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. His wife reports he was watching television when he suddenly couldn't speak clearly and his right arm became weak. On examination, blood pressure is 168/98 mmHg, heart rate 92/min regular, and he has right facial droop, right arm power 3/5, and expressive aphasia. Non-contrast CT head shows no hyperdensity. What is the most appropriate immediate next step in management?

Explanation

## Clinical Assessment This patient presents with acute ischemic stroke symptoms (right hemiparesis, expressive aphasia) within the 4.5-hour thrombolytic window. Non-contrast CT excludes hemorrhage, which is the critical prerequisite for thrombolysis. **Key Point:** Intravenous thrombolysis with rt-PA is indicated for acute ischemic stroke within 4.5 hours of symptom onset in eligible patients, provided hemorrhage is excluded and no contraindications exist. ## Why rt-PA is the Correct Choice 1. **Time window:** 2 hours from onset is well within the 4.5-hour window for IV thrombolysis 2. **CT exclusion of hemorrhage:** Non-contrast CT is negative, ruling out intracerebral hemorrhage 3. **Clinical presentation:** Clear focal neurological deficit consistent with acute stroke 4. **Evidence base:** IV thrombolysis reduces disability at 3 months (NNT ~9) when given within this window [cite:Harrison 21e Ch 369] **High-Yield:** The absolute time window for IV thrombolysis is **4.5 hours** from symptom onset. After this, thrombolysis is contraindicated due to increased risk of intracranial hemorrhage. ## Mechanism of Action rt-PA (alteplase) is a tissue plasminogen activator that: - Binds fibrin in the thrombus - Converts plasminogen to plasmin - Dissolves the thrombus, restoring cerebral perfusion - Reduces infarct volume if given early **Clinical Pearl:** The earlier rt-PA is administered, the better the outcome. Every 15 minutes of delay reduces the benefit. This is why "time is brain" is the cardinal principle in acute stroke management. ## Contraindications to rt-PA (Brief Screen) - Active bleeding or recent surgery - Severe hypertension (SBP >185 or DBP >110 mmHg unresponsive to treatment) - Recent stroke, head trauma, or intracranial pathology - Platelet count <100,000 - INR >1.7 or PT >15 seconds (if on warfarin) - Glucose <50 or >400 mg/dL This patient has no documented contraindications.