A 71-year-old man presents 2.5 hours after onset of right-sided hemiplegia and aphasia. NIHSS score is 14. Non-contrast CT shows no haemorrhage or early infarct signs. BP is 178/96 mmHg. He has no contraindications to thrombolysis. What is the MOST appropriate immediate treatment?

• A CT angiogram first, then thrombectomy without alteplase
• B Aspirin 300 mg loading dose and admit for monitoring
• C Lower blood pressure to below 140 mmHg before treating
• D IV alteplase 0.9 mg/kg (max 90 mg) immediately ✓

Explanation

The patient is within the 4.5-hour thrombolysis window with no contraindications; IV alteplase 0.9 mg/kg (10% as bolus, rest over 60 minutes) is indicated per AHA/ASA 2019 guidelines. Blood pressure should be lowered to <185/110 mmHg only if required before alteplase, not to <140 mmHg. Mechanical thrombectomy is appropriate if large vessel occlusion is present but should not delay alteplase when eligible. Antiplatelet therapy is deferred for 24 hours after thrombolysis.

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

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.