A 67-year-old man presents 3.5 hours after onset of right hemiplegia and aphasia. NIHSS score is 14. NCCT brain shows no haemorrhage or early ischaemic changes. BP is 168/94 mmHg. Which intervention is appropriate?

• A IV alteplase alone, no further intervention required
• B Mechanical thrombectomy only, withhold thrombolysis
• C Anticoagulation with heparin infusion
• D IV alteplase followed by assessment for mechanical thrombectomy ✓

Explanation

Current AHA/ASA 2019 stroke guidelines and DAWN/DEFUSE-3 trial data support a bridging strategy: IV alteplase within 4.5 hours followed by transfer for mechanical thrombectomy if large vessel occlusion is suspected or confirmed (NIHSS ≥ 6 with proximal occlusion). In centres capable of both, alteplase + MT is superior to MT alone in eligible patients (SWIFT-DIRECT and DIRECT-SAFE trials had conflicting results, but bridging remains standard). BP need only be lowered below 185/110 mmHg before thrombolysis, not aggressively treated. Heparin is not indicated in acute ischaemic stroke.

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

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.