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Status Epilepticus First-Line — RACP Adult Medicine MCQ

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HardNeurologyStatus Epilepticus First-LineRACP Adult Medicine

A 68-year-old with atrial fibrillation develops sudden aphasia and right hemiplegia 90 minutes ago. CT excludes haemorrhage; CTA shows a left M1 occlusion. He took apixaban four hours ago and has a functionally independent baseline. What is the most appropriate reperfusion decision?

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Reveal the answer and explanation

Correct answer: D — Proceed to thrombectomy assessment now; recent apixaban precludes standard IV thrombolysis but not mechanical thrombectomy

Explanation lettering: E = shown as D · D = shown as E

E is correct. E proximal large-vessel occlusion within the early window requires immediate transfer to a thrombectomy-capable pathway; recent therapeutic apixaban generally precludes standard IV thrombolysis but is not itself a contraindication to mechanical thrombectomy. A reverses both principles. B sacrifices time-dependent brain tissue while waiting for drug clearance. C uses reversal to force an unestablished thrombolysis pathway and ignores the proven large-vessel treatment. D confuses thrombolysis restrictions with endovascular eligibility. Treatment should proceed without waiting for advanced perfusion imaging in an early-window patient with a disabling deficit and favourable non-contrast imaging, subject to local stroke-network protocols.

Reference: Heart Foundation and CSANZ: Australian acute coronary syndromes guideline 2025: https://www.heartfoundation.org.au/for-professionals/acs-guideline