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Acute ischemic stroke — USMLE Step 3 MCQ

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HardEmergency MedicineAcute ischemic strokeUSMLE Step 3

A 70-year-old man presents 90 minutes after onset of disabling aphasia and right hemiparesis. CT shows no hemorrhage, glucose is normal, and blood pressure is 198/112 mm Hg. He otherwise qualifies for IV thrombolysis. What is the best next step?

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Correct answer: D — Lower blood pressure below 185/110, then give thrombolytic therapy

The best answer is “Lower blood pressure below 185/110, then give thrombolytic therapy”. Eligible patients must have blood pressure below 185/110 before IV thrombolysis. A titratable IV agent is used, avoiding excessive reduction; failure to maintain the threshold precludes thrombolysis. Blood pressure must be lowered below the thrombolysis threshold before IV thrombolytic treatment.

Reference: AHA/ASA Acute Ischemic Stroke Guideline: https://professional.heart.org/en/science-news/2026-guideline-for-the-early-management-of-patients-with-acute-ischemic-stroke