A 70-year-old man with atrial fibrillation has an ischaemic stroke with NIHSS 14. CT brain: no haemorrhage, ASPECTS score 8. He arrives 3.5 hours after symptom onset. CT angiography shows M1 segment MCA occlusion. What is the optimal treatment strategy?
- A IV alteplase followed immediately by mechanical thrombectomy ✓
- B Mechanical thrombectomy alone without prior thrombolysis
- C IV alteplase only; thrombectomy reserved if no clinical improvement at 30 minutes
- D IV tenecteplase then thrombectomy if no recanalization at 90 minutes
Explanation
For large vessel occlusion (LVO) strokes within the IV thrombolysis window (up to 4.5 hours), current AHA/ASA 2019 guidelines recommend IV alteplase followed immediately by mechanical thrombectomy — the bridging approach. Multiple trials (MR CLEAN, SWIFT-PRIME, DAWN, DEFUSE-3) established thrombectomy benefit in LVO stroke up to 24 hours in selected patients. The SKIP and DIRECT-SAFE trials examined direct thrombectomy without tPA, but meta-analyses show non-inferiority rather than superiority, so the standard remains bridging therapy when eligible. Tenecteplase is an emerging alternative but not yet universally adopted.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.