The FDA’s recent approval of tenecteplase (TNK) for acute ischemic stroke (AIS) has broadened the landscape of thrombolytic therapy. As a modified tissue plasminogen activator (tPA), tenecteplase provides an alternative to alteplase, the long-standing standard of care. Both agents function by dissolving clots and restoring cerebral perfusion with Tenecteplase within the critical 3-hour treatment window and alteplase in the 4.5-hour treatment window, though they differ in administration and pharmacokinetics.1
A key distinction between these agents is the mode of administration. Alteplase requires a bolus followed by a continuous one-hour infusion, whereas tenecteplase is given as a single intravenous bolus over five to ten seconds. This simplified approach may streamline workflow and has the potential to reduce potential delays in treatment. The recommended tenecteplase dose for AIS is 0.25 mg/kg (maximum 25 mg), with studies evaluating its safety and efficacy at both this dose and a higher 0.4 mg/kg dose. 1
Clinical trials have compared the two thrombolytics, with EXTEND-IA TNK suggesting improved reperfusion rates prior to thrombectomy with tenecteplase, while the ACT trial found tenecteplase to be non-inferior to alteplase in functional outcomes.1,2 Both agents remain viable options, and ongoing research continues to refine their optimal use in different patient populations.
The potential for prehospital administration of tenecteplase, particularly in mobile stroke units, may expand access to timely thrombolysis in regions without immediate stroke center access. As stroke care advances, both tenecteplase and alteplase play essential roles in ensuring rapid, effective treatment for AIS patients, reinforcing the importance of timely intervention within the established therapeutic window.
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