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Acute ischemic stroke — USMLE Step 3 MCQ

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HardEmergency MedicineAcute ischemic strokeUSMLE Step 3

A 68-year-old awakens with aphasia and right hemiparesis. He was last known well 7 hours ago. CT excludes hemorrhage, CT angiography shows no large-vessel occlusion, and MRI shows a small diffusion-weighted lesion without corresponding FLAIR hyperintensity. Which reperfusion approach is supported for a selected patient?

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Correct answer: B — Offer intravenous thrombolysis after eligibility review using imaging mismatch

The best answer is “Offer intravenous thrombolysis after eligibility review using imaging mismatch”. Current AHA/ASA guidance supports extended-window thrombolysis in selected unknown-onset or 4.5–9-hour strokes using advanced-imaging mismatch. Absence of a large-vessel occlusion removes the thrombectomy target but does not automatically exclude imaging-selected intravenous therapy.

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