Reperfusion Therapy – Thrombolysis Guidelines

Thrombolysis is recommended by many national guidelines for the treatment of selected patients with acute ischaemic stroke.

Current American guidelines (AHA/ASA) recommend intravenous thrombolysis for selected patients within 4.5 hours of onset of ischaemic stroke [19].

UK NICE Guidelines advise that alteplase is recommended for the treatment of acute ischaemic stroke when used by experienced physicians. ED physicians, if appropriately trained and supported, can administer alteplase provided that patients can be managed within an acute stroke service. Protocols should be in place for the delivery and management of thrombolysis, including post-thrombolysis complications [16].

The most recent Cochrane Review is similarly supportive: the ‘overall benefit [of thrombolytic therapy] was apparent despite an increase in symptomatic intracranial haemorrhage, deaths at seven to 10 days, and deaths at final follow-up’ [20].

The UK Royal College of Physicians 2016 guidelines have loosened eligibility criteria further, suggesting that ‘patients with acute ischaemic stroke, regardless of age or stroke severity, in whom treatment can be started within 3 hours of known onset should be considered for treatment with alteplase’ [1].

By current NICE guidelines, approximately 20% of stroke patients are eligible to receive thrombolysis treatment. In England, Wales and Northern Ireland, 87% of hospital sites offer 24 hours a day, 7 days a week on-site thrombolysis [21]. In Q2 2016, 87.7% of patients eligible for thrombolysis actually received it (3300 patients approximately) [22].