A 72-year-old man with atrial fibrillation presents with left hemispheric ischaemic stroke. MRI DWI shows an infarct of 45 mL. NIHSS is 14. Time from symptom onset to hospital arrival is 3 hours. CT angiography shows left MCA M2 occlusion with excellent collaterals (ASPECTS 8). The BEST management strategy is:

• A IV alteplase alone (0.9 mg/kg, max 90 mg) within the 4.5-hour window
• B IV alteplase followed immediately by mechanical thrombectomy (bridging strategy) ✓
• C Direct mechanical thrombectomy without IV thrombolysis (direct EVT)
• D Anticoagulation with heparin to prevent early stroke recurrence in AF

Explanation

Current AHA/ASA 2023 stroke guidelines support bridging therapy (IV alteplase followed by mechanical thrombectomy) for eligible large vessel occlusion strokes when the patient arrives within the thrombolysis window. M2 segment occlusion with ASPECTS ≥6 and good collaterals qualifies for EVT. Recent trials (MR CLEAN, DAWN, DEFUSE-3) support combining thrombolysis + EVT. Anticoagulation is generally deferred 4–14 days after cardioembolic stroke to reduce haemorrhagic conversion risk.

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

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Written and medically reviewed by the StethoPrep medical team.