombectomy. The vessel is fairly distal too. However, provided patient is willing, thrombolysis is reasonable.
Dr Tracey Baird
Decision
- No BP intervention
- No lysis
- No thrombectomy
Rationale
There is a case to be made both for and against lysis here. Outwith 4.5 hrs with a matched perfusion defect lysis is likely to be unhelpful With three hours it is much more nuanced with less robust evidence, but given the plain CT changes I would probably err not to lyse and move simply to antiplatelet therapy.
Dr Anthony Pereira
Decision
- No BP intervention is needed
- Request CT, CTA & CTP
- No lysis
- No referral for thrombectomy
Rationale
Here I would request a CT, CTA and CTP at the outset. A left sylvian dot is visible on the plain CT. It corresponds to a left M2 occlusion. The CTP shows a matched defect. Therefore, in this case I would not opt for either thrombolysis nor refer for thrombectomy.
Dr Shelagh Coutts
Decision
- No BP intervention
- Treat with alteplase 0.9mg/kg
- No thrombectomy
Rationale
I would go back to the patient and confirm that the time of onset was correct. If it was correct I would still go ahead with thrombolysis as we are early. Given the low NIHSS, distal occlusion and lack of a large penumbra I would not go ahead with thrombectomy. I would discuss the fact that I already see significant changes on the scan so I’m not sure how much benefit we will see from thrombolysis. But given the severity of the motor weakness I would go ahead.
Dr William Whiteley
Decision
- No BP intervention
- Treat with alteplase 0.9mg/kg
- No thrombectomy
Rationale
I would discuss thombectomy with my radiology colleagues to see whether they would consider thrombectomy, but the occlusion seems to be in a distal artery. Otherwise, alteplase alone.
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