A 72-year-old man presents with sudden right hemiplegia and aphasia. CT head shows no hemorrhage. NIHSS score is 14. Time from symptom onset is 2.5 hours. MRI DWI shows a left MCA territory infarct. He has no contraindications to thrombolysis. BP is 168/95 mmHg. What is the next critical step?

• A Administer IV alteplase (tPA) immediately ✓
• B Reduce BP to below 140/90 mmHg before administering tPA
• C Administer aspirin 325 mg and arrange MRI with perfusion imaging
• D Proceed directly to mechanical thrombectomy without tPA

Explanation

For acute ischemic stroke within 4.5 hours of onset, IV alteplase is indicated if BP is <185/110 mmHg (AHA/ASA 2019 guidelines). A BP of 168/95 is within the acceptable range — BP should be reduced only if it exceeds 185/110 mmHg, and only to that threshold (not to normal levels) before administering tPA. Overcorrecting BP can worsen ischemia. Given an NIHSS of 14 (large vessel occlusion territory), he is also a candidate for concurrent mechanical thrombectomy, but tPA must not be withheld while thrombectomy is being arranged.

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

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.