A 72-year-old man with atrial fibrillation presents with sudden onset left hemiplegia and hemisensory loss. CT head at 90 minutes shows no hemorrhage. NIHSS score is 14. He is on aspirin. What is the MOST appropriate immediate management?
- A IV heparin infusion to prevent further embolism
- B Mechanical thrombectomy alone without IV thrombolysis
- C IV alteplase (0.9 mg/kg) followed by assessment for mechanical thrombectomy ✓
- D Aspirin 300 mg loading dose and admission for monitoring
Correct answer: C. IV alteplase (0.9 mg/kg) followed by assessment for mechanical thrombectomy
Explanation
Within 4.5 hours of ischemic stroke onset with no contraindications, IV alteplase is indicated (Class I recommendation). NIHSS ≥6 with large vessel occlusion also qualifies for assessment for mechanical thrombectomy (up to 24 hours in selected patients per DAWN/DEFUSE-3 criteria). Bridging IV alteplase before thrombectomy is standard unless direct thrombectomy access is immediately available and delay would be minimized. Heparin is not indicated for acute ischemic stroke treatment. Aspirin alone is insufficient for NIHSS 14.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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