A 69-year-old man is brought to the emergency department 75 minutes after suddenly developing slurred speech, deviation of the mouth and weakness of his left arm and face. He has a background of hypertension, type 2 diabetes mellitus and dyslipidaemia. Prior to this event, he was fully independent, living with his spouse and regularly playing recreational sports.
On examination, he has spasticity and markedly reduced power (2/5) in the left upper limb with expressive dysphasia. His National Institutes of Health Stroke Scale (NIHSS) score is 9.
A non-contrast CT brain shows no intracranial haemorrhage. CT angiography demonstrates an acute occlusion of a proximal anterior circulation artery.
What is the most appropriate immediate management?
A. Aspirin monotherapy
B. Therapeutic low-molecular-weight heparin
C. Dual antiplatelet therapy
D. Intravenous thrombolysis alone
E. Intravenous thrombolysis followed by mechanical thrombectomy
Correct answer: E. Intravenous thrombolysis followed by mechanical thrombectomy
Detailed discussion
Core principles of hyperacute ischaemic stroke care
The management of acute ischaemic stroke is centred on rapid reperfusion of threatened but viable brain tissue (the ischaemic penumbra). Two key treatments exist: intravenous thrombolysis and mechanical thrombectomy. The choice depends on time from onset, imaging findings, stroke severity, vessel involved and premorbid functional status.
NIHSS (National Institutes of Health Stroke Scale)
The NIHSS is a validated tool used to quantify neurological deficit in acute stroke.
- Scores range from 0 to 42
- 0: No stroke symptoms
- 1–4: Minor stroke
- 5–15: Moderate stroke
- 16–20: Moderate to severe stroke
- >20: Severe stroke
An NIHSS score >5 is particularly important because it identifies patients more likely to benefit from thrombectomy if a large vessel occlusion (LVO) is present.
Modified Rankin Scale (mRS)
The modified Rankin Scale measures pre-stroke and post-stroke functional disability:
- 0 – No symptoms
- 1 – Symptoms but no significant disability
- 2 – Slight disability; independent in daily activities
- 3 – Moderate disability; needs some help but walks independently
- 4 – Moderately severe disability; unable to walk or attend bodily needs without help
- 5 – Severe disability; bedridden
- 6 – Dead
For thrombectomy, guidelines generally require a pre-stroke mRS ≤ 2 (sometimes ≤ 3), indicating that the patient was functionally independent.
Thrombolysis: time windows and indications
- Standard window: within 4.5 hours of symptom onset
- Wake-up stroke / unknown onset: thrombolysis may be given up to 9 hours from symptom onset or from the midpoint of sleep if advanced imaging shows salvageable tissue
- CT perfusion: core–penumbra mismatch
- MRI: DWI–FLAIR mismatch
Blood pressure must be reduced to <185/110 mmHg before thrombolysis.
Mechanical thrombectomy: role and timing
Mechanical thrombectomy is the treatment of choice for large vessel occlusion, particularly:
- Internal carotid artery (ICA)
- Proximal middle cerebral artery (M1 segment)
Anterior circulation strokes
- 0–6 hours: thrombectomy for eligible patients with LVO
- 6–24 hours (including wake-up strokes): thrombectomy if imaging shows salvageable brain tissue
Thrombectomy should be performed in addition to thrombolysis, not instead of it, if the patient presents within the thrombolysis window.
Posterior circulation strokes
Posterior circulation strokes (especially basilar artery occlusion) carry high mortality.
- Thrombectomy is recommended for basilar artery occlusion, even beyond 6 hours, up to 24 hours, provided imaging suggests viable tissue.
- NIHSS may underestimate severity in posterior strokes—clinical judgment is crucial.
- Thrombolysis is still given if within the appropriate time window.
