Neuro emergencies

Acute ischaemic stroke and thrombolysis

Reviewed Nov 2026·1 references
New· views rounded down, updated weekly

Time is brain: non-contrast CT (± CT angiography), glucose check, then IV thrombolysis (tenecteplase 0.25 mg/kg or alteplase 0.9 mg/kg) within 4.5 h if eligible, and thrombectomy for large vessel occlusion up to 24 h. Keep BP < 185/110 before and < 180/105 for 24 h after lysis.

At the bedside

Timed steps
  1. 1

    Recognise

    0 min

    BE-FAST; last known well time; NIHSS; glucose (treat < 60 mg/dL).

  2. 2

    Imaging

    0-25 min

    Non-contrast CT to exclude haemorrhage; CT angiography for large vessel occlusion if thrombectomy is possible; perfusion imaging for late or wake-up presentations.

  3. 3

    Thrombolysis

    < 4.5 h

    Tenecteplase 0.25 mg/kg (max 25 mg) single bolus, or alteplase 0.9 mg/kg (max 90 mg, 10% bolus, rest over 1 h). Door-to-needle target ≤ 60 min (ideally ≤ 45).

  4. 4

    Before and after

    BP

    Lower to < 185/110 before lysis; keep < 180/105 for 24 h (labetalol, nicardipine). Not lysed: treat only if > 220/120.

  5. 5

    Thrombectomy

    LVO

    Anterior circulation LVO up to 24 h with favourable imaging (including selected large cores); basilar occlusion also benefits. Transfer early; do not wait to see the effect of lysis.

  6. 6

    24 h

    ICU care

    Neuro checks and BP every 15 min for 2 h, then 30-minutely for 6 h, then hourly; no antiplatelets/anticoagulants for 24 h after lysis; repeat CT at 24 h; dysphagia screen; glucose 140-180 mg/dL; malignant MCA infarction: early decompressive hemicraniectomy discussion (age ≤ 60).

Stroke thrombolysis

Tenecteplase

IV bolus over 5 s
Dose
0.25 mg/kg, max 25 mg
Worked example
68 kg: 17 mg (3.4 mL of 5 mg/mL)

Stroke thrombolysis

Alteplase

IV
Dose
0.9 mg/kg (max 90 mg): 10% over 1 min, 90% over 60 min
Worked example
70 kg: 63 mg total; 6.3 mg bolus then 56.7 mg over 1 h
Red flag · call your senior now
Neurological worsening, headache, vomiting or BP surge during/after lysis: stop infusion, urgent CT, check fibrinogen, give cryoprecipitate and tranexamic acid.
Red flag
Tongue/lip swelling after alteplase: angio-oedema; stop, antihistamine, steroids, adrenaline if airway threatened.
Pitfall
Using the STEMI weight-band tenecteplase dose (up to 50 mg) for stroke.
Pitfall
Waiting for coagulation results in a patient not on anticoagulants.
Pearl
Stroke mimics (hypoglycaemia, Todd's paresis, migraine) have very low haemorrhage risk with lysis; do not delay to exclude every mimic.

References

  1. 1

    Prabhakaran S, Gonzalez NR, Zachrison KS, et al. 2026 Guideline for the early management of patients with acute ischemic stroke: a guideline from the American Heart Association/American Stroke Association. Stroke. 2026;57(8):e316-e436

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