Thrombolysis and Mechanical Thrombectomy in Acute Stroke

Principle. “Time is brain” — reperfusion aims to salvage the ischaemic penumbra before infarction is complete. A non-contrast CT to exclude haemorrhage is mandatory before thrombolysis; the target door-to-needle time is 60 minutes or less. Every patient, whether or not eligible for reperfusion, benefits from stroke unit care.

Intravenous thrombolysis. Alteplase 0.9 mg/kg (maximum 90 mg; 10% as bolus, remainder over 60 minutes) within 4.5 hours of onset or last-known-well. The number needed to treat for improved outcome is about 10 when given within 3 hours. Age over 80 is not a contraindication — IST-3 and pooled analyses confirm benefit in the very elderly.

Contraindications and risks. Intracranial haemorrhage; uncontrolled BP >185/110 mmHg; platelets <1,00,000/mm3; INR >1.7 or a DOAC taken within 48 hours; blood glucose <50 mg/dL; major surgery or gastrointestinal bleed within 21 days; stroke or head injury within 3 months; known AVM, aneurysm or intracranial neoplasm. The principal hazard is symptomatic intracerebral haemorrhage in about 2–6%; orolingual angio-oedema also occurs.

Mechanical thrombectomy — indications. Anterior circulation large-vessel occlusion (ICA or M1), NIHSS ≥6, pre-stroke mRS 0–1, ASPECTS ≥6, within 6 hours. The window extends to 6–24 hours with perfusion or clinical– core mismatch selection (DAWN and DEFUSE-3). With a NNT of about 2.6 for reduced disability, it is the most powerful single intervention in acute stroke.

Combined use and post-procedure care. Patients eligible for both should receive intravenous thrombolysis and proceed to thrombectomy — never delay the procedure to see whether symptoms improve. After thrombolysis: no antiplatelet or anticoagulant for 24 hours, repeat CT at 24 hours, maintain BP below 180/105 mmHg, intensive neurological observation, early swallow screen and stroke unit admission.

Indian and practical context. The principal barriers are delayed presentation, cost of alteplase and a limited number of thrombectomy-capable centres. Tenecteplase is single-bolus, cheaper and widely used in India. Telestroke networks, pre-hospital notification and stroke-ready hospital certification under national programmes are the practical levers for improving access.

AHA/ASA 2026 Guideline for the Early Management of Acute Ischaemic Stroke (Stroke, 2026), replacing the 2018/2019 guidelines. Key changes: tenecteplase 0.25 mg/kg (maximum 25 mg) as a single bolus is now a Class 1 recommendation, equivalent to alteplase within 4.5 hours; thrombolyse eligible disabling strokes within 4.5 hours regardless of NIHSS score and without waiting for advanced imaging; extended-window thrombolysis at 4.5–9 hours or in wake-up stroke using perfusion or DWI–FLAIR mismatch is Class 2a; thrombectomy eligibility is broadened to ASPECTS 3–10, admitting large-core infarcts; and mobile stroke units are endorsed.