A 68-year-old hypertensive man presents with sudden-onset aphasia and right hemiplegia. NIHSS is 14. Non-contrast CT head shows no haemorrhage. Time from symptom onset to hospital arrival is 2.5 hours. CT perfusion shows a core infarct of 30 mL and penumbra of 80 mL. The mismatch ratio is 2.7. What is the appropriate reperfusion strategy?

• A IV alteplase alone; mechanical thrombectomy not indicated with NIHSS <15
• B Mechanical thrombectomy only; alteplase contraindicated if thrombectomy is planned
• C Conservative management with antiplatelet therapy; reperfusion is contraindicated with core >20 mL
• D IV alteplase followed by mechanical thrombectomy if large vessel occlusion confirmed ✓

Explanation

Within 4.5 hours of symptom onset, IV alteplase is indicated for eligible ischemic stroke patients (no haemorrhage on CT), followed immediately by mechanical thrombectomy if large vessel occlusion is identified. The bridging approach (IV thrombolysis + EVT) remains standard per AHA/ASA 2023 guidelines, as alteplase may lyse clot in distal vessels not accessible to thrombectomy. The penumbra-to-core mismatch ratio of 2.7 (>1.8) confirms viable tissue worth salvaging. Core >50 mL is a relative contraindication for EVT in some protocols, but 30 mL is within eligible range.

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

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Written and medically reviewed by the StethoPrep medical team.