Tenecteplase in Acute Ischemic Stroke AIS

Updated:
January 21, 2026
Published:
August 31, 2021

 Alteplase (tPA) will no longer be used for AIS, but will be available for other indications.

WHY THE SWITCH? 

  • Tenecteplase was added as an option for thrombolytic therapy in AIS in the 2019 AHA Guideline Update.
  • Tenecteplase is given as a single IV bolus while alteplase is an IV bolus PLUS an infusion.
  • Studies have shown that tenecteplase has comparable neurological outcomes and adverse event occurrences when compared to alteplase in AIS. 

TENECTEPLASE AIS DOSING: 

  • 0.25 mg/kg (Max 25 mg) IV bolus over 5 seconds 
  • Administer within 4.5 hours of symptom onset 

WHO CAN ORDER? WHERE? 

  • May be ordered by an emergency physician, teleneurologist, advanced practice provider or hospitalist
  • May be initiated in the ED, any critical care unit, or in a telemetry-monitored bed with monitoring by a critical care nurse 

ORDERING TENECTEPLASE IN EPIC: 

1. Open patient’s profile 
2. Click Manage Orders tab and type in search bar “tenecteplase” 
3. Click Thrombolytic Therapy for Ischemic Stroke 
4. Click Tenecteplase and check appropriate weight-based dosing 

IMPORTANT NOTES: 

  • Patients should be monitored for BP > 180/105, O2 saturation <94%, change in mental status, new or severe headache, seizures, any signs of symptoms of bleeding, or nausea/vomiting. 
  • No antiplatelets or anticoagulants x 24 hours after administration of tenecteplase. 
  • Avoid central lines, nasogastric tube placements, or urinary catheter placement in the first 24 hours after tenecteplase. 

TENECTEPLASE REVERSAL GUIDELINES: 

For thrombolytic-related symptomatic intracranial hemorrhage in patients who have received tenecteplase in the previous 24 hours:

  • First Line: Cryoprecipitate 10 units; check fibrinogen and may repeat dose if fibrinogen < 200 mg/dL
  • Alternative Agents: 
    • Aminocaproic acid (Amicar) 5 g in 250 mL NS IV over 1 hour followed by 1 g/hr infusion until bleeding controlled, or 
    • Tranexamic acid 10-15 mg/kg in 100 mL NS IV over 20 minutes 
  • Labs: Monitor fibrinogen levels and platelets 
  • Transfusion: May consider platelet transfusion, however, there is insufficient data supporting the benefit
  • Coagulation Effects: Time to normal coagulation activity after drug administration is 24-48 hours 

References: 

1. Campbell BCV, et al. Tenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke. N Engl J Med. 2018;378(17):1573-1582.
2. Parsons M, Spratt N, Bivard A, et al. A randomized trial of tenecteplase versus alteplase for acute ischemic stroke. N Engl J Med. 2012;366(12):1099-1107. 
3. Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association [published correction appears in Stroke. 2019 Dec;50(12):e440-e441]. Stroke. 2019;50(12):e344-e418.