A 72-year-old woman with atrial fibrillation presents 6 hours after onset of acute ischemic stroke. CT head excludes hemorrhage. She is ineligible for IV thrombolysis due to recent hip surgery. What is the drug of choice for acute reperfusion in this scenario?

Explanation

## Endovascular Reperfusion Therapy in Acute Ischemic Stroke ### Clinical Context: Thrombolysis Contraindication This patient has a **contraindication to IV thrombolysis** (recent surgery) but presents within the window for endovascular intervention. The question asks for the drug of choice for acute reperfusion — however, the correct answer in current guidelines is **mechanical thrombectomy alone**, which is not a pharmacotherapy but is the standard-of-care reperfusion strategy when IV thrombolysis is contraindicated. **Key Point:** When IV thrombolysis is contraindicated due to recent surgery, **mechanical thrombectomy** is the preferred reperfusion strategy for large vessel occlusion (LVO) in acute ischemic stroke, per AHA/ASA 2019 guidelines and Harrison's Principles of Internal Medicine, 21e, Ch. 445. Intra-arterial (IA) alteplase is NOT a first-line recommendation and is reserved for very specific scenarios (distal vessel occlusion, thrombectomy failure); it is not routinely combined with or offered as an equivalent alternative to mechanical thrombectomy. ### Why Mechanical Thrombectomy Alone (Option A) is Correct | Feature | Mechanical Thrombectomy | IA Alteplase | |---------|------------------------|--------------| | **Guideline status** | First-line for LVO (Class I, Level A) | Not first-line; adjunctive/rescue only | | **Hemorrhage risk** | Low (localized, no systemic thrombolysis) | Higher (thrombolytic agent) | | **Time window** | Up to 24 hrs (selected LVO cases) | Up to 6 hrs | | **Recent surgery** | Safe — no systemic bleeding risk | Contraindicated (same risk as IV thrombolysis) | ### Evidence Base - **MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME, DAWN, DEFUSE-3 trials:** Mechanical thrombectomy is superior to medical management alone in anterior circulation LVO, including in patients ineligible for IV thrombolysis. - **PROACT II:** IA thrombolysis showed benefit in MCA occlusion, but this predates modern thrombectomy and is no longer first-line. - **AHA/ASA 2019 Stroke Guidelines:** Mechanical thrombectomy is recommended (Class I, Level A) for eligible patients with LVO up to 24 hours; IA thrombolysis is NOT a standard first-line alternative. ### Why Other Options Are Wrong - **Option B (IA alteplase OR mechanical thrombectomy):** IA alteplase carries systemic thrombolytic risk and is contraindicated in recent surgery — the same concern as IV alteplase. Offering it as co-equal to thrombectomy is factually inaccurate per current guidelines. - **Option C (Immediate anticoagulation with heparin):** Heparin is NOT recommended for acute reperfusion in ischemic stroke; it increases hemorrhagic transformation risk without proven benefit. - **Option D (IV alteplase despite recent surgery):** Explicitly contraindicated; recent major surgery within 14 days is a contraindication to IV thrombolysis. **Clinical Pearl:** Recent surgery (within 14 days) is a contraindication to both IV and IA thrombolysis due to systemic bleeding risk. Mechanical thrombectomy, being a localized catheter-based intervention without systemic thrombolytics, is the safe and guideline-recommended reperfusion option [Harrison 21e, Ch. 445; AHA/ASA Stroke Guidelines 2019]. **High-Yield:** The extended window (6–24 hours) for mechanical thrombectomy applies to LVO with salvageable penumbra (DAWN/DEFUSE-3 criteria). This patient at 6 hours is within the standard window and should undergo CTA to confirm LVO before proceeding to thrombectomy.