Thrombolysis and thrombectomy evidence for the Stroke Medicine Portfolio Pathway means documented DOPS and case logs showing independent consultant-level decision-making: imaging interpretation, eligibility assessment, treatment decisions including contraindication management, administration or referral, immediate monitoring, and complication management. Case volume matters less than the quality of each entry and the breadth of clinical scenarios covered. Engagement with SSNAP, audit of your unit's door-to-needle times, and structured reports from stroke colleagues all contribute to a complete evidence picture. Check the current JRCPTB Stroke Medicine SSG for the specific indicative numbers - they are the definitive reference, not this article.
What acute intervention evidence means for the Stroke Medicine Portfolio Pathway
Stroke Medicine sits within the JRCPTB family of medicine specialties, assessed against a Specialty Specific Guidance (SSG) published by JRCPTB and available through the GMC website. Reading that SSG in full before building your evidence is the single most important step you can take. This article is a practical companion to the SSG, not a substitute for it.
Within the Stroke Medicine Portfolio Pathway, the ability to manage acute stroke presentations at independent consultant level sits within the core Capabilities in Practice (CiPs) that applicants must demonstrate. Acute stroke management - covering hyperacute assessment, imaging interpretation, reperfusion decisions, and the ongoing management of patients through the first hours and days after a stroke - is not a peripheral element of the portfolio. It is the element that most distinguishes Stroke Medicine from its parent specialties (General Internal Medicine, Geriatric Medicine, and Neurology depending on route) and is therefore the element that receives the most sustained scrutiny from assessors.
The two interventions at the centre of this evidence strand are IV thrombolysis (currently delivered with alteplase or, in some centres, tenecteplase following NICE guidance updates) and mechanical thrombectomy for large vessel occlusion (LVO). These are time-critical, guideline-governed interventions with high stakes clinical decision-making at every step - imaging interpretation, eligibility assessment, contraindication management, treatment administration, and complication monitoring. Every one of those steps is an evidence-generating opportunity, and the Portfolio Pathway asks you to have documented enough of them to demonstrate independent competence across the full clinical process.
The Portfolio Pathway framework distinguishes between two types of applicants in this context. The first is the stroke physician who is the designated thrombolysis decision-maker on their rota, performing eligibility assessments and administering treatment daily. The second is the senior doctor in a stroke-adjacent role - perhaps in geriatric medicine or general internal medicine - who has managed acute strokes and participated in thrombolysis decisions but whose primary role is not hyperacute stroke. The evidence requirements in the SSG apply equally to both, but the documentation strategy differs: the first applicant has volume and needs to ensure each case is adequately documented; the second may have fewer cases and needs each one to be exceptionally well documented.
NICE guideline NG128 - Stroke and transient ischaemic attack in over 16s: diagnosis and initial management - governs the clinical standards for thrombolysis and thrombectomy in England. Your acute stroke intervention evidence should be presented against these standards. When you reference your eligibility assessment process in a DOPS or case log, the assessor is implicitly asking whether it follows NG128. Knowledge of NG128, and evidence that your practice aligns with it, is part of what a Stroke Medicine Portfolio Pathway application demonstrates.
The SSG for Stroke Medicine is not the only document to read. The Royal College of Physicians publishes the National Clinical Guideline for Stroke, which sets the UK standards for stroke service organisation, acute management, rehabilitation, and secondary prevention that underpin the SSG. The British Association of Stroke Physicians (BASP) publishes resources for stroke physicians that address training, competencies, and acute stroke service standards. The Sentinel Stroke National Audit Programme (SSNAP), run by the Royal College of Physicians, generates national comparative data on thrombolysis rates, door-to-needle times, and thrombectomy access that is directly relevant to quality improvement evidence. Together, these documents frame the clinical and organisational context in which your acute stroke intervention evidence sits.
How the Stroke Medicine SSG frames acute intervention evidence
The Stroke Medicine SSG sets out the CiPs that assessors use to evaluate Portfolio Pathway applications. For acute stroke intervention, the relevant CiPs cover the assessment and immediate management of acute ischaemic stroke, haemorrhagic stroke, TIA, and complex stroke presentations. Within these CiPs, specific reference is made to thrombolysis eligibility assessment, administration, monitoring and complication management, and to the pathways for mechanical thrombectomy referral and, in appropriate centres, thrombectomy participation.
