CT Head — Stroke Thrombolysis
CTNICE NG1282019, updated 2022 (Replaces CG68)NICE TA990 (July 2024)RCP National Clinical Guideline for Stroke (2023)v2.0 · March 2026
Immediate
ED
All imaging requests must be justified by an IR(ME)R practitioner (radiologist or radiographer)Required Assessment Tools
REQUIRED
ROSIER
Recognition of Stroke in the Emergency Room — clinical assessment tool for suspected stroke
Standard window (≤4.5 hours)
Immediate— ALL of the following must be met
- Indications for thrombolysis being considered
- Patient on anticoagulant treatment (to exclude haemorrhage)
- Known bleeding tendency
- Symptom onset ≤4.5 hours with pre-stroke mRS 0–2NICE NG128
Extended window (4.5–9 hours or wake-up stroke)
ImmediateCT perfusion or MRI DWI-FLAIR mismatch imaging to identify salvageable tissue — requires specialist stroke team decision
- CT perfusion or MRI DWI-FLAIR mismatch imaging to identify salvageable tissue
- Requires specialist stroke team decision
Haemorrhage exclusion
Immediate— ANY of the following
- Patient on anticoagulation — CT to exclude haemorrhage prior to thrombolysis
Notes
Information
ABCD2 score is NO LONGER recommended for TIA risk stratification
NICE NG128 Rec 1.1.6Information
Tenecteplase now recommended as thrombolytic agent for acute ischaemic stroke
NICE TA990 (July 2024)Warning
4.5-hour window replaces previously used 4-hour threshold
Information
NCCT must be performed and reviewed before thrombolysis is administered
Radiation Dose
CT head effective dose ~2 mSv; CT perfusion adds ~2–5 mSv
Change Log
v1.02026-03-05Initial publication
v2.02026-03-08ROSIER scoring tool added. ABCD2 deprecation noted. Tenecteplase confirmed as recommended agent.