To assess a patient's eligibility for thrombolysis in the context of acute ischaemic stroke, first confirm the diagnosis rapidly using validated clinical tools such as FAST or ROSIER and exclude hypoglycaemia as a cause of neurological symptoms NICE NG128. Immediate brain imaging with a non-enhanced CT scan is essential to exclude intracranial haemorrhage before considering thrombolysis NICE NG128. Thrombolysis with alteplase is recommended if treatment can be started within 4.5 hours of symptom onset and intracranial haemorrhage has been excluded by imaging NICE NG128.
Eligibility criteria include:
- Confirmed acute ischaemic stroke diagnosis.
- Symptom onset within 4.5 hours.
- No evidence of intracranial haemorrhage on imaging.
- Patient managed within a well-organised stroke service with trained staff and immediate access to imaging and monitoring NICE NG128.
Additional considerations include assessing the patient's pre-stroke functional status (modified Rankin scale less than 3) and stroke severity (NIHSS score greater than 5) to inform treatment decisions, especially if thrombectomy is also considered NICE NG128.
Contraindications include known bleeding tendencies, recent major surgery, or anticoagulant use without reversal, which must be carefully evaluated NICE NG128. Emergency admission to a hyperacute stroke unit and pre-arrival notification to the hospital stroke team improve timely assessment and treatment NICE NG128,NICE CKS.
Recent phase 3 trials comparing tenecteplase to alteplase suggest tenecteplase may be a non-inferior alternative for thrombolysis within the same time window, especially when selected by perfusion imaging, potentially offering simpler administration Wang et al. 2023Parsons et al. 2024. However, current UK guidelines recommend alteplase as the licensed thrombolytic agent NICE NG128.
In summary, eligibility assessment hinges on rapid clinical diagnosis, exclusion of haemorrhage by imaging, timing within 4.5 hours of symptom onset, and management within a specialised stroke service, with emerging evidence supporting alternative thrombolytic agents under specific imaging selection criteria NICE NG128; Wang et al. 2023Parsons et al. 2024.
Key References
- NG128 - Stroke and transient ischaemic attack in over 16s: diagnosis and initial management
- CKS - Stroke and TIA
- (Wang et al., 2023): Tenecteplase versus alteplase in acute ischaemic cerebrovascular events (TRACE-2): a phase 3, multicentre, open-label, randomised controlled, non-inferiority trial.
- (Majoie et al., 2023): Value of intravenous thrombolysis in endovascular treatment for large-vessel anterior circulation stroke: individual participant data meta-analysis of six randomised trials.
- (Parsons et al., 2024): Tenecteplase versus alteplase for thrombolysis in patients selected by use of perfusion imaging within 4·5 h of onset of ischaemic stroke (TASTE): a multicentre, randomised, controlled, phase 3 non-inferiority trial.