Tenecteplase Dosing for Acute Ischemic Stroke
The recommended dose of tenecteplase for acute ischemic stroke thrombolysis is 0.25 mg/kg (maximum 25 mg) administered as a single intravenous bolus. 1, 2
Standard Dosing Protocol
- Administer 0.25 mg/kg as a single IV bolus with a maximum dose of 25 mg 1, 2
- This dose should be given within 4.5 hours of symptom onset 2, 3
- The single-bolus administration offers significant workflow advantