Stroke is a major cause of mortality and morbidity, and thrombolysis has served 
as a catalyst for major changes in the management of acute ischaemic stroke. 
Intravenous alteplase (recombinant tissue plasminogen activator) is the only 
approved thrombolytic agent at present indicated for acute ischaemic stoke. 
While the licensed time window extends to 3h from symptom onset, recent data 
suggest that the trial window can be extended up to 4.5 h with overall benefit. 
Nonetheless, 'time is brain' and every effort must be made to reduce the time 
delay to thrombolysis. Intracranial haemorrhage is the major complication 
associated with thrombolysis, and key factors increasing risk of haemorrhage 
include increasing age, high blood pressure, diabetes and stroke severity. 
Currently, there is no direct evidence to support thrombolysis in patients >80 
years of age, with a few case series indicating no overt harm. Identification of 
viable penumbra based on computed tomography/magnetic resonance imaging may 
allow future extension of the time window. Adjuvant transcranial Doppler 
ultrasound has the potential to improve reperfusion rates. While intra-arterial 
thrombolysis has been in vogue for a few decades, there is no clear advantage 
over intravenous thrombolysis. The evidence base for thrombolysis in specific 
situations (e.g. dissection, pregnancy) is inadequate, and individualized 
decisions are needed, with a clear indication to the patient/carer about the 
lack of direct evidence, and the risk-benefit balance. Patient-friendly 
information leaflets may facilitate the process of consent for thrombolysis. 
This article summarizes the recent advances in thrombolysis for acute ischaemic 
stroke. Key questions faced by clinicians during the decision-making process are 
answered based on the evidence available.