M3 occlusion with aphasia, 18 hours — TNK, thrombectomy, both, or neither?
HPI. 62-year-old right-handed woman, history of hypertension and diabetes. Family reports she started to have problems with her speech Tuesday around 6 PM. Wednesday at noon she was unable to get any words out and had right-sided arm and face weakness, so EMS was called.
Last known well: Tuesday 6 PM. Time since onset: 18 hours.
Exam. Severe expressive aphasia, right facial droop, right arm weakness (3/5), mild right leg weakness (4/5). NIHSS 8.
Imaging.
- Non-contrast CT: Normal, ASPECTS 10.
- CTA: left M3 (anterior superior division) occlusion. No tandem cervical disease.
- CT perfusion: 2 mL core / 16 mL penumbra / mismatch ratio 8.
Labs. INR 1.1, platelets 220k, glucose 124.
Quick poll
What would you do?
TNK alone (late-window IVT per OPTIMISTmain / TIMELESS — if DOAC level is reversible/safe)
3 · 50%
MeVO thrombectomy alone (despite the recent DISTAL/ESCAPE-MeVO results)
2 · 33%
TNK + thrombectomy (bridging)
0 · 0%
Best medical management — supportive care only
1 · 17%
6 votes
Discussion
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