Always read the current SSG on the day you build your evidence plan: the SSG is updated periodically, and indicative numbers for DOPS and case log entries can change. What the SSG describes in more stable terms is the quality of evidence required, not merely the quantity. The indicative numbers are a floor. The real question the SSG asks assessors to answer is whether the collective evidence across all case log entries, DOPS, WBAs, and reflective practice demonstrates consultant-level independent practice - meaning the applicant could take on thrombolysis call responsibility from day one of a substantive consultant post without needing supervision or graduated autonomy.
| Evidence element | Primary tool | Performance level | Notes |
|---|---|---|---|
| IV thrombolysis - decision and administration | DOPS | Level 4 - independent | Core evidence element. Each DOPS entry should capture the full clinical process, not just administration confirmation. Assessor feedback must describe the specific case and the decision-making observed. |
| Acute stroke imaging interpretation | DOPS / CbD | Level 4 - independent | Non-contrast CT interpretation, early ischaemic change recognition, CT angiography for LVO, and ASPECTS scoring. This is a distinct competency from thrombolysis administration and should be evidenced separately. |
| Mechanical thrombectomy pathway | DOPS / Case log | Level 4 - independent | Depends on centre type. Thrombectomy-capable centres: direct procedure evidence. Non-thrombectomy centres: pathway activation, pre-transfer imaging, LVO eligibility assessment, and outcome tracking. Both need documentation. |
| Haemorrhagic stroke management | Mini-CEX / CbD | Level 4 - independent | Intracerebral haemorrhage and subarachnoid haemorrhage management, including neurosurgical referral decisions. Distinct from ischaemic stroke evidence; a portfolio without it leaves a gap. |
| Stroke audit and QI | Audit documentation | Closed-loop preferred | SSNAP engagement, door-to-needle time audit, or pathway quality improvement. Specialty-specific audit aligned with RCP or SSNAP benchmarks carries more weight than generic clinical audit. |
| Post-thrombolysis monitoring | DOPS / Reflective practice | Level 4 - independent | Neurological monitoring protocols, blood pressure management, haemorrhagic transformation recognition and management, symptomatic ICH response. Monitoring plans documented in DOPS show the full process, not just the intervention decision. |
The SSG also expects evidence across a range of clinical presentations within the acute stroke evidence strand. A case log that contains predominantly straightforward wake-up strokes in the standard treatment window - with no evidence of more complex decisions, wake-up stroke imaging protocols, late-presenting strokes with advanced imaging, contraindication management, or patients where treatment was considered and withheld on clinical grounds - will not fully demonstrate the consultant-level decision-making range that the CiPs require. Assessors read across the whole case log and consider whether the clinical scenarios documented cover the realistic spectrum of acute stroke presentations that a Stroke Medicine Consultant would encounter.
Documenting thrombolysis: what assessors need to see
IV thrombolysis documentation begins before the treatment decision. The eligibility assessment - the clinical examination, the imaging review, the contraindication checklist, the shared decision-making conversation with the patient or their representatives, and the final consultant-level decision - is where most of the evidential weight sits. A DOPS that captures only the physical act of administration, without documenting the reasoning that preceded it, misses the element assessors are most interested in.
Each thrombolysis DOPS entry should tell a complete clinical story. Think of it as a micro-case report: what was the presentation, what was the time from onset, what did imaging show, what eligibility criteria were applied, what contraindications were considered, what was the treatment decision and why, what was administered, what monitoring was initiated, and what happened in the immediate period after treatment. This level of documentation takes time to complete well, but a smaller number of richly documented cases is worth far more than a larger log of entries that record little beyond the date and drug dose.
