A 70-year-old man with AF is found to have a left MCA territory ischemic stroke. He is within the thrombolysis window but has a large territory infarction (>1/3 MCA territory on CT). His NIHSS score is 22. Regarding IV alteplase, which statement is correct per current AHA/ASA guidelines?
- A Alteplase is absolutely contraindicated if stroke involves >1/3 MCA territory
- B Alteplase dose must be reduced to 0.6 mg/kg in large hemispheric strokes
- C Alteplase can be given if within 3 hours and no CT exclusion criterion; large infarct is a relative consideration, not absolute contraindication ✓
- D Tenecteplase 0.25 mg/kg is now preferred over alteplase in all acute ischemic stroke
Correct answer: C. Alteplase can be given if within 3 hours and no CT exclusion criterion; large infarct is a relative consideration, not absolute contraindication
Explanation
According to AHA/ASA 2019 acute ischemic stroke guidelines, large infarct volume (>1/3 MCA territory by CT) is a relative, not absolute, contraindication to alteplase. The standard dose is 0.9 mg/kg (maximum 90 mg). The 2024 AHA/ASA update gives tenecteplase 0.25 mg/kg a Class IIa recommendation for patients eligible for mechanical thrombectomy but it is not universally preferred over alteplase in all acute ischemic stroke. Treatment decisions must weigh benefit-risk individually.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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