A 65-year-old man presents to the ED 3.5 hours after sudden-onset left hemiparesis and dysarthria. NIHSS is 12. CT brain shows no hemorrhage. CT angiography reveals right MCA occlusion. Blood pressure is 165/90 mmHg. What is the MOST appropriate treatment?
- A IV tPA alone (no thrombectomy window)
- B IV tPA followed by mechanical thrombectomy (bridging strategy) ✓
- C Mechanical thrombectomy alone without IV tPA
- D Anticoagulation with IV heparin
Explanation
For acute ischemic stroke with large vessel occlusion (LVO) presenting within 4.5 hours, the standard of care per AHA/ASA 2019 guidelines is IV alteplase (tPA) followed by mechanical thrombectomy (MT) when eligible—the so-called bridging strategy. IV tPA is given while the patient is being prepared for thrombectomy. Multiple RCTs (MR CLEAN, ESCAPE, SWIFT PRIME, EXTEND-IA) established MT benefit for proximal LVO up to 6 hours, and extended to 24 hours in selected patients (DAWN/DEFUSE-3). IV heparin is not indicated in acute ischemic stroke due to hemorrhagic transformation risk.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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