A 67-year-old man with atrial fibrillation presents 3.5 hours after onset of right-sided weakness and aphasia (NIHSS score 14). CT head shows no haemorrhage. CT perfusion shows a mismatch ratio of 2.0 with ischaemic core of 18 mL and penumbra of 95 mL. He is on apixaban, last dose 14 hours ago. He is otherwise eligible for thrombolysis. What is the CORRECT management?
- A Proceed with IV alteplase (0.9 mg/kg, max 90 mg) and consider mechanical thrombectomy
- B IV tenecteplase 0.25 mg/kg as it is safer than alteplase with DOAC use
- C Mechanical thrombectomy alone; IV alteplase is contraindicated with recent DOAC use ✓
- D Reversal of apixaban with andexanet alfa, then IV alteplase
Explanation
Per current AHA/ASA 2019 stroke guidelines, IV alteplase is generally contraindicated if the patient has taken a DOAC within the previous 48 hours (or if coagulation tests indicate significant anticoagulant effect). While 14 hours since last apixaban dose is within this window, apixaban has a half-life of approximately 12 hours and without specific reversal and drug level testing, IV thrombolysis carries increased haemorrhagic risk. However, mechanical thrombectomy (EVT) is NOT contraindicated by anticoagulation and is the preferred approach for large vessel occlusion — this patient has an NIHSS of 14 and favourable penumbra:core ratio suggesting eligibility. Direct mechanical thrombectomy without bridging thrombolysis is appropriate when thrombolysis is contraindicated.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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