Beyond the basic procedure record, a convincing thrombolysis DOPS should include: (1) time from onset to imaging and onset to treatment - documenting these shows adherence to time-critical pathway standards; (2) the specific imaging findings - not just "CT head: no haemorrhage" but what early ischaemic changes, if any, were seen, how they were graded, and how they influenced the decision; (3) the contraindication assessment - specifically any relative contraindications that required clinical judgement; (4) the consent process - particularly if the patient lacked capacity and the approach to a best-interests decision; (5) the post-thrombolysis monitoring plan with the specific blood pressure targets and neurological observation frequency; and (6) any clinical change in the immediate period, including any complications and how they were managed. Assessors notice when DOPS entries are formulaic; cases that capture a genuine clinical decision carry more weight.
Documenting cases where thrombolysis was withheld
One of the most consistently underdocumented elements of acute stroke intervention evidence is the case where thrombolysis was considered and withheld. These cases often represent the most complex and high-stakes clinical decisions in stroke medicine - a patient with a significant contraindication, a late-presenting or wake-up stroke where the imaging risk-benefit was genuinely uncertain, an elderly patient with frailty and comorbidity where the treatment decision required careful discussion, or a patient who declined treatment after a clear information-giving conversation. Every one of these scenarios demonstrates consultant-level decision-making that a straightforward DOPS of a routine thrombolysis does not capture.
A CbD (Case-based Discussion) is often the right tool for these cases. A CbD focused on a patient where thrombolysis was considered and not given, with structured discussion of the reasoning, the alternatives considered, how the conversation with the patient or family was managed, and what the outcome was, provides assessors with evidence of the full range of acute stroke decision-making at independent level. Including several such CbDs in a Stroke Medicine Portfolio Pathway application substantially strengthens the acute intervention evidence strand.
Protocols for wake-up stroke (using DWI-FLAIR mismatch imaging to guide thrombolysis) and extended treatment windows using perfusion imaging (as used in DAWN and DEFUSE 3 trials) are now incorporated into UK stroke practice guidelines and NICE NG128. Evidence that you can interpret advanced stroke imaging protocols and apply them to real treatment decisions - not just in standard-window cases - demonstrates a level of specialist competence that goes beyond the basics. If your centre uses perfusion imaging or wake-up stroke protocols, including evidence of cases managed under these pathways adds depth to your acute intervention evidence strand. Link the clinical decision to the specific imaging criteria that supported it in each DOPS or CbD entry.
Thrombectomy evidence: access, case logs, and DOPS
Mechanical thrombectomy for large vessel occlusion has become a central part of acute stroke management, but access to thrombectomy-capable services is not uniform across the NHS. The NHS England Integrated Stroke Delivery Networks (ISDNs) provide the organisational framework for thrombectomy delivery, with designated thrombectomy-capable stroke centres serving defined regional catchments. Where a stroke physician works determines what kind of thrombectomy evidence they can generate, and the JRCPTB SSG acknowledges this geography.
Stroke physicians at thrombectomy-capable centres are expected to demonstrate direct involvement in the thrombectomy decision-making pathway: patient selection using advanced imaging, activation of the thrombectomy team, consent, and involvement in the peri-procedural management. The procedural intervention itself is typically performed by interventional neuroradiologists or, in some centres, by stroke physicians with additional procedural training. For Portfolio Pathway purposes, the evidence expectation is around the clinical assessment, selection, and pathway activation - not the procedural technique itself, unless the applicant has specific procedural training.
For stroke physicians at non-thrombectomy centres, the evidence requirement shifts to the referral pathway: the ability to rapidly identify LVO using clinical examination and CTA, make the transfer decision, manage the patient in the pre-transfer period (including thrombolysis where indicated as a bridge), and liaise with the receiving thrombectomy centre. This requires documentation of the clinical and imaging assessment, the conversation with the thrombectomy centre, the transfer decision, and the outcome. DOPS completed at the referring centre, with assessor comments describing the LVO identification and pathway activation, provide appropriate evidence for applicants in non-thrombectomy settings.
