A 58-year-old man from Delhi presents to the emergency department with acute onset of right-sided weakness and slurred speech that began 90 minutes ago. His wife reports he was watching television when he suddenly couldn't speak clearly and his right arm went limp. On examination: BP 168/98 mmHg, HR 92/min regular, temperature 37.2°C. Neurological exam shows right facial droop, right arm power 2/5, right leg power 3/5, and expressive aphasia. CT head (non-contrast) is normal. Blood glucose is 118 mg/dL. What is the most appropriate next step in management?

Explanation

## Clinical Assessment This patient presents with acute ischemic stroke within the thrombolytic window (90 minutes from symptom onset, well within the 4.5-hour window for IV thrombolysis). The clinical presentation is classic: sudden onset focal neurological deficits (facial droop, hemiparesis, aphasia) with no hemorrhage on CT head. **Key Point:** IV thrombolysis with alteplase (rt-PA) is the gold standard for acute ischemic stroke within 4.5 hours of symptom onset in eligible patients [cite:Harrison 21e Ch 435]. ## Eligibility Criteria Met - Time window: 90 minutes (well within 4.5 hours) - Non-contrast CT excludes hemorrhage - No contraindications evident (normal glucose, no seizure, no recent surgery) - Clear clinical stroke syndrome **High-Yield:** The standard dose of IV alteplase for acute ischemic stroke is **0.9 mg/kg** (maximum 90 mg), with 10% given as bolus over 1 minute and remainder over 60 minutes [cite:Stroke Guidelines 2019]. ## Why Other Options Are Suboptimal | Option | Why Incorrect | |--------|---------------| | Aspirin alone + observation | Delays definitive reperfusion therapy; aspirin is inferior to thrombolysis in acute phase | | CT angiography first | Adds delay; not required before thrombolysis in this clear-cut case; can be done post-thrombolysis if indicated | | Heparin anticoagulation | No evidence for acute phase; thrombolysis is superior; heparin may be considered post-thrombolysis | **Clinical Pearl:** The "door-to-needle" time should be <60 minutes for IV thrombolysis — every minute of delay increases morbidity and mortality.