A 71-year-old wakes with right hemiplegia and global aphasia (NIHSS 18). Last seen well 9 hours ago. CT: no haemorrhage, dense MCA sign. How do you proceed?

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Accepted Answer

This is a **hyperacute large-vessel ischaemic stroke**. He is outside the IV thrombolysis window (4.5 h) but may be eligible for **mechanical thrombectomy up to 24 hours** under **NICE NG128**, supported by **DAWN and DEFUSE-3**.

**Pathway activation.** Activate the stroke pathway and **call the regional thrombectomy centre immediately** — every 30 minutes of delay reduces good functional outcome.

**Assessment.** ABCDE, **NIHSS 18** confirms a severe deficit consistent with MCA territory. Capillary glucose to exclude hypoglycaemia, ECG (AF), bloods including FBC, U&E, coagulation, glucose, troponin.

**Imaging — the decisive step.**
- **Non-contrast CT** — confirms no haemorrhage, dense MCA sign.
- **CT angiography from arch to vertex** — confirms LVO.
- **CT perfusion** (or MR DWI/FLAIR) — identifies **salvageable penumbra**; **DAWN** used clinical-core mismatch, **DEFUSE-3** used perfusion-core mismatch. Modest core, large penumbra = thrombectomy candidate.

**Transfer.** Phone the neurointerventional consultant, send images on the image-share network, arrange **blue-light transfer** with anaesthetic escort if airway concern.

**Blood pressure.** **Permissive hypertension** up to 220/120 pre-reperfusion if thrombectomy alone; if any thrombolysis use, target **<185/110**. Avoid aggressive lowering — it extends infarct.

**Adjuncts.** Stroke-unit admission post-procedure, **swallow screen** before any oral intake, **intermittent pneumatic compression** for VTE (CLOTS-3, not LMWH in first 24 h), antiplatelet at 24 h or per centre protocol, statin.

**Secondary prevention workup.** Carotid imaging, **prolonged cardiac monitoring** for paroxysmal AF (consider implantable loop recorder), HbA1c, lipid profile, MDT rehabilitation referral.

**Communication and ethics.** Honest conversation with family — NIHSS 18 has a high disability risk even with successful reperfusion; explore prior wishes and goals. Document the timeline meticulously (last-seen-well, door, imaging, decision, transfer) — this is auditable through **SSNAP**.

Acute ischaemic stroke beyond thrombolysis window but eligible for thrombectomy

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