| Setting | Evidence elements | Primary tools |
|---|---|---|
| Thrombectomy-capable centre | Patient selection using CTA/CTP, ASPECTS scoring, multidisciplinary decision-making, consent, peri-procedural management, and outcome documentation. Direct observation of procedure where clinically possible. | DOPS CbD |
| Non-thrombectomy acute stroke unit | Rapid LVO identification (NIHSS, clinical exam), CTA interpretation for LVO, bridge thrombolysis decision, transfer activation, communication with thrombectomy centre, outcome tracking. Supernumerary visits to thrombectomy centre where feasible. | DOPS CbD |
| Rehabilitation or community stroke | Limited direct thrombectomy evidence possible. Supernumerary sessions at acute stroke centre essential. Outcome review evidence (following up patients who have received thrombectomy). Portfolio narrative must address the limitation explicitly. | Supplementary sessions |
The imaging competency required for thrombectomy - reading CT angiography for large vessel occlusion, applying ASPECTS scoring to non-contrast CT, interpreting CT perfusion maps where used - is a distinct competency that requires its own evidence. Many Stroke Medicine Portfolio Pathway applicants have performed these imaging assessments routinely for years without having documented the interpretation as a formal evidence element. A DOPS where the assessor's comments specifically address the imaging interpretation, describing what was seen, how ASPECTS was scored, and what the imaging showed about penumbra versus core, generates evidence that a generic "CT head reviewed" entry does not.
Scan-to-needle time and decision-making as evidence
The time from imaging to treatment - the scan-to-needle time for thrombolysis and the equivalent pathway time for thrombectomy referral - is a quality metric that the national stroke audit (SSNAP) tracks at hospital level and that the RCP National Clinical Guideline for Stroke sets performance standards for. For Portfolio Pathway applicants, this temporal dimension of acute stroke care is evidence in two ways: as documentation in individual case entries, and as a quality improvement opportunity through audit.
Each of those moments is an evidence-generating step. A DOPS that captures the pathway from arrival to 24-hour outcome - even in summary - provides assessors with a complete picture of the clinical process at every stage, not just a snapshot of a procedure. If your DOPS entries currently record only administration and immediate monitoring, enriching them to capture the imaging interpretation and decision-making steps will substantially improve the evidential quality of your existing case log without requiring additional clinical cases.
Using SSNAP data as audit evidence
Your unit's SSNAP data is a ready-made audit dataset for quality improvement evidence. SSNAP publishes quarterly summary data at hospital level, including thrombolysis rate (as a proportion of eligible patients), door-to-needle time, thrombectomy rate, and stroke unit outcomes. Comparing your unit's performance to the SSNAP national median in any of these domains, identifying an underperformance, designing an intervention to address it, implementing it, and re-measuring represents a complete closed-loop audit that is directly relevant to the Stroke Medicine curriculum and generates strong Domain 2 evidence.
Beyond the formal audit, SSNAP data can contextualise your individual thrombolysis case log. If you present a table summarising your personal thrombolysis activity over the past two years - number of patients assessed, number treated, door-to-needle time range, and complication rate - alongside the relevant SSNAP national benchmarks, you situate your individual clinical activity within the national quality framework. Assessors reading this can see that your practice is both high-volume and aligned with national standards. The raw SSNAP case-level extract is not a substitute for DOPS and WBA-level documentation, but it is a legitimate contextualising supplement.
Mapping acute stroke evidence to the four GMC domains
Every element of your acute stroke intervention evidence maps to the GMC's four domains: Knowledge, Skills and Performance; Safety and Quality; Communication, Partnership and Teamwork; and Maintaining Trust. A Stroke Medicine Portfolio Pathway application that is rich in Domain 1 procedural evidence but thin in Domains 2, 3, and 4 will not produce a clean pass.
