A 68-year-old man presents 1.5 hours after onset of acute left MCA territory ischaemic stroke (NIHSS 12). CT head shows no haemorrhage. His BP is 175/95 mmHg, blood glucose 8.4 mmol/L. He was on warfarin for AF with a recent INR of 2.8 two weeks ago; today's INR is 1.6. The MOST appropriate immediate management is:
- A IV alteplase 0.9 mg/kg immediately
- B Withhold thrombolysis; proceed to mechanical thrombectomy directly
- C Withhold thrombolysis (INR borderline); check current coagulation and give IV alteplase only if INR ≤1.7 ✓
- D Administer idarucizumab and then IV alteplase
Correct answer: C. Withhold thrombolysis (INR borderline); check current coagulation and give IV alteplase only if INR ≤1.7
Explanation
AHA/ASA 2019 guidelines permit IV alteplase in anticoagulated patients if INR ≤1.7. This patient's current INR is 1.6 (within threshold), so IV alteplase 0.9 mg/kg is appropriate. The previous INR of 2.8 is irrelevant; current coagulation status is what matters. Direct thrombectomy (option B) is appropriate for large vessel occlusion but alteplase should not be withheld if eligible. Idarucizumab reverses dabigatran, not warfarin. BP up to 185/110 mmHg is acceptable for thrombolysis; mild hyperglycaemia alone is not a contraindication.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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