A 68-year-old man presents with sudden onset left-sided weakness and neglect. MRI-DWI shows a right MCA territory infarct. He is 2 hours from symptom onset. NIHSS score is 14. CT angiography shows a right M1 occlusion. His BP is 188/100 mmHg and blood glucose is 142 mg/dL. He is on warfarin with INR 2.2 from atrial fibrillation. What is the most appropriate next step?

• A IV alteplase (tPA) immediately
• B Reverse warfarin with vitamin K and hold tPA
• C Aspirin 325 mg stat
• D Endovascular mechanical thrombectomy ✓

Explanation

INR >1.7 is a contraindication to IV alteplase in ischemic stroke. However, for large vessel occlusion (M1 segment), endovascular mechanical thrombectomy (EVT) is indicated within 6–24 hours (extended window with DAWN/DEFUSE criteria) and can be performed without regard to anticoagulation status. With NIHSS 14 and confirmed M1 occlusion within 2 hours, thrombectomy is the treatment of choice. This evidence is supported by multiple RCTs (HERMES meta-analysis) showing absolute benefit even when IV tPA is contraindicated.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.