Tenecteplase vs alteplase for acute ischemic stroke: ready for practice change?
The AcT trial (2024) and TASTE-A (2023) both showed tenecteplase non-inferiority to alteplase for acute ischemic stroke. Several centers are now switching to tenecteplase for practical reasons (single IV bolus vs 1-hour infusion).
Questions for the group:
- Has your center switched to tenecteplase? At what dose (0.25 mg/kg)?
- For LVO patients going to thrombectomy, do you still give IV thrombolysis with tenecteplase before the procedure?
- Any difference in bleeding complications in your experience?
- Extended window thrombolysis (4.5 to 9 hours): EXTEND trial used alteplase. Is tenecteplase appropriate in the extended window?
1 Answer
We switched to tenecteplase 6 months ago and have treated approximately 40 patients. Here is our experience:
1. Dose: We use 0.25 mg/kg IV single bolus (max 25mg). This is the dose used in AcT and most recent RCTs. The convenience is transformative for the ED. Instead of setting up a 60-minute infusion with nursing monitoring for rate adjustments, we give one push and the patient is ready for transfer to CT angiography or the angio suite.
2. LVO + thrombectomy: Yes, we still give tenecteplase pre-thrombectomy. The EXTEND-IA TNK trial showed higher reperfusion rates with tenecteplase vs alteplase before thrombectomy, and thrombectomy outcomes were at least equivalent. In our center, the door-to-needle time for tenecteplase averages 18 minutes vs our previous alteplase average of 32 minutes. That 14-minute difference matters.
3. Bleeding: In our 40-patient experience, no symptomatic intracranial hemorrhage (sICH). The pooled RCT data shows sICH rates of 1 to 3% for both tenecteplase and alteplase, with no significant difference. The theoretical advantage of tenecteplase's greater fibrin specificity has not translated into a measurable bleeding reduction in the trials.
4. Extended window: This is where the evidence is weakest. EXTEND used alteplase, and there is no RCT of tenecteplase in the extended window (4.5 to 9h with perfusion imaging). Our center still uses alteplase for extended window cases because we lack RCT support for tenecteplase in this setting. That said, pharmacokinetically, tenecteplase's mechanism should work identically in the extended window.