A 68-year-old man presents with acute right hemiplegia and aphasia. CT head shows no haemorrhage. NIHSS score is 14. He was last seen normal 3.5 hours ago. CT angiography reveals M1 occlusion. What is the OPTIMAL management?

• A IV alteplase alone
• B Mechanical thrombectomy alone without IV alteplase
• C Antiplatelet therapy + heparin infusion
• D IV alteplase followed by mechanical thrombectomy (bridging therapy) ✓

Explanation

Current AHA/ASA 2019 stroke guidelines recommend IV alteplase (if within 4.5 hours and eligible) followed by mechanical thrombectomy as standard of care for acute ischemic stroke with large vessel occlusion. The SWIFT PRIME, EXTEND-IA, and MR CLEAN trials established thrombectomy benefit for LVO stroke. While several trials (DIRECT-MT, SKIP) suggested non-inferiority of direct thrombectomy, meta-analyses and current guidelines still recommend bridging IV thrombolysis unless specific contraindications exist.

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

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Written and medically reviewed by the StethoPrep medical team.