Should mRS be incorporated into determining eligibility for extended window thrombolysis?

Key thrombolysis trials (WAKE UP, OPTION, EXTEND, TIMELESS, ECASS-4, HOPE, EXTEND IA) excluded patients with mRS of 2 or greater. The reason for this was the outcome of functional independence at 90 days. Hence, for trial purposes, to look at the outcome, it was necessary to exclude patients with disability so that confounding due to other underlying conditions did not affect the outcomes. In real-world practice, don’t exclude patients for an extended thrombolysis window based solely on mRS because we know that the benefits of extended thrombolysis and the alternative in the setting of disabling deficits, especially in those who cannot get prompt thrombectomy or thrombectomy can be devastating, and at the very least any benefit would be at ...

I would re-phrase the question and ask if the pre-morbid status of the patient should be considered prior to stroke thrombolysis in any time window, early or late?

First the mRS is an outcome scale and not designed to assess pre-treatment status. It is designed to assess post-stroke outcome. It is both a functional neurological outcome scale and, because of the domains it assesses, it overlaps substantially with quality of life instruments. The latter means that it correlates very well with the EQ5D and SSQOL, and effectively functions as a quality of life assessment.

Second, the issue in thrombolysis decision-making is whether or not stroke treatment is likely to help the patient or not and what the risk of treatment is. This is true in al...