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NEUROSAE 2018 ANNUAL MEETING EDITION (VOLUME 10, ISSUE 3)
QUESTION 27 OF 100
A right-handed, 45-year-old woman with a history of atrial fibrillation controlled with apixaban presents 1 hour after awakening with right-sided weakness, left gaze deviation, and aphasia. Her NIH Stroke Scale (NIHSS) score is 23. The patient’s husband reports her last known well time was 4 hours before presentation and that she took her apixaban last night. Noncontrast CT of the brain and CT angiography of the head and neck confirm a left M1 occlusion. Her ASPECTS score is 10. Which of the following is the most appropriate course of action?
A. Administer IV recombinant tissue plasminogen activator (rtPA) at 0.9 mg/kg.
B. Initiate IV argatroban with hourly monitoring of partial thromboplastin time.
C. Consult the neurointerventional team for emergent thrombectomy. **
D. Administer aspirin and admit the patient to the neuro ICU.
E. Administer a loading dose of clopidogrel 300 mg and admit to stroke unit for permissive hypertension.
** = Your answer
After publication of the inaugural thrombectomy study, MR CLEAN, more than five other confirmatory studies reported the benefit of mechanical thrombectomy within the first 6 hours from the last known well time. Ongoing but still unpublished studies, including DEFUSE 3 and DAWN, are examining lengthening the time window for clot retrieval. Preliminary data suggest select patients with a small core infarct shown on diffuse weighted imaging MRI scans or CT perfusion, with large clinical mismatch, may benefit from thrombectomy up to 24 hours from the last known well time.
* Fransen PS, Beumer D, Berkhemer OS, et al. MR CLEAN, a multicenter randomized clinical trial of endovascular treatment for acute ischemic stroke in the Netherlands: study protocol for a randomized controlled trial. Trials. 2014 Sept 1;15:343.