A 68-year-old woman with atrial fibrillation presents with sudden onset left hemiplegia and hemianopia. CT brain at 90 minutes is normal. She is within 4.5 hours of symptom onset. What is the most appropriate treatment?
- A IV alteplase 0.9 mg/kg followed by evaluation for mechanical thrombectomy ✓
- B Immediate anticoagulation with heparin
- C IV alteplase alone, thrombectomy not required
- D Aspirin 300 mg loading dose, no thrombolysis due to AF
Correct answer: A. IV alteplase 0.9 mg/kg followed by evaluation for mechanical thrombectomy
Explanation
Current AHA/ASA 2023 stroke guidelines recommend IV alteplase (0.9 mg/kg, max 90 mg) within 4.5 hours of ischaemic stroke onset if no contraindications exist; AF is not a contraindication. If large vessel occlusion is present (as suggested by cortical signs including hemianopia and hemiplegia), mechanical thrombectomy evaluation should follow immediately — the DAWN and DEFUSE-3 trials extended the window to 24 hours for selected patients. Heparin does not improve acute stroke outcomes. Aspirin alone is not equivalent to thrombolysis in the acute phase.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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