A 70-year-old hypertensive man presents with sudden onset left hemiplegia, hemisensory loss, and left hemineglect. MRI DWI shows acute infarct in the right MCA territory. He is brought to the ER at 3.5 hours from symptom onset. NIHSS is 12, no haemorrhage on CT. He is on aspirin. What is the next BEST treatment?

• A Mechanical thrombectomy alone without IV thrombolysis
• B IV heparin infusion to prevent propagation
• C Aspirin 300 mg loading dose and admission
• D IV alteplase 0.9 mg/kg, followed by evaluation for thrombectomy ✓

Explanation

IV alteplase is indicated within 4.5 hours of ischaemic stroke onset in eligible patients (NINDS/ECASS III criteria); this patient at 3.5 hours qualifies. NIHSS 12 indicates moderate stroke. Following thrombolysis, large vessel occlusion must be assessed (CTA) for potential mechanical thrombectomy. Current AHA/ASA 2023 guidelines recommend IV alteplase + thrombectomy evaluation as the bridging approach; direct thrombectomy without tPA is only for patients where tPA is contraindicated. IV heparin is not indicated in acute ischaemic stroke.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.