Acute stroke intervention evidence mapped to the GMC four domains
Stroke Medicine- DOPS for IV thrombolysis across a range of presentations
- Imaging interpretation evidence: CT, CTA, and advanced imaging protocols
- Thrombectomy pathway activation and case log
- Haemorrhagic stroke management evidence
- NIHSS documentation and neurological assessment
- Post-thrombolysis monitoring protocol adherence
- Haemorrhagic transformation recognition and management
- MRCP(UK), SCE Stroke Medicine evidence
- SSNAP-linked audit of door-to-needle times or thrombolysis rates
- Quality improvement projects on acute stroke pathway performance
- Significant Event Analysis (SEA) reports involving adverse outcomes after thrombolysis or thrombectomy
- Mortality and morbidity meeting presentations on stroke complications
- Haemorrhagic transformation rate monitoring and learning
- ISDN engagement and pathway improvement contributions
- Patient feedback from acute stroke episodes, including thrombolysis consent conversations
- MSF from stroke nursing staff, junior colleagues, and neuroradiology colleagues
- Documentation of thrombectomy referral conversations with receiving centres
- Family and carer communication evidence from hyperacute phase
- MDT participation in stroke unit meetings and ISDN governance
- Teaching on acute stroke recognition and management
- Reflective practice entries on complex thrombolysis decisions, adverse events, and uncertainty management
- Documentation of consent processes, including capacity assessments and best-interests decisions
- CPD records covering acute stroke, thrombectomy pathways, and imaging interpretation
- Probity evidence including honest reflection on adverse outcomes
- Appraisal documentation covering thrombolysis call performance
Domain 2 is where stroke portfolios most commonly have unexplained gaps. A stroke physician who has given hundreds of thrombolyses may have extensive Domain 1 evidence but sparse Domain 2 documentation if they have not engaged formally with SSNAP, have not led or contributed to a stroke-specific audit, and have not presented at or contributed to mortality review meetings or SEA. The existence of SSNAP makes this gap particularly avoidable in stroke: there is more comparative quality data available for stroke performance than for almost any other acute specialty, and failing to use it as audit evidence is an opportunity missed.
Domain 3 evidence from the hyperacute stroke setting is naturally generated in daily practice - thrombolysis consent conversations with distressed relatives, rapid communication with the thrombectomy centre under time pressure, handovers to the receiving team - but needs to be captured. Structured reports from colleagues who observe these communication episodes are appropriate evidence. Patient feedback specifically gathered after an acute stroke admission (while respecting the sensitivities of approaching recently ill patients) can also be a legitimate source if handled carefully. The patient feedback guide covers appropriate ways to gather this evidence.
Thin vs convincing acute stroke intervention documentation
Thin acute stroke intervention documentation has identifiable patterns. Understanding those patterns before building your evidence - or before auditing what you already have - is the most efficient route to a credible portfolio.
- Assessor comment: "IV tPA given appropriately. Good decision-making." No case details, no imaging findings mentioned.
- Case description: "85-year-old with right-sided weakness, thrombolysed." No NIHSS, no time from onset, no imaging description.
- Contraindication assessment absent: no reference to whether any relative contraindications were considered.
- Post-thrombolysis plan not described: no monitoring frequency, blood pressure targets, or complication recognition plan documented.
- Outcome unknown: no follow-up documentation in the DOPS entry itself.
- All entries formulaic and similar: the same language across fifteen cases suggests a template, not genuine engagement with each specific case.
- Assessor describes the specific case: imaging findings, ASPECTS score, decision about relative contraindication (prior oral anticoagulation discontinued 72 hours earlier), treatment decision rationale.
- Consent process documented: patient lacked capacity; applicant led the best-interests discussion with the family, documented in the contemporaneous medical record and summarised in the DOPS.
- Time from onset to treatment noted: within standard window with specific onset time confirmed by family history.
- Post-thrombolysis monitoring plan specified: BP target below 180/105, neuro obs every 15 minutes for two hours, protocol for haemorrhagic transformation response.
- 24-hour outcome: repeat CT confirmed no haemorrhage, neurological improvement, NIHSS reduction documented.
- Self-assessment from applicant reflects on what was clinically most challenging and why the decision made was correct.
The principle: the DOPS exists to show what was decided, why, and at what level of independence. An assessor reading your portfolio should be able to reconstruct the clinical episode from the DOPS entry alone. If they cannot, the entry adds case count but not evidential weight.
Building your acute stroke evidence log
An evidence log for acute stroke intervention is not a filing system. It is a deliberate strategy for capturing evidence across the portfolio window in a way that collectively demonstrates everything the SSG CiPs require. For most stroke physicians, the clinical experience already exists; the gap is systematic documentation of that experience.
