What are the guidelines for post Tenecteplase (TNK) management of stroke?

Post-Tenecteplase (TNK) Management of Stroke

After administering tenecteplase (TNK) for acute ischemic stroke, patients should be closely monitored with careful clinical assessment including neurological examination, with no waiting period to assess for clinical response if endovascular thrombectomy is being considered. 1

Immediate Post-TNK Care

• Establish an acute stroke team including physicians, nurses, and laboratory/radiology personnel for careful clinical assessment and neurological examination 1
• Do not delay endovascular thrombectomy (EVT) to observe for clinical response after TNK administration in eligible patients 1
• Monitor for signs of symptomatic intracranial hemorrhage (sICH), which occurs in approximately 0.9-3.0% of patients receiving TNK 2
• Withhold adjunctive antithrombotic therapy for the first 24 hours after TNK administration 1

Monitoring Parameters

• Perform regular neurological assessments to detect early neurological deterioration, which may occur in up to 22.6% of patients after TNK 3
• Be vigilant for clot migration, which has been identified in 8.3% of patients with confirmed vessel occlusion on baseline imaging and can cause neurological worsening 3
• Consider early vascular imaging if neurological deterioration occurs to identify potential clot migration 3

Blood Pressure Management

• Maintain systolic blood pressure <185 mmHg and diastolic blood pressure <110 mmHg 1
• Continue blood pressure monitoring throughout the post-thrombolysis period to minimize hemorrhagic complications 1

Multicomponent Quality Improvement

• Implement multicomponent quality improvement initiatives, which have been shown to safely increase IV thrombolytic treatment 1
• Establish door-to-needle (DTN) time goals, with a primary goal of achieving DTN times within 60 minutes in ≥50% of acute ischemic stroke patients 1
• Consider a secondary DTN time goal of achieving DTN times within 45 minutes in ≥50% of patients 1

Telemedicine Considerations

• For sites without in-house imaging interpretation expertise, utilize FDA-approved teleradiology systems for timely review of brain imaging 1
• When implemented within a telestroke network, teleradiology systems are useful in supporting rapid imaging interpretation for timely treatment decisions 1

Special Considerations for Extended Time Windows

• TNK may be considered for selected patients with large vessel occlusion in the 4.5-24 hour time window if they have salvageable brain tissue identified on perfusion imaging 2, 4
• In patients treated with TNK beyond the standard 4.5-hour window, there is a 33% higher likelihood of achieving functional independence (mRS 0-2) at 90 days compared to standard medical therapy 4
• Be aware that extended window treatment may be associated with a slightly higher risk of symptomatic intracranial hemorrhage (3.0% vs 0.8%) 2

Pitfalls and Caveats

• Avoid waiting to assess for clinical response after TNK if endovascular thrombectomy is being considered, as this can delay definitive treatment 1
• Be vigilant for clot migration after TNK administration, particularly in posterior circulation strokes, as this may contribute to early neurological deterioration 3
• Do not administer adjunctive antithrombotic therapy within the first 24 hours after TNK administration despite promising preliminary results, as additional data are needed 1
• Recognize that TNK is given as a single IV bolus, which differs from the 1-hour infusion required for alteplase 1