How do I assess the eligibility of a patient for thrombolysis in the context of ischaemic stroke?

To assess the eligibility of a patient for thrombolysis in the context of acute ischaemic stroke, first confirm the diagnosis rapidly using validated clinical tools such as FAST or ROSIER to identify stroke symptoms ¹. Immediate brain imaging with a non-enhanced CT scan is essential to exclude intracranial haemorrhage before considering thrombolysis ¹. Thrombolysis with alteplase is recommended if treatment can be started as soon as possible and within 4.5 hours of symptom onset, provided intracranial haemorrhage has been excluded by imaging ¹.

Eligibility also requires that the patient is managed within a well-organised stroke service with trained staff and immediate access to imaging and monitoring for complications ¹. Patients on anticoagulants, with known bleeding tendencies, depressed consciousness (Glasgow Coma Score below 13), unexplained fluctuating symptoms, papilloedema, neck stiffness, fever, or severe headache at onset require urgent imaging to assess suitability ¹.

Additional considerations include assessing pre-stroke functional status (modified Rankin scale less than 3) and stroke severity (NIH Stroke Scale score greater than 5) to inform treatment decisions ¹. Thrombectomy may be considered alongside thrombolysis in selected patients with proximal large vessel occlusion confirmed by CT or MR angiography ¹.

Recent phase 3 trials comparing tenecteplase to alteplase suggest tenecteplase may be a non-inferior alternative for thrombolysis within the same 4.5-hour window, especially when selected by perfusion imaging, potentially offering practical advantages [Wang et al., 2023; Parsons et al., 2024]. Meta-analyses also support the value of intravenous thrombolysis in combination with endovascular treatment for large-vessel anterior circulation strokes [Majoie et al., 2023].

In summary, eligibility assessment for thrombolysis involves rapid clinical diagnosis, exclusion of haemorrhage by urgent brain imaging, treatment initiation within 4.5 hours of symptom onset, and management within a specialised stroke service, with emerging evidence supporting alternative thrombolytic agents and combined approaches in selected cases [1; Wang et al., 2023; Parsons et al., 2024; Majoie et al., 2023].