A 68-year-old man with atrial fibrillation not on anticoagulation presents with sudden left hemiplegia and global aphasia. NIHSS is 18. CT angiogram shows right internal carotid artery terminus occlusion. CT perfusion shows a core infarct volume of 30 mL and a penumbral volume of 110 mL. Time from symptom onset is 5 hours. According to current evidence, which intervention is indicated?

• A Intravenous alteplase only
• B Mechanical thrombectomy only
• C Conservative management; beyond window for intervention
• D Both IV alteplase and mechanical thrombectomy ✓

Explanation

Current guidelines (AHA/ASA 2019, based on DAWN and DEFUSE 3 trials) support mechanical thrombectomy up to 24 hours from last known well in anterior circulation large vessel occlusion with favorable perfusion imaging (mismatch between core and penumbra). IV alteplase is indicated within 4.5 hours. This patient is 5 hours from onset, so IV alteplase is outside the window. However, with favorable CT perfusion (small core, large penumbra), mechanical thrombectomy alone is indicated. The question tests whether the student knows the extended window for thrombectomy. IV alteplase is contraindicated beyond 4.5 hours, so the correct answer is thrombectomy only.

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

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Written and medically reviewed by the StethoPrep medical team.