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Acute Ischaemic Stroke — RACP Adult Medicine MCQ

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HardNeurologyAcute Ischaemic StrokeRACP Adult Medicine

A 72-year-old man with a history of hypertension presents with acute onset right hemiplegia and global aphasia. CT brain shows a large left MCA territory infarct. He is 8 hours from symptom onset with an NIHSS of 22. CT perfusion shows a large penumbra-to-core mismatch. What is the most appropriate treatment?

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Correct answer: B — Endovascular thrombectomy

Beyond 4.5 hours, IV thrombolysis alone is not standard for unselected patients (imaging-guided thrombolysis may extend to 9 hours). However, endovascular thrombectomy (EVT) has strong evidence for large vessel occlusion up to 24 hours when perfusion imaging demonstrates salvageable tissue (DAWN, DEFUSE 3 trials). In this time window, EVT is the primary reperfusion strategy.

Reference: Stroke Foundation – 2024 – Clinical Guidelines for Stroke Management; AHA/ASA – 2026 – Acute Ischaemic Stroke Guideline