A 68-year-old man presents with right-sided weakness and aphasia with onset 90 minutes ago. NIHSS score is 16. Non-contrast CT head shows no hemorrhage. CT perfusion shows penumbra/core mismatch with salvageable tissue. He is eligible for IV thrombolysis. He also has a large vessel occlusion of the left MCA on CTA. What is the optimal treatment strategy?

• A IV alteplase alone; mechanical thrombectomy is not indicated within the standard window
• B Mechanical thrombectomy alone; alteplase is contraindicated with large vessel occlusion
• C Antiplatelet therapy and observation with follow-up imaging
• D IV alteplase followed immediately by mechanical thrombectomy (bridging therapy) ✓

Explanation

Current guidelines (AHA/ASA 2023) recommend bridging IV thrombolysis followed by mechanical thrombectomy for eligible patients with large vessel occlusion (LVO) presenting within 4.5 hours. IV alteplase is given while the patient is prepared for thrombectomy. The SWIFT-PRIME, ESCAPE, and MR-CLEAN trials demonstrated that thrombectomy combined with IV alteplase is superior to alteplase alone for LVO. Thrombectomy alone (drip and ship vs. mothership debates) is under study but bridging remains the standard of care.

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

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Written and medically reviewed by the StethoPrep medical team.