A 67-year-old presents with acute right hemiplegia and aphasia. Last known well 2.5 hours ago. CT shows no hemorrhage. BP 192/106. Which action is the priority?
1Administer aspirin 325 mg PO and reassess in 1 hour
2Wait until BP is under 140/90 before considering thrombolytic
3Lower BP to under 185/110 with IV labetalol, then administer alteplase✓ Correct answer
4Withhold thrombolytic because hemiparesis is mild
Explanation
Acute ischemic stroke within 4.5 hours of LKW with no contraindications: BP must be lowered to under 185/110 with IV labetalol or nicardipine BEFORE thrombolytic, then alteplase 0.9 mg/kg IV (10 percent bolus, 90 percent over 60 min). Tenecteplase 0.25 mg/kg single bolus is increasingly used. Aggressive lowering to under 140/90 risks ischemic penumbra worsening. Aspirin alone misses the thrombolytic window. NIHSS 18 is significant — withholding for mild deficit is incorrect.
After tPA: BP under 180/105 for 24h, no antithrombotics for 24h, repeat CT at 24h before adding aspirin. LVO patients still get thrombectomy up to 24h with imaging selection.
NIHSS 18. INR 1.0, glucose 124, no recent surgery, no anticoagulants.
alteplase — Recombinant tissue plasminogen activator; thrombolytic for ischemic stroke within 4.5h.
NIHSS — National Institutes of Health Stroke Scale; quantifies stroke severity.
ischemic penumbra — Salvageable brain tissue around infarct core; saved by reperfusion.