A 72-year-old man arrives at the emergency department 4.5 hours after onset of left-sided hemiparesis. NIHSS is 14; NCCT head shows no haemorrhage or early ischaemic changes. DWI-MRI shows infarct core of 40 mL with penumbra of 90 mL. He is haemodynamically stable. According to EXTEND-IA and DAWN/DEFUSE-3 trial evidence, what is the most appropriate intervention?
- A IV alteplase alone as the extended window closes at 4.5 hours
- B Aspirin 300 mg loading dose and admit for observation
- C IV alteplase followed by mechanical thrombectomy if large vessel occlusion is confirmed ✓
- D Tenecteplase 0.25 mg/kg IV as the only intervention
Correct answer: C. IV alteplase followed by mechanical thrombectomy if large vessel occlusion is confirmed
Explanation
With an NIHSS of 14 and a favourable penumbra-to-core mismatch (penumbra >1.8:1 with core <70 mL), mechanical thrombectomy is indicated for large vessel occlusion up to 24 hours per DAWN/DEFUSE-3 criteria. IV alteplase within 4.5 hours followed by thrombectomy (bridging thrombolysis) improves outcomes per ESO/ASA guidelines. Aspirin alone is insufficient in large vessel occlusion. Tenecteplase may be used as an alternative to alteplase in some guidelines but does not replace thrombectomy.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.