A 58-year-old man from Delhi presents to the emergency department with acute onset left-sided weakness and facial droop. He was last seen normal 2.5 hours ago. On examination, he has right-sided hemiparesis (MRC 2/5 in lower limb), right facial weakness, and dysarthria. Blood pressure is 168/98 mmHg, heart rate 88/min regular. Blood glucose 145 mg/dL. Non-contrast CT head shows no hypodensity. What is the most appropriate next step in management?

Explanation

## Clinical Assessment This patient presents with acute ischemic stroke within the thrombolytic window (2.5 hours from last known normal, well within the 4.5-hour window for IV thrombolysis). ### Key Clinical Features - **Time window:** 2.5 hours — within IV thrombolysis eligibility - **Symptom severity:** NIHSS-equivalent suggests moderate stroke (hemiparesis, facial weakness, dysarthria) - **CT head:** Negative for hemorrhage — prerequisite for thrombolysis met - **Vital signs:** Hypertension present but NOT a contraindication to thrombolysis; BP ≤185/110 is acceptable - **Blood glucose:** 145 mg/dL — normal range, no contraindication **Key Point:** IV alteplase (tissue plasminogen activator, tPA) is the standard of care for acute ischemic stroke within 4.5 hours of symptom onset, provided hemorrhage is excluded and no absolute contraindications exist [cite:Harrison 21e Ch 443]. **High-Yield:** Hypertension alone is NOT a contraindication to IV thrombolysis. Absolute contraindications include: - Active bleeding or recent major surgery - Intracranial hemorrhage on imaging - Blood glucose <50 or >400 mg/dL - Seizure at stroke onset - Recent ischemic stroke (within 3 months) **Clinical Pearl:** The 2023 AHA/ASA guidelines emphasize that door-to-needle time should be <60 minutes; delays to obtain additional imaging (like CTA) should not defer IV thrombolysis in eligible patients with clear clinical stroke syndrome. **Mnemonic — IV tPA Contraindications (Absolute):** **INCH** — INtracranial hemorrhage, No recent stroke, Coagulopathy/active bleeding, Hypoglycemia or Hyperglycemia (extreme values). ### Why IV Alteplase Now? 1. Patient is within the therapeutic window 2. Non-contrast CT excludes hemorrhage 3. No clinical contraindications present 4. Early reperfusion improves outcomes (NNT ~9 to prevent one major disability) ## Dosing $$\text{IV alteplase dose} = 0.9 \text{ mg/kg (max 90 mg)}$$ - 10% as bolus over 1 minute - Remainder as infusion over 60 minutes ## Post-Thrombolysis Management - Monitor for bleeding complications and neurological deterioration - CTA can be obtained post-thrombolysis if large vessel occlusion suspected (to guide rescue thrombectomy if thrombolysis fails)