What is the optimal acute management for an elderly patient with expressive aphasia, hemiparesis, and a proximal M1 segment occlusion, with elevated blood pressure and a large area of penumbra on CT perfusion?

Optimal Acute Management: Mechanical Thrombectomy Without tPA

This patient should undergo mechanical thrombectomy without administering intravenous tPA, as she presents beyond the 4.5-hour window for thrombolysis but has favorable imaging showing large penumbra with small core, making her an excellent candidate for endovascular intervention alone. 1

Time Window Analysis

• The patient presents at 6 hours from symptom onset, which is beyond the standard 4.5-hour window for intravenous tPA administration 1, 2
• However, mechanical thrombectomy can be performed up to 24 hours after symptom onset in patients with demonstrable proximal artery occlusions in the anterior circulation and favorable perfusion imaging 1
• The presence of a large penumbra with small ischemic core on CT perfusion indicates substantial salvageable brain tissue, making her an ideal candidate for thrombectomy despite the extended time window 1, 3

Why Mechanical Thrombectomy Alone is Optimal

Mechanical thrombectomy is recommended as first-line treatment for proximal M1 occlusions when tPA is contraindicated or the time window has passed. 1

• The patient has a proximal left M1 segment occlusion, which is a large vessel occlusion with poor recanalization rates with tPA alone (less than 40% regain functional independence) 4, 5
• Every 30-minute delay in recanalization decreases the chance of good functional outcome by 8-14% 1, making immediate thrombectomy without the delay of tPA administration the priority
• Recent trials demonstrate that thrombectomy achieves 88% substantial reperfusion rates and significantly improves functional independence (60% vs 35% with tPA alone) 5

Blood Pressure Management Strategy

Do NOT aggressively lower blood pressure before thrombectomy in this patient. 1

• For ischemic stroke patients not receiving thrombolytic therapy, routine treatment of hypertension should not be undertaken 1
• Her blood pressure of 175/100 mmHg does not meet the threshold for extreme elevation (>220/120 mmHg) requiring treatment 1
• Avoid rapid or excessive lowering of blood pressure as this may exacerbate existing ischemia, particularly in the setting of intracranial arterial occlusion 1
• Maintaining adequate perfusion pressure is critical to preserve the penumbra until recanalization is achieved 1

Why Other Options Are Incorrect

Administering tPA then thrombectomy:

• tPA is only indicated within 4.5 hours of symptom onset; this patient is at 6 hours 1, 2
• Administering tPA outside the approved window increases hemorrhagic risk without proven benefit 2

Lowering BP before tPA:

• This combines two errors: giving tPA outside the window AND potentially compromising collateral flow with aggressive BP reduction 1

Lowering BP without tPA:

• Aggressive BP reduction (target <140/90) in acute ischemic stroke with large vessel occlusion can worsen ischemia by reducing perfusion to the penumbra 1
• This approach provides no reperfusion therapy, abandoning the only proven treatment

No acute therapy due to age:

• Age alone should not be a contraindication to thrombectomy 1
• The patient was previously independent in all ADLs, indicating good baseline functional status
• Favorable imaging (large penumbra, small core) predicts potential for meaningful recovery regardless of age 1

Critical Implementation Points

The key to success is minimizing door-to-groin puncture time:

• Median time from imaging to groin puncture should be approximately 57 minutes 5
• Avoid time-consuming additional imaging that delays treatment 1
• Use a combined approach with stent-retrievers and aspiration for optimal first-pass reperfusion 1

Common pitfall to avoid: Do not delay mechanical thrombectomy to attempt medical management or wait for "stabilization" - the penumbra is actively progressing to infarction with each passing minute 1