A 65-year-old man with AF presents with acute left hemiparesis and dysarthria. CT head is normal. MRI DWI shows an infarct in the right posterior limb of the internal capsule. His NIHSS is 8. He is 2.5 hours from symptom onset. His INR is 1.1 (on no anticoagulation). What is the MOST appropriate immediate management?
- A IV alteplase 0.9 mg/kg (max 90 mg) over 60 minutes ✓
- B IV tenecteplase 0.25 mg/kg (max 25 mg) as single bolus
- C Mechanical thrombectomy as primary treatment (no IV thrombolysis)
- D IV alteplase followed by immediate mechanical thrombectomy (bridging therapy)
Explanation
IV alteplase (0.9 mg/kg, max 90 mg) within 4.5 hours of symptom onset remains the standard of care for acute ischaemic stroke per AHA/ASA 2019 and ESO guidelines. The patient has no contraindications (INR normal, no haemorrhage on CT). Tenecteplase 0.25 mg/kg is an emerging alternative (AHA 2022 Class IIb) showing non-inferiority and some superiority in EXTEND-IA TNK trial, but alteplase remains the standard first-line. Mechanical thrombectomy is indicated for large vessel occlusion (LVO); the posterior limb capsular infarct here is a small vessel/perforator territory, not typically amenable to thrombectomy. Bridging therapy applies when LVO is confirmed on imaging.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.