Synopsis
Select and prepare eligible patients for intravenous thrombolysis or mechanical thrombectomy while controlling avoidable delays, treatment-specific hazards and post-reperfusion complications.
- Reperfusion decisions are made by an acute stroke service using disabling deficit, last-known-well, imaging, premorbid function, bleeding risk and patient wishes; age or NIHSS alone should not become an automatic exclusion.
- NICE recommends tenecteplase or alteplase as intravenous thrombolysis options for selected acute ischaemic stroke within 4.5 hours when intracranial haemorrhage has been excluded and contraindications are addressed; use the locally commissioned stroke protocol.
- Wake-up or later-presenting stroke may be thrombolysed when MRI or perfusion imaging demonstrates a favourable tissue pattern under current specialist protocols; clock time is not the only modern selection tool.
- Mechanical thrombectomy is offered rapidly for eligible proximal intracranial large-vessel occlusion, commonly within 6 hours and in selected patients up to 24 hours using clinical and advanced-imaging criteria.
- Do not withhold intravenous thrombolysis from an otherwise eligible patient merely because thrombectomy is planned; bridging treatment and transfer should proceed in parallel unless a specialist contraindication applies.
- Before thrombolysis, blood pressure must be reduced to 185/110 mmHg or lower and glucose, anticoagulant exposure, recent bleeding or surgery and platelet or coagulation concerns must be evaluated without unnecessary testing delays.
- After intravenous thrombolysis, maintain blood pressure below 180/105 mmHg for the first 24 hours under the stroke protocol, avoid antiplatelet and anticoagulant treatment for 24 hours, perform follow-up imaging before starting it, and investigate any neurological decline, headache, vomiting or hypertension immediately.
- Thrombectomy care includes anaesthetic strategy, arterial access, reperfusion assessment and post-procedure blood-pressure planning at a specialist centre; successful recanalisation does not guarantee completed tissue recovery.
Key red flags
Suspected intracranial haemorrhage, active major bleeding or a known severe haemostatic abnormality requires immediate specialist review and usually precludes thrombolysis.
A direct oral anticoagulant taken recently, an elevated relevant drug level or uncertain exposure cannot be dismissed by a normal INR; use the local anticoagulant-specific pathway.
Blood pressure remaining above the treatment threshold despite careful protocol therapy prevents safe intravenous thrombolysis at that moment.
Basilar occlusion can deteriorate to coma or locked-in syndrome despite initially fluctuating symptoms and requires immediate thrombectomy-centre contact.
Airway swelling, haemodynamic instability, access-site expansion or any post-treatment neurological decline needs emergency senior and critical-care support.
Investigation priorities
Exclude intracranial haemorrhage and assess the extent of established infarction before either reperfusion treatment.
Management branches
A patient has a disabling acute ischaemic stroke within a standard or imaging-selected treatment window.
- Confirm last-known-well, deficit and premorbid function, exclude haemorrhage on imaging and review anticoagulants, bleeding, procedures, blood pressure and glucose with the stroke physician.
- Correct a treatable pressure excess carefully to the protocol threshold and obtain only laboratory results that are clinically necessary before treatment.
- Discuss material benefit, symptomatic haemorrhage and uncertainty with the patient or appropriate representative without creating disproportionate delay.
- Administer the approved thrombolytic using the exact weight-based local protocol, document timestamps and begin protocolised post-treatment observations.