A 72-year-old man with atrial fibrillation presents with sudden right-sided weakness, aphasia, and right facial droop. NIHSS score is 16. CT brain shows no hemorrhage. CT angiography reveals left MCA M1 segment occlusion. Time from symptom onset to hospital arrival is 3.5 hours. He has no contraindications. What is the optimal management?
- A IV alteplase alone (0.9 mg/kg, max 90 mg)
- B IV alteplase followed immediately by mechanical thrombectomy ✓
- C Mechanical thrombectomy alone without alteplase
- D Anticoagulation with heparin for cardioembolic stroke
Correct answer: B. IV alteplase followed immediately by mechanical thrombectomy
Explanation
For acute ischemic stroke with large vessel occlusion (LVO) within the thrombolysis window (<4.5 hours), the current standard is bridging therapy: IV alteplase followed by mechanical thrombectomy. Multiple RCTs (MR CLEAN, ESCAPE, SWIFT PRIME) demonstrated superiority of combined approach or thrombectomy alone; however, when the patient is eligible for IV thrombolysis AND has LVO, alteplase should not be withheld prior to thrombectomy (bridging thrombolysis). Anticoagulation is not indicated acutely for cardioembolic stroke due to hemorrhagic transformation risk.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.