Hyperacute management of acute ischaemic stroke

Thrombolysis. She is within 4.5 hours of a witnessed last-known-well time with no haemorrhage on CT. Tenecteplase 0.25 mg/kg (maximum 25 mg) or alteplase 0.9 mg/kg is recommended, started as quickly as possible without waiting for further multimodal imaging; alteplase is given over 60 minutes with 10 per cent as a 1-minute bolus.^[6]

Blood pressure. Her BP of 178/98 is below the 185/110 level used before reperfusion in major thrombectomy trials; after thrombolysis SBP is maintained between 140 and 180 mm Hg.^[6]

Thrombectomy. A right M1 occlusion within 6 hours with NIHSS of 6 or more, prestroke mRS 0 to 1 and ASPECTS 3 to 10 meets the recommendation for endovascular thrombectomy.^[6]

The evidence. ECASS III showed benefit from alteplase between 3 and 4.5 hours, and AcT compared tenecteplase 0.25 mg/kg with alteplase 0.9 mg/kg within 4.5 hours.^[2][10]

Complications to anticipate. Symptomatic intracranial haemorrhage occurred in 3.3 per cent of rtPA-treated patients in one series, with in-hospital mortality of 52.3 per cent; orolingual angioedema occurred in 0.4 per cent in another and can need intubation.^[11][9]