Clinical characteristics and recovery after intravenous thrombolysis for acute ischaemic stroke in Sri Lanka: a single centre prospective cohort study

South Asians experience stroke at a younger age than Western populations. There is limited access to advanced neuroimaging and neuro-interventional services. Prospective data from South Asia on outcomes after intravenous thrombolysis are scarce. We aimed to describe the clinical characteristics, treatment, complications and longitudinal functional outcomes of patients treated with intravenous thrombolysis for acute ischaemic stroke in Sri Lanka. We conducted a prospective, single-centre cohort study of consecutive patients who received intravenous thrombolysis for acute ischaemic stroke at the Institute of Neurology, National Hospital of Sri Lanka, from July 2023 to June 2025. Neurological deficit (National Institutes of Health Stroke Scale [NIHSS]), disability (modified Rankin Scale [mRS]) and activities of daily living (Barthel Index) were assessed at presentation, 12 h, 24 h, discharge, 30 days and 90 days. We analysed clinical characteristics, treatment-related complications and mortality. We used multivariable logistic regression to identify predictors of death. We recruited 193 patients (mean age 59.9 ± 11.6 years). Hypertension (61.5%) and diabetes mellitus (42.7%) were the most common vascular risk factors. Lacunar infarction was the predominant stroke subtype (48.7%). The median onset-to-needle time was 3 h 30 min, and the median door-to-needle time was 1 h 50 min. Tenecteplase was used in 56.5% of patients and alteplase in 43.5%; 6.2% underwent mechanical thrombectomy. Radiologically detected post thrombolysis intracerebral haemorrhage (rICH) occurred in 13.0%. NIHSS, mRS and Barthel Index scores improved significantly over 90 days (all p < 0.001). At 90 days, 75.7% achieved functional independence (mRS 0–2) and 72.2% achieved an excellent functional outcome (mRS 0–1). Overall mortality was 11.4%. Higher NIHSS at admission (OR 1.18, 95%CI 1.06–1.30) and rICH (OR 5.03, 95%CI 1.59–15.97) independently predicted mortality. In this largest prospective Sri Lankan thrombolysis cohort to date, patients had stroke at a relatively young age and thrombectomy use was low. Baseline stroke severity and rICH were the main predictors of mortality. About three-quarters of patients with 90-day follow-up achieved functional independence. The favourable outcomes should be interpreted in light of mild baseline stroke severity.