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

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 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 within 4.5 hours of symptom onset and intracranial haemorrhage has been excluded by imaging ¹.

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 ¹.

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 ¹.

Contraindications include known bleeding tendencies, recent major surgery, or anticoagulant use without reversal, which must be carefully evaluated ¹. Emergency admission to a hyperacute stroke unit and pre-arrival notification to the hospital stroke team improve timely assessment and treatment ¹,².

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., 2023; Parsons et al., 2024). However, current UK guidelines recommend alteplase as the licensed thrombolytic agent ¹.

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 ¹; (Wang et al., 2023; Parsons et al., 2024).