Exam cheat sheet
- NIHSS > 5 + LVO + good premorbid status → thrombectomy
- mRS ≤ 2–3 required for thrombectomy consideration
- Thrombolysis window: ≤ 4.5 h (≤ 9 h with imaging in wake-up stroke)
- Thrombectomy window (anterior circulation): ≤ 6 h (up to 24 h with imaging)
- Posterior circulation (basilar): thrombectomy up to 24 h
- Always give thrombolysis first if eligible
- Do not use heparin in acute ischaemic stroke
20 MCQs (5 options each)
1. Which NIHSS score best supports thrombectomy consideration?
A. 2
B. 4
C. 5
D. 8
E. 1
Answer: D
2. Which pre-stroke Rankin score allows thrombectomy?
A. 4
B. 5
C. 3
D. 6
E. 0 only
Answer: C
3. Maximum BP before IV thrombolysis?
A. 200/120
B. 180/100
C. 170/90
D. 185/110
E. 160/90
Answer: D
4. Best treatment for proximal MCA occlusion at 2 hours?
A. Aspirin
B. Heparin
C. Thrombolysis only
D. Thrombectomy only
E. Thrombolysis + thrombectomy
Answer: E
5. Which vessel is most suitable for thrombectomy?
A. Distal ACA branch
B. Lacunar perforator
C. Proximal MCA
D. Small cortical branch
E. Choroidal artery
Answer: C
6. Wake-up stroke with DWI–FLAIR mismatch at 7 hours—best option?
A. Aspirin
B. No treatment
C. Thrombolysis
D. Heparin
E. Clopidogrel
Answer: C
7. Which scale assesses stroke severity?
A. CHADS-VASc
B. ABCD2
C. NIHSS
D. Rankin
E. Barthel
Answer: C
8. Modified Rankin score of 2 indicates:
A. Bedridden
B. Fully asymptomatic
C. Independent with mild limitation
D. Needs full nursing care
E. Dead
Answer: C
9. Thrombectomy is most beneficial in:
A. Minor stroke without LVO
B. Haemorrhagic stroke
C. Large vessel occlusion
D. TIA
E. Lacunar infarct
Answer: C
10. Which is NOT an indication for acute thrombectomy?
A. ICA occlusion
B. Proximal MCA occlusion
C. Basilar artery occlusion
D. Small vessel lacunar stroke
E. Wake-up stroke with salvageable tissue
Answer: D
11. Maximum thrombectomy window for anterior circulation with imaging?
A. 6 hours
B. 9 hours
C. 12 hours
D. 18 hours
E. 24 hours
Answer: E
12. Posterior circulation thrombectomy is especially important because:
A. NIHSS always high
B. Mortality is low
C. Symptoms are mild
D. High risk of death if untreated
E. Thrombolysis is contraindicated
Answer: D
13. Which drug should be avoided acutely in ischaemic stroke?
A. Alteplase
B. Tenecteplase
C. Aspirin
D. Heparin
E. Oxygen
Answer: D
14. NIHSS score of 0 means:
A. Severe stroke
B. Moderate stroke
C. No neurological deficit
D. TIA
E. Brain death
Answer: C
15. Which imaging best identifies penumbra?
A. Plain CT
B. Skull X-ray
C. CT perfusion
D. EEG
E. Doppler only
Answer: C
16. Thrombolysis should be given:
A. After thrombectomy only
B. Before thrombectomy if eligible
C. Only if NIHSS >15
D. Only in young patients
E. Only if posterior stroke
Answer: B
17. Basilar artery occlusion should be treated:
A. With aspirin only
B. Conservatively
C. With thrombectomy if feasible
D. With heparin infusion
E. With carotid endarterectomy
Answer: C
18. Which factor does NOT exclude thrombolysis?
A. Previous ICH
B. INR 2.5
C. BP 210/120
D. Age 85 years
E. Recent GI bleed
Answer: D
19. NIHSS is particularly limited in:
A. Anterior strokes
B. Lacunar strokes
C. Posterior circulation strokes
D. MCA strokes
E. ICA strokes
Answer: C
20. Best secondary prevention after acute phase?
A. Heparin
B. Clopidogrel
C. Alteplase
D. Tenecteplase
E. Warfarin for all
Answer: B
Summary for quick exam revision
Acute ischaemic stroke management focuses on rapid reperfusion to salvage penumbral tissue. NIHSS quantifies stroke severity, while the modified Rankin scale assesses premorbid and post-stroke functional status. Intravenous thrombolysis is indicated within 4.5 hours of onset and can be extended up to 9 hours in wake-up strokes if imaging shows viable brain tissue. Mechanical thrombectomy is strongly recommended for large vessel occlusion, particularly in the anterior circulation, within 6 hours and up to 24 hours with advanced imaging. Thrombolysis should be given first if the patient is eligible. Posterior circulation strokes, especially basilar artery occlusion, also benefit from thrombectomy, often up to 24 hours. Anticoagulation has no role in the hyperacute phase, while antiplatelets are reserved for secondary prevention.