Acute ischaemic stroke — thrombolysis and thrombectomy viva

Eligibility. He was last seen well 3.5 hours ago, inside the 4.5-hour window, so tenecteplase 0.25 mg/kg (maximum 25 mg) or alteplase 0.9 mg/kg is recommended.^[5]

Blood pressure. At 192/108 he is above the 185/110 level used before reperfusion in major thrombectomy trials, which the guideline finds reasonable to apply; after thrombolysis SBP is maintained between 140 and 180 mm Hg.^[5]

The alteplase regimen. 0.9 mg/kg (maximum 90 mg), with 10 per cent as a bolus and the remainder infused over 60 minutes.^[5]

Thrombectomy. For ICA or M1 occlusion within 6 hours, NIHSS of 6 or more, prestroke mRS 0 to 1 and ASPECTS 3 to 10, thrombectomy is recommended. Beyond 6 hours, DAWN (6 to 24 hours, deficit-infarct mismatch) and DEFUSE 3 (6 to 16 hours, perfusion selection) showed large gains in functional independence.^[5][3][4]