NeurologyTier 2Topic

Indication for and application of thrombolysis

Principle

Intravenous thrombolysis (alteplase or tenecteplase) for acute ischaemic stroke - dissolves the occluding thrombus to restore perfusion before infarction is complete
Time-dependent: "time is brain" - each minute of large-vessel occlusion costs an estimated ~1.9 million neurons
Applicable to a minority of presenting strokes given strict time and eligibility criteria - underscores the importance of rapid pre-hospital recognition and transfer

Alteplase and tenecteplase are both tissue plasminogen activators - convert plasminogen to plasmin, which degrades fibrin in the clot
Tenecteplase: single bolus (vs alteplase's bolus + 1-hour infusion), longer half-life, more fibrin-specific - the 2026 AHA/ASA guideline endorses either as non-inferior, with tenecteplase's dosing simplicity increasingly favouring its use

Standard window: within 4.5 hours of clearly known symptom onset (or last known well), disabling deficit, no contraindication - given without requiring advanced imaging selection
Extended window (4.5-9 hours, or wake-up/unknown onset) - eligible with advanced imaging showing salvageable tissue (DWI-FLAIR mismatch or CT/MR perfusion mismatch)
Key contraindications: recent significant haemorrhage, recent major surgery, anticoagulation with elevated INR/therapeutic DOAC levels, uncontrolled BP >185/110, haemorrhage on CT, rapidly improving/minor non-disabling deficit (relative)

Thrombolysis does not exclude thrombectomy - both can be given together ("bridging therapy") for large-vessel occlusion; thrombectomy has its own, longer time window (up to 24 hours with imaging selection)
BP must be controlled to <185/110 before and <180/105 after thrombolysis
Monitor closely for symptomatic intracranial haemorrhage (the major complication) - any acute neurological deterioration -> stop infusion, urgent CT

Large-vessel occlusion stroke (co-managed with thrombectomy), atrial fibrillation (cardioembolic source), stroke mimics that must be considered (hypoglycaemia, seizure with Todd's paresis, migraine with aura)

Earlier treatment produces substantially better functional outcomes ("time is brain") - door-to-needle time is a key quality metric in stroke care

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