A patient presents within 3 hours of sudden onset left hemiparesis and aphasia. What is the next step in management?

• A. Non-contrast head CT to exclude hemorrhage, then consider IV alteplase if no contraindications and within window.
• B. Begin IV alteplase immediately without imaging
• C. MRI brain first
• D. Start antiplatelet therapy

Answer: (A)

In acute stroke management, the priority is to decide quickly whether the event is ischemic and treat within the therapeutic window, while ruling out conditions where thrombolysis would be dangerous. The first step is a non-contrast head CT. This test is fast and widely available and is used to exclude a hemorrhage, which would be a contraindication to IV thrombolysis. If the CT shows no bleed and there are no other contraindications, IV alteplase can be given within the 3-hour window.

Starting thrombolysis without imaging would risk catastrophic bleeding if the stroke were hemorrhagic, so imaging before treatment is essential. An MRI could provide more detail, but it takes longer and would delay therapy in this time-critical scenario. Starting antiplatelet therapy right away isn’t the initial move when thrombolysis is being considered, because the main urgent action is to reperfuse the brain with tPA if eligible, and adding antiplatelets too soon can increase bleeding risk. Therefore, the best next step is to obtain a non-contrast head CT to exclude hemorrhage, then proceed with IV alteplase if there are no contraindications within the allowed window.