Thrombolysis beyond 3 hours for acute ischaemic stroke

Intravenous thrombolysis is an accepted form of treatment for acute ischaemic stroke when administered within 3 h of symptom onset. However, evidence for its benefit when given beyond this time continues to strengthen. The case history of a young woman is presented with an ischaemic stroke who was successfully thrombolysed with recombinant tissue-type plasminogen activator more than 3 h after presentation. Perfusion CT scanning was used to stratify the likelihood of benefit. Thrombolysis was administered through a combination of intravenous and intra-arterial routes. This case illustrates the advances being made both in the imaging techniques used and the forms of drug administration which can be applied to maximise benefit in this extended therapeutic window. These recent advances are reviewed and their possible impact on current and future practice assessed. While the drive remains the introduction of thrombolysis at a local level for ischaemic stroke within 3 h of symptom onset, it is necessary to consider treatment of subjects presenting beyond 3 h in tertiary centres with the appropriate facilities and expertise.