While thrombolysis in clinical trials have been conducted in populations with a clinical and radiological features narrow restrictions, its use in the general population could be performed routinely whenever radiological criteria and most clinicians are met. There are criteria that could be considered “relative” as age> 80 years have diabetes and prior stroke, anticoagulation INR levels <1.7, hypertension> 185/105, peristroke seizure that could allow the use of thrombolytic treatment as compassionate use. But recently there is consensus about include patient with age over 80 years old with baseline good functional situation and low comorbidity.
These decisions must be evaluated individually in each case, very important is the value of neuroimaging (dismiss cases on large of recent ischemia, ASPECTscore <7) and in case of doubt apply a neuroimage with perfusion CT or CT angiography.
As a general rule if more than one criteria to thrombolysis could be questioned regarding neuroimaging unless there is a major vessel occlusion proximal and no other procedure was possible to reperfusion as thrombectomy, thrombolysis could be dangerous and inefective.
Trombolisys is only accepted with rt-PA at doses of 0.9 mg / kg with 10% of total dose in intravenous bolus and the rest by infusion. Curiously the maximum dose of thrombolytic is 90 mg (maximum weight of 100 kg, which can undertreated to pacients with morbid obesity or overweight certain populations).
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Moreover drug elimination is renal which may limit its clearance in renal failure, but is not considered in clinical guidelines.
New thrombolytic drugs such as Desmoteplase (DIAS-III) have provided no benefit in patients treated for more than 4.5 -9h onset of symptoms. Although the Desmoteplase was more specific thrombolytic action on thrombus with less deleterious effects on vessel wall.
It is important to remember according to recent recommendations: treatment with intravenous thrombolysis should never be delayed administration in possible benefit of another technique such as thrombectomy or to test complex image angio / CT or CAT scan percussion type to be complex its implementation or analysis suppose a delay in the administration of bolus rtPA.
Drugs such as tenecteplase (TNK) has not demonstrated superior efficacy to rtPA and if bleeding in Phase II. They do not have more clinical trials