A 67-year-old man presents with sudden-onset left hemiplegia and aphasia 2.5 hours after symptom onset. CT head rules out haemorrhage. NIHSS score is 16. CT angiography shows a right M1 segment MCA occlusion. He is eligible for both IV thrombolysis and mechanical thrombectomy. According to AHA/ASA 2019 guidelines, the management is:
- A Mechanical thrombectomy alone, withholding IV alteplase
- B IV alteplase followed immediately by mechanical thrombectomy (bridging therapy) ✓
- C IV alteplase alone; reserve thrombectomy for alteplase failure
- D Anticoagulation with IV heparin before thrombectomy
Explanation
Current AHA/ASA and ESO guidelines (corroborated by pooled HERMES data) recommend IV thrombolysis followed by mechanical thrombectomy (bridging strategy) for large vessel occlusion strokes when patients arrive within the IV alteplase window. Trials such as SWIFT-DIRECT and MR CLEAN-NoIV are evaluating direct thrombectomy; pending definitive data, bridging remains standard unless specific contraindications to IV alteplase exist. Withholding alteplase without a contraindication is not guideline-supported. Heparin is not indicated acutely in ischaemic stroke for revascularisation.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.