Mechanical Thrombectomy with Concurrent IV Thrombolytics
This patient should proceed immediately to mechanical thrombectomy while simultaneously receiving IV thrombolytics (alteplase), as they meet all criteria for both interventions and delays to determine thrombolytic response are contraindicated. 1, 2
Rationale for Combined Therapy
Patients eligible for both IV alteplase and endovascular thrombectomy (EVT) should receive both treatments in parallel, with IV thrombolytics initiated while simultaneously preparing the angiography suite. 1
This patient is within the 6-hour window for EVT (last seen normal 5 hours ago), has confirmed M1 occlusion on CTA, NIHSS of 8 (≥6), and no hemorrhage on CT—meeting all established criteria for mechanical thrombectomy. 1, 2
The patient also remains within the extended 4.5-hour window for IV thrombolytics, making them eligible for both interventions. 1
The American Heart Association explicitly advises against delaying EVT while waiting for response to IV tPA, as the landmark trials (MR CLEAN, ESCAPE) that established thrombectomy efficacy included 83.7-91.5% of patients who received IV thrombolytics alongside mechanical intervention. 1, 2, 3
Why Not the Other Options
Blood Pressure Management (Option A)
- The BP of 170/100 does not require immediate lowering before intervention. 1
- Blood pressure should be maintained ≤180/105 mmHg for 24 hours after thrombectomy, not before. 3
- Lowering BP before reperfusion could compromise collateral flow and worsen outcomes. 1
CT Perfusion (Option B)
- CT perfusion is not required within the 6-hour window when there is confirmed large vessel occlusion and favorable clinical parameters. 1, 2
- Advanced perfusion imaging becomes essential only in the extended window (6-24 hours) to confirm salvageable tissue using DAWN or DEFUSE-3 criteria. 3
- Delaying treatment for unnecessary testing beyond confirming blood glucose and obtaining essential vascular imaging (already completed with CTA) should be avoided. 3
Thrombolytics Alone (Option D)
- While IV thrombolytics should be given, they are insufficient as monotherapy for M1 occlusions. 1, 2
- IV alteplase achieves recanalization in less than 50% of large vessel occlusions, with particularly poor results in proximal occlusions like M1. 1, 4
- The adjusted odds ratio for improved functional outcomes with combined therapy versus medical management alone is 1.67 (95% CI 1.21-2.30). 1
Technical Implementation
Door-to-groin puncture time should be minimized, with target times under 110 minutes from arrival. 1, 3
Stent retrievers are the preferred device, achieving TICI 2b/3 recanalization in approximately 59-87.8% of cases. 1, 5
The goal is TICI 2b/3 reperfusion to maximize functional outcomes. 3
Procedural sedation is generally preferred over general anesthesia unless medically indicated for airway compromise or severe agitation. 1
Critical Pitfall to Avoid
Do not wait to assess clinical response to IV thrombolytics before proceeding to thrombectomy. The time-dependent nature of stroke outcomes means every minute of delay reduces the probability of favorable outcome by approximately 10.6% per 30-minute increment. 1 The patient should receive IV alteplase in the emergency department while the interventional team is mobilized simultaneously. 1