A 70-year-old man with AF presents with left hemiplegia and hemisensory loss at 3.5 hours from symptom onset. NIHSS is 14. MRI-DWI shows a right MCA territory infarct (1/3 MCA territory involvement), no hemorrhage on MRI-GRE/SWI. BP is 165/90. He takes rivaroxaban 20 mg daily, last dose was 18 hours ago. What is the correct management regarding IV thrombolysis?
- A Give IV alteplase — rivaroxaban taken >12 hours ago makes it safe
- B Withhold IV alteplase — proceed directly to mechanical thrombectomy ✓
- C Withhold IV alteplase — give andexanet alfa first, then alteplase
- D Give IV tenecteplase instead of alteplase
Explanation
For patients on direct oral anticoagulants (DOACs), IV thrombolysis with alteplase is contraindicated unless DOAC levels are undetectable or specific reversal is performed. With rivaroxaban taken 18 hours ago (within 48 hours), anti-Xa levels may still be above safe thresholds. This patient with large vessel occlusion (NIHSS 14, MCA territory) qualifies for mechanical thrombectomy, which is the correct approach. Andexanet alfa reversal followed by alteplase is not a validated sequence and adds risk. The AHA/ASA 2023 stroke guidelines state that DOACs taken within 48 hours are a contraindication to IV thrombolysis without proven reversal and undetectable drug levels.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.