A 58-year-old man from Delhi presents to the emergency department with acute onset of right-sided weakness and slurred speech that began 2 hours ago. He has a history of hypertension (on amlodipine) and type 2 diabetes mellitus. On examination, blood pressure is 168/98 mmHg, heart rate 88/min regular, and he has right facial droop with right arm and leg weakness (grade 3/5). NIHSS score is 12. Non-contrast CT head shows no hyperdensity. What is the most appropriate next step in management?

Explanation

## Clinical Assessment This patient presents with acute ischemic stroke (NIHSS 12, focal neurological deficits) within the 3-hour thrombolytic window. The non-contrast CT excludes hemorrhage, making him a candidate for IV thrombolysis. ## Thrombolytic Eligibility **Key Point:** Intravenous alteplase (tissue plasminogen activator, tPA) is the gold standard for acute ischemic stroke within 4.5 hours of symptom onset, with strongest evidence in the 0–3 hour window. **High-Yield:** The patient meets inclusion criteria: - Time from onset < 3 hours ✓ - Non-contrast CT negative for hemorrhage ✓ - NIHSS 12 (moderate stroke, not minor) ✓ - No absolute contraindications (diabetes is NOT a contraindication) ✓ **Clinical Pearl:** Diabetes mellitus is often incorrectly cited as a contraindication to thrombolysis—it is not. Absolute contraindications include active bleeding, recent surgery, intracranial hemorrhage on imaging, and severe thrombocytopenia. ## Dosing & Administration **Mnemonic:** IV-tPA dosing = **0.9 mg/kg** (max 90 mg): - 10% as bolus over 1 minute - Remainder over 60 minutes ## Why Not Mechanical Thrombectomy Alone? Mechanical thrombectomy is indicated for large-vessel occlusion (LVO) in anterior circulation, typically identified on CT angiography (CTA) or MR angiography. This patient has not undergone vascular imaging yet, and IV-tPA should be initiated immediately while CTA is being arranged. If CTA shows LVO, thrombectomy can be performed in parallel or after thrombolysis fails. [cite:Harrison 21e Ch 297]