Audit your current evidence against the SSG CiPs
Before creating new evidence, map what you already have. Download the current Stroke Medicine SSG from the JRCPTB website and work through the CiPs relevant to acute intervention. For each CiP, note whether your existing DOPS, WBAs, or case logs demonstrate independent performance with adequate documentation. This takes half a day but prevents you from building more of what you already have enough of. Also apply the five-year rule: identify which older entries will need refreshing with contemporaneous evidence before submission.
Set up a documentation routine for every thrombolysis case
The most effective change most stroke physicians can make is to commit to completing a DOPS for every thrombolysis decision - including cases where treatment was not given. Complete each DOPS within 24 hours while the clinical detail is fresh, and ask the assessing Consultant to write specific feedback, not a generic confirmation. If you are the decision-maker on thrombolysis call, you need a trusted senior colleague to observe and comment periodically, not just to sign off that a drug was given. Approach two or three Consultant colleagues and ask them to engage with you on specific cases rather than blanket sign-off.
Build imaging interpretation evidence separately
Agree with a stroke or neuroradiology colleague that they will specifically comment on your imaging interpretation when they observe your acute assessments. A DOPS where the assessor has noted "correctly identified early left MCA territory ischaemia on non-contrast CT, ASPECTS 8, and supported the treatment decision with appropriate imaging rationale" is meaningfully different from one where the imaging is mentioned only in passing. If your existing entries lack this detail, go back to your assessors and ask them to add imaging-specific feedback to future entries from the outset.
Plan a SSNAP-linked audit project
Identify your unit's current performance against the SSNAP median for at least one meaningful metric - door-to-needle time is the most directly relevant to thrombolysis evidence. If your unit is above the median, document that with SSNAP data and describe the pathway elements that enable it. If your unit is below the median, that is an even more compelling QI opportunity: identify the rate-limiting step, design an intervention, implement it, and re-measure. A completed SSNAP-linked audit cycle is Domain 2 evidence of the kind that assessors consistently find convincing because it is grounded in real national comparative data.
Address haemorrhagic stroke evidence explicitly
If your current portfolio has a gap in haemorrhagic stroke evidence, plan to fill it now rather than at submission. Two or three Mini-CEX or CbD entries covering intracerebral haemorrhage or subarachnoid haemorrhage management, with assessor feedback specifically addressing your decision-making on haematoma evacuation referral, blood pressure management, anticoagulation reversal, and neurosurgical interface communication, will address this CiP area adequately. The haemorrhagic stroke CiP is often where portfolio gaps emerge because doctors who are strong in ischaemic stroke have documented the ischaemic side extensively and assumed the haemorrhagic side is implicitly covered.
Audit the completed log three months before submission
Three months before your intended submission date, lay out all acute stroke intervention evidence in the order in which an assessor would read it. Ask a trusted Stroke Medicine Consultant colleague who knows the Portfolio Pathway to read the thrombolysis and thrombectomy sections and identify anything that reads as thin or generic. Pay particular attention to case breadth - are all your documented cases standard window, straightforward presentations? - and to the balance between Domain 1 procedural evidence and Domain 2 and 3 evidence. Fix gaps before submission. The assessment process article explains what happens after you submit and why investing time before submission is always more efficient than addressing the same gaps under a Request for Additional Evidence.
If your post has limited thrombolysis or thrombectomy access
Not every doctor who wants to apply for the Stroke Medicine Portfolio Pathway is currently in a post with regular thrombolysis activity. This is a real constraint for doctors in rehabilitation stroke posts, community stroke teams, or general medicine posts where acute stroke is part of the on-call workload but not the primary clinical focus. The solution is practical rather than theoretical.
The most direct route to building thrombolysis evidence from a post with limited acute stroke activity is to negotiate supernumerary sessions at an acute stroke unit with regular thrombolysis activity. Even one or two sessions per month at such a unit, sustained over twelve months, can generate enough well-documented thrombolysis DOPS to address the core CiP requirement. The job plan flexibility article covers how to frame this request to your clinical director and employer - presenting it as a time-limited, goal-oriented educational activity with a specific end point is usually more effective than a general request for cross-site working.
