A 67-year-old man with AF presents with acute right hemiplegia and aphasia. CT shows no haemorrhage and early ischaemic changes in less than one-third of the MCA territory. NIHSS score is 14. Time from symptom onset is 90 minutes. He is on warfarin with INR of 1.3. What is the best management?
- A IV alteplase followed by assessment for mechanical thrombectomy ✓
- B Mechanical thrombectomy alone without IV alteplase
- C Withhold IV alteplase because the patient is anticoagulated; proceed directly to thrombectomy
- D IV alteplase is contraindicated because NIHSS > 10; refer for thrombectomy only
Explanation
An INR of 1.3 (below the 1.7 contraindication threshold) does not preclude IV alteplase in acute ischaemic stroke within the 4.5-hour window. Current AHA/ASA 2019 guidelines recommend IV thrombolysis followed by assessment for mechanical thrombectomy in eligible patients with large vessel occlusion. NIHSS score does not exclude tPA; high NIHSS scores are if anything an indicator that thrombectomy should also be sought. The DAWN and DEFUSE-3 trials support extended thrombectomy windows, but initial tPA within 4.5 hours is still indicated in eligible patients before bridging to thrombectomy.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.