A 72-year-old man presents with sudden right hemiplegia and global aphasia. Non-contrast CT brain at 2 hours is normal. NIHSS score is 14. He is not on anticoagulants. Last known well was 90 minutes ago. What is the CORRECT reperfusion strategy?

• A IV alteplase (tPA) 0.9 mg/kg only; mechanical thrombectomy is not indicated without CT angiography evidence of large vessel occlusion
• B Direct mechanical thrombectomy without tPA as NIHSS > 10
• C Aspirin 300 mg only as CT shows no haemorrhage
• D IV alteplase followed by CT angiography; if large vessel occlusion confirmed, proceed to mechanical thrombectomy ✓

Explanation

Current AHA/ASA 2019 stroke guidelines recommend IV alteplase (0.9 mg/kg, max 90 mg) for eligible ischaemic stroke within 4.5 hours of onset, followed immediately by CTA to identify large vessel occlusion (LVO). If LVO is confirmed (particularly internal carotid or M1 MCA), mechanical thrombectomy improves outcomes up to 24 hours in appropriately selected patients (DAWN and DEFUSE-3 trials). Withholding tPA to proceed directly to thrombectomy is appropriate only when tPA is contraindicated; bridging tPA + thrombectomy is standard in centres capable of both.

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

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Written and medically reviewed by the StethoPrep medical team.