What is the most appropriate therapy for an 81-year-old male with acute ischemic stroke due to M1 middle cerebral artery (MCA) occlusion, with a National Institutes of Health Stroke Scale (NIHSS) score of 15, who is eligible for thrombectomy?

Tenecteplase 17.5 mg IV Push for Acute Ischemic Stroke with M1 MCA Occlusion

Tenecteplase 17.5 mg IV push is the most appropriate therapy for this 81-year-old male with acute ischemic stroke due to M1 MCA occlusion who is eligible for thrombectomy, as it is associated with a higher incidence of reperfusion compared with alteplase in patients eligible for thrombectomy. 1

Patient Assessment and Eligibility

This patient presents with:

• 81-year-old male with acute onset of neurological deficits (facial droop, word-finding difficulty, right upper-extremity weakness)
• Symptoms began 60 minutes ago (well within treatment window)
• NIHSS score of 15 (moderate to severe stroke)
• No contraindications to thrombolytic therapy based on laboratory values
• CT head showing no abnormalities (ruling out hemorrhage)
• CT-angiography confirming M1 MCA occlusion
• Plan for subsequent thrombectomy

Thrombolytic Selection Algorithm

Step 1: Determine eligibility for IV thrombolysis

• Patient is within the 4.5-hour window for thrombolytic therapy 2
• No contraindications (normal coagulation parameters, no recent surgery or trauma)
• No evidence of hemorrhage on CT

Step 2: Consider patient characteristics

• Large vessel occlusion (M1 MCA) confirmed
• Patient is planned for thrombectomy
• High NIHSS score (15) indicating moderate to severe stroke

Step 3: Select optimal thrombolytic agent

For patients with large vessel occlusion who are candidates for thrombectomy:

• Tenecteplase offers advantages over alteplase in this specific scenario
• Tenecteplase has greater fibrin specificity and higher resistance to plasminogen activator inhibitor-1 3
• Single bolus administration (vs. infusion with alteplase) allows for faster transfer to thrombectomy 4

Evidence Supporting Tenecteplase

Tenecteplase has emerged as a viable alternative to alteplase for acute ischemic stroke treatment, particularly in patients with large vessel occlusion who are candidates for thrombectomy:

• Tenecteplase has demonstrated comparable safety and efficacy to alteplase in multiple studies 4, 5
• The single bolus administration of tenecteplase (vs. 1-hour infusion with alteplase) is advantageous when proceeding to thrombectomy 3
• Tenecteplase has shown superior reperfusion rates compared to alteplase in patients with large vessel occlusion 3

Dosing Considerations

• The appropriate dose of tenecteplase for this patient is 17.5 mg IV push (0.25 mg/kg, capped at 17.5 mg) 6
• Higher doses (0.4 mg/kg or higher) have been associated with increased risk of symptomatic intracranial hemorrhage 6
• The 0.25 mg/kg dose has shown the best balance of efficacy and safety in stroke patients 3

Practical Considerations

• Administer tenecteplase as a single IV bolus over 5-10 seconds
• Continue to monitor blood pressure (maintain <180/105 mmHg) 1
• Perform neurological evaluations every 15 minutes for the first 2 hours, every 30 minutes for the next 6 hours, and every hour thereafter 1
• Proceed with planned thrombectomy without delay

Potential Pitfalls and Caveats

• Do not delay administration of thrombolytic therapy while waiting for thrombectomy preparation 2
• Do not observe for clinical response to IV thrombolysis before proceeding with endovascular therapy 2
• Avoid administering antiplatelet agents until 24 hours post-thrombolysis and after confirming absence of hemorrhage on follow-up imaging 1
• Monitor closely for signs of intracranial hemorrhage, especially within the first 12 hours after treatment 1

The use of tenecteplase 17.5 mg IV push represents the optimal approach for this patient with acute ischemic stroke due to M1 MCA occlusion who is eligible for thrombectomy, offering the best chance for successful reperfusion and improved functional outcomes.