Large MCA infarct 15 h after LKW – ASPECTS 3 — go straight to thrombectomy, or get CT perfusion first?
HPI. 76-year-old right-handed woman, hypertension, diabetes, atrial fibrillation on warfarin (sub-therapeutic, INR 1.6). Baseline mRS 1 — lives independently, drives, still volunteers. Family last saw her well last night around 10 PM. This morning around 6 AM the visiting daughter found her on the floor, not responsie, with right-sided weakness. EMS arrived; ED arrival 1 PM.
Last known well: yesterday 10 PM. Time since LKW: 15 hours.
Exam. Awake, global aphasia. Left gaze preference, dense global aphasia, right facial droop, dense right arm and leg plegia (0/5). NIHSS 18.
Imaging.
- Non-contrast CT: established hypodensity across the left M1, M2, M4, M5 territories — ASPECTS 3. (See axial NCCT below.)
- CTA: left proximal M1 occlusion. Patent right ICA, no tandem cervical lesion.
Labs. INR 1.2, platelets 245k, glucose 158.
Quick poll
What would you do?
Straight to thrombectomy — NCCT ASPECTS 3 is enough (SELECT-2 / ANGEL-ASPECT / TENSION criteria)
2 · 17%
Get CT perfusion first — only proceed if mismatch is favorable
6 · 50%
Get MRI / DWI first for accurate core volume
4 · 33%
Best medical management — futility / low likelihood of meaningful recovery
0 · 0%
12 votes
Discussion
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