A 72-year-old man with atrial fibrillation develops sudden right-sided hemiplegia, aphasia, and right homonymous hemianopia. Brain CT (non-contrast) is normal. The NIHSS score is 18. Time of symptom onset is confirmed at 2 hours ago. He is not on anticoagulation. The most appropriate acute intervention is:
- A Mechanical thrombectomy alone without IV thrombolysis
- B Immediate anticoagulation with unfractionated heparin
- C IV alteplase (0.9 mg/kg) followed by mechanical thrombectomy if large vessel occlusion confirmed ✓
- D Aspirin 300 mg and aggressive BP control only
Correct answer: C. IV alteplase (0.9 mg/kg) followed by mechanical thrombectomy if large vessel occlusion confirmed
Explanation
In acute ischaemic stroke within 4.5 hours with no contraindications, IV alteplase (0.9 mg/kg, max 90 mg) is the first-line treatment. If CT/CTA confirms large vessel occlusion (as suggested by the cortical syndrome — aphasia, hemianopia, hemiplegia), mechanical thrombectomy should follow. The combined bridging approach (IVT + EVT) has been validated by multiple RCTs. Heparin is not indicated acutely in cardioembolic stroke per current guidelines.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.