A 68-year-old hypertensive man presents with sudden left hemiplegia and hemisensory loss at 2 hours. NIHSS score is 14. CT head shows no haemorrhage. CT perfusion shows ischaemic core 28 mL and penumbra 110 mL (mismatch ratio 3.9). He receives IV alteplase at 2.5 hours. Which additional intervention should be offered?
- A Mechanical thrombectomy (EVT) up to 24 hours if large vessel occlusion confirmed ✓
- B Decompressive hemicraniectomy within 6 hours
- C Aspirin 300 mg and IV heparin infusion
- D No further intervention; alteplase alone is definitive
Correct answer: A. Mechanical thrombectomy (EVT) up to 24 hours if large vessel occlusion confirmed
Explanation
For large vessel occlusion stroke with favourable penumbra-to-core mismatch, mechanical thrombectomy (EVT) up to 24 hours is beneficial (DAWN and DEFUSE-3 trials). The mismatch ratio >1.8 and penumbra >15 mL suggests viable salvageable tissue. IV alteplase does not adequately recanalise large vessel occlusions and EVT is the standard of care when indicated. Hemicraniectomy is for malignant MCA infarction, not at 6 hours in this scenario. Heparin infusion post-thrombolysis increases haemorrhage risk.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.