A 68-year-old man is brought in 2.5 hours after onset of right hemiplegia and aphasia. CT brain shows no haemorrhage. NIHSS is 14. CT angiography shows left M1 MCA occlusion. BP is 168/92 mmHg. What is the correct management sequence according to current AHA/ASA 2019 guidelines?
- A IV alteplase immediately if no contraindications, followed by mechanical thrombectomy as soon as possible (bridging strategy) ✓
- B Lower BP to < 140/90 mmHg before IV alteplase, then proceed to mechanical thrombectomy
- C Mechanical thrombectomy alone is preferred over IV alteplase for M1 occlusion — alteplase is unnecessary
- D Observe for spontaneous recanalisation for 4 hours before thrombectomy given time window
Correct answer: A. IV alteplase immediately if no contraindications, followed by mechanical thrombectomy as soon as possible (bridging strategy)
Explanation
For patients with proximal LVO (M1 MCA) presenting within 4.5 hours of onset without contraindications, AHA/ASA 2019 recommends IV alteplase immediately, followed by mechanical thrombectomy (bridging strategy). Multiple trials (MR CLEAN, SWIFT PRIME, EXTEND-IA, etc.) established thrombectomy up to 24 hours (DAWN, DEFUSE-3) for selected patients. BP should be < 185/110 mmHg before alteplase, not < 140/90. Thrombectomy alone vs. bridging is studied in DIRECT-MT and SKIP trials but guideline standard remains bridging when alteplase eligible.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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