For applicants whose current NHS post is not in an acute stroke centre, the framing of supernumerary activity matters for the DOPS: the sessions need to be documented as independent clinical practice (you assessing and deciding, with a supervising Consultant observing), not as observation. Observation contributes to CPD records but not to procedural DOPS. The distinction matters because assessors read DOPS entries for evidence of what you did independently, not what you watched.
Doctors whose stroke medicine practice has been entirely overseas face specific challenges with thrombolysis and thrombectomy evidence. The eligibility criteria, drug protocols, imaging pathways, and governance frameworks used in non-UK centres may differ from NICE NG128 and RCP standards. DOPS completed by assessors at overseas institutions are valid evidence, but they need to be supported by clear documentation that the practice context is broadly comparable and that the assessors are appropriately senior. The overseas evidence article covers the general principles. Applicants who have built their acute stroke experience entirely overseas are generally advised to supplement it with at least some UK-based thrombolysis evidence before submission - either through NHS employment or, failing that, through documented equivalence that makes the comparison explicit and evidence-based.
Older thrombolysis evidence from earlier in your career contributes context but should not be the primary evidential base. The five-year rule applies to acute stroke evidence as it does to all Portfolio Pathway evidence: entries more than five years old from the submission date carry less weight and may be viewed as historical rather than demonstrating current competence. A portfolio where the most recent thrombolysis evidence is three or four years old, with nothing more recent, raises questions about whether you are currently competent to take independent thrombolysis call. That question is better answered by building recent evidence than by providing explanations.
The bottom line for applicants with limited current access is clear and consistent with every other area of Portfolio Pathway preparation: it is better to invest the time building adequate evidence before submission than to submit with gaps and manage a Request for Additional Evidence under time pressure. The deferrals and RAE article explains what that process involves. The same evidence required before submission is also required under an RAE - but under significantly less favourable conditions. A six-month investment in supernumerary thrombolysis sessions before your intended submission date is almost always worth it.
All 18 specialisms
The documentation discipline this article describes for acute stroke intervention applies across all procedural and time-critical evidence elements in the Portfolio Pathway. The principle - that every decision is an evidence opportunity, that documentation quality matters more than volume, and that thin confirmation of a procedure matters far less than a complete record of clinical reasoning - holds across every specialism. In Anaesthetics, it applies to regional anaesthesia and airway management; in Interventional Radiology, to procedure logs; in Gastroenterology, to endoscopy documentation.
Primary sources
| Source | Publisher |
|---|---|
| Portfolio Pathway: applying for the specialist register | GMC |
| Stroke Medicine specialty page and Specialty Specific Guidance | JRCPTB |
| Stroke and transient ischaemic attack in over 16s: diagnosis and initial management (NG128) | NICE |
| National Clinical Guideline for Stroke | Royal College of Physicians |
| Sentinel Stroke National Audit Programme (SSNAP) | Royal College of Physicians |
| British Association of Stroke Physicians | BASP |
| NHS England stroke clinical policy and Integrated Stroke Delivery Networks | NHS England |
| Good Medical Practice (2024) | GMC |
| Portfolio Pathway fees and charges | GMC |
| GIRFT Stroke report: improving care for stroke patients | GIRFT / NHS England |
Frequently asked questions
Does every Stroke Medicine Portfolio Pathway applicant need thrombolysis evidence?
Yes, in practice, although the precise requirements are set out in the Stroke Medicine Specialty Specific Guidance (SSG) published by JRCPTB, which should always be read in full. The ability to assess a patient for IV thrombolysis, make an independent treatment decision, and administer or supervise treatment safely sits within the core acute stroke CiPs (Capabilities in Practice) that every applicant must demonstrate. Applicants who work in a hospital that delivers thrombolysis are expected to document this as a primary evidence element. Where a doctor's current post does not deliver thrombolysis, alternative arrangements - including supernumerary sessions at a thrombolysing centre - may be needed to build adequate evidence. A Stroke Medicine Portfolio Pathway application that contains no thrombolysis-related evidence is a significant gap that will draw attention from assessors.
How many thrombolysis cases do I need to document for the Stroke Medicine Portfolio Pathway?
The indicative minimum for thrombolysis documentation is set in the current Stroke Medicine SSG published by JRCPTB. Always check the live SSG document for the current figure, as indicative numbers are subject to periodic review. The number is a floor, not a target: what matters more than reaching the minimum count is that the documented cases collectively demonstrate the full clinical decision-making process - from imaging interpretation and eligibility assessment through to administration, monitoring, complication management, and outcome documentation. A smaller number of richly documented cases, each capturing the clinical reasoning in full, is more credible than a larger number of cases that only record the outcome. The SSG figure should be read alongside the requirement for cases across different time windows, different patient presentations, and different eligibility considerations.
What if I work in a hospital that does not do mechanical thrombectomy?
Not all NHS acute trusts deliver mechanical thrombectomy; it is concentrated in designated thrombectomy-capable stroke centres. If your current substantive post is not at a thrombectomy centre, the Stroke Medicine SSG sets out what is expected - typically, evidence of active participation in the thrombectomy pathway, which may include assessing and referring patients rather than personally performing or supervising the procedure, as well as demonstrating familiarity with imaging interpretation for thrombectomy eligibility (ASPECTS scoring, CTA interpretation, penumbra assessment). Some Portfolio Pathway applicants have arranged sessions at a thrombectomy centre specifically to build this evidence. Document those visits formally, with DOPS or structured feedback from the supervising interventional neuroradiologist or stroke physician, not simply as an observation. The JRCPTB SSG should guide exactly what level of engagement with thrombectomy is required for your specific application.
What does a convincing thrombolysis DOPS entry look like?
A convincing thrombolysis DOPS entry does more than confirm the procedure was performed. The assessor's comments should describe the specific case: the presenting symptoms, the time from onset, the imaging findings that supported eligibility, any contraindications that were considered and why they did not preclude treatment, the treatment decision process, the administration itself, and the immediate post-thrombolysis monitoring plan. The applicant's self-assessment should reflect on what was most complex about the case - a borderline presentation, a relative contraindication that required clinical judgement, an imaging ambiguity that was discussed - and what the outcome was. DOPS that consist of a single sentence from an assessor confirming the procedure was done correctly, without any description of the specific clinical context, add volume but not evidential weight. The best DOPS entries allow an assessor who was not present to reconstruct what happened and why.
Can overseas thrombolysis experience count for the Stroke Medicine Portfolio Pathway?
Overseas thrombolysis experience can contribute to a Stroke Medicine Portfolio Pathway application, but it faces particular scrutiny for several reasons. The clinical protocols, imaging pathways, and eligibility criteria used in non-UK centres may differ from the NHS stroke pathway framework and NICE NG128 standards. DOPS completed by assessors at overseas institutions need to be supported by evidence that the assessors are appropriately senior and that the practice context is comparable. The JRCPTB SSG and the overall Portfolio Pathway framework require evidence of current competence within or equivalent to an NHS environment. Applicants who have built the majority of their thrombolysis experience overseas are generally advised to supplement it with UK-based evidence before submission, even if that means a period of supernumerary sessions at an NHS stroke centre. The translating overseas evidence article covers the general principles that apply across all specialties.
What is the Sentinel Stroke National Audit Programme (SSNAP) and does it count as Portfolio Pathway evidence?
SSNAP is the national clinical audit for stroke care in England, Wales and Northern Ireland, run by the Royal College of Physicians. It collects data on every stroke admission and publishes hospital-level performance data quarterly, including thrombolysis rates, door-to-needle times, thrombectomy rates, and patient outcomes. Engagement with SSNAP is itself a Portfolio Pathway evidence opportunity: presenting your unit's SSNAP data at a departmental meeting, contributing to an action plan responding to a SSNAP finding, or conducting a local audit comparing your unit's door-to-needle performance to the SSNAP national median are all legitimate audit and quality improvement evidence items that carry more weight than generic clinical audit. SSNAP data about your own cases can also contextualise your thrombolysis case log, though the raw SSNAP data extract is a supplement to, not a substitute for, DOPS and WBA-level documentation.