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Acute ischaemic stroke with proximal middle cerebral artery occlusion during direct oral anticoagulant treatme

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HardNeurological emergenciesAcute ischaemic stroke with proximal middle cerebral artery occlusion during direct oral anticoagulant treatmentMRCEM SBA

A 68-year-old woman develops sudden left-sided weakness and neglect 90 minutes before arriving at an emergency department without an on-site thrombectomy service. Her NIHSS score is 16; before this event she was independent in all activities. She takes apixaban for atrial fibrillation and took her usual dose four hours ago. Capillary glucose is 6.1 mmol/L and INR is 1.1. Non-contrast CT shows no haemorrhage or extensive established infarction. CT angiography shows a proximal right middle cerebral artery occlusion. Her airway is maintained and blood pressure is 158/86 mmHg. What is the most appropriate immediate management plan?

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Correct answer: D — Withhold thrombolysis and arrange urgent thrombectomy transfer.

This is a disabling acute ischaemic stroke with a confirmed proximal anterior-circulation occlusion. She was previously independent, has an NIHSS score above 5, and has no extensive established infarction. NICE recommends thrombectomy as soon as possible within six hours for such patients, with intravenous thrombolysis **if it is not contraindicated**. She therefore needs immediate discussion with the stroke and thrombectomy teams and urgent transfer. ([nice.org.uk](https://www.nice.org.uk/guidance/ng128/chapter/Recommendations)) **A** correctly prioritises thrombectomy but adds tenecteplase despite an apixaban dose four hours ago. **B** has the same thrombolysis problem and omits thrombectomy. A normal INR does not establish that apixaban has ceased to have an anticoagulant effect; a current NHS hyperacute stroke protocol lists a direct oral anticoagulant dose within 24 hours as a thrombolysis contraindication and advises thrombectomy referral when thrombolysis is contraindicated. ([doclibrary-rcht.cornwall.nhs.uk](https://doclibrary-rcht.cornwall.nhs.uk/GET/d10297024)) **C** recognises that thrombolysis is unsuitable, but aspirin and local admission must not replace urgent assessment for clot retrieval. Aspirin may be considered within the stroke pathway without delaying transfer. **E** substitutes therapeutic heparin for reperfusion; NICE does not recommend routine anticoagulation to treat acute arterial stroke. ([nice.org.uk](https://www.nice.org.uk/guidance/ng128/resources/stroke-and-transient-ischaemic-attack-in-over-16s-diagnosis-and-initial-management-pdf-66141665603269))

Reference: NICE NG128: Stroke and transient ischaemic attack in over 16s — recommendations 1.4.5, 1.4.8 and 1.4.12 (Published May 2019; last updated April 2022) — https://www.nice.org.uk/guidance/NG128/chapter/recommendations Royal Cornwall Hospitals NHS Trust: Hyperacute Stroke Protocol – Thrombolysis and Mechanical Thrombectomy Clinical Guideline, version 13.1 (February 2026) — https://doclibrary-rcht.cornwall.nhs.uk/GET/d10297024