Tenecteplase Dosage and Administration for Acute Ischemic Stroke

Dosing Guidelines

The recommended dosage of tenecteplase for acute ischemic stroke is 0.25 mg/kg administered as a single intravenous bolus (maximum dose of 25 mg) 1
Tenecteplase should be administered as a single IV weight-based bolus with the following dosing recommendations: 0.25 mg/kg (maximum dose of 25 mg) 1

Unlike alteplase, tenecteplase is administered as a single bolus due to its longer half-life (90-130 minutes) 1
The single-bolus administration of tenecteplase offers significant workflow advantages, particularly in centers considering endovascular therapy or patient transfer 1

Both tenecteplase and alteplase share similar contraindications, including evidence of intracranial hemorrhage, recent significant trauma or surgery, and uncontrolled hypertension 1

The American Heart Association/American Stroke Association suggests that tenecteplase might be considered as an alternative to alteplase in patients with minor neurological impairment and no major intracranial occlusion (Class IIb, Level of Evidence B-R) 1
The 0.25 mg/kg dose of tenecteplase is specifically recommended for large vessel occlusions based on trials demonstrating superior recanalization and improved 3-month outcomes relative to alteplase 1

Treatment with tenecteplase should be initiated as soon as possible after patient arrival and CT scan, with every effort made to minimize door-to-needle times 2

The American Heart Association/American Stroke Association suggests tenecteplase might be considered as an alternative to alteplase in patients with minor neurological impairment and no major intracranial occlusion (Class IIb, Level of Evidence B-R) 3

Relative contraindications for tenecteplase administration include recent internal bleeding (within 2-4 weeks), noncompressible vascular punctures, pregnancy, active peptic ulcer, and current use of oral anticoagulant therapy, as stated by the American Heart Association 4

The American Heart Association recommends tenecteplase and alteplase as the only fibrinolytic agents for acute ischemic stroke, with tenecteplase being a potential alternative to alteplase in certain cases 3, 5
Streptokinase is not recommended for use due to high rates of hemorrhage, according to the American Heart Association 4

Earlier administration of tenecteplase is strongly linked to better functional outcomes; each minute of delay reduces the likelihood of favorable recovery. 6

Recent major trauma or surgery within the preceding 3 months precludes tenecteplase use. 6
Patients with an unknown or unwitnessed symptom onset and a last‑known‑well time > 4.5 hours are ineligible for tenecteplase. 6
A prior ischemic stroke occurring within the past 3 months is an absolute contraindication. 6

Systolic/diastolic blood pressure must be reduced to < 185/110 mm Hg before tenecteplase can be administered. 6
A non‑contrast CT scan must rule out intracranial hemorrhage and exclude extensive hypoattenuation (i.e., frank hypodensity indicating irreversible injury) prior to thrombolysis. 6

The stroke‑specific dose of tenecteplase is 0.25 mg/kg (maximum 25 mg); the higher STEMI dose of 0.5 mg/kg must never be used for stroke patients. 7

For basilar artery occlusion, combined intravenous tenecteplase plus endovascular thrombectomy is recommended over direct thrombectomy alone when intravenous thrombolysis is not contraindicated. 7