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.
Key red flags
Suspected intracranial haemorrhage, active major bleeding or a known severe haemostatic abnormality requires immediate specialist review and usually precludes thrombolysis.
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.
Key medicines
AlteplaseFor eligible acute ischaemic stroke, give 0.9 mg/kg intravenously to a maximum 90 mg, with 10% as an initial bolus and the remainder infused over 60 minutes.
TenecteplaseFor eligible adult acute ischaemic stroke, give 0.25 mg/kg intravenously to a maximum 25 mg as a single bolus, using the dedicated stroke presentation and exact local weight-band protocol.