ZyraDoc #08 - August 10, 2026

A 68-year-old man presents to the emergency department with acute right-sided hemiparesis and aphasia that began 2 hours ago.

Non-contrast CT head rules out hemorrhage, CT angiography confirms a proximal left middle cerebral artery (MCA) occlusion, and IV alteplase (rtPA) is promptly initiated.

One hour after starting alteplase, his severe neurological deficits (NIHSS score 18) remain completely unchanged.

Case Summary

Clinical Focus:

A 68-year-old male with an acute ischemic stroke secondary to a proximal large vessel occlusion (LVO) shows no clinical improvement after receiving intravenous thrombolysis (Alteplase).

Indications for Emergency Endovascular Thrombectomy (EVT):

Confirmed proximal large vessel occlusion in the anterior circulation (e.g., internal carotid artery or proximal MCA)
Presentation within 6 hours of symptom onset (or up to 24 hours with favorable perfusion imaging mismatch)
Pre-stroke functional independence (modified Rankin Scale 0 to 1)

When an acute ischemic stroke is caused by a large vessel occlusion, intravenous thrombolysis alone is frequently insufficient, and mechanical thrombectomy should be performed urgently without waiting to assess thrombolytic response.

Here is the Management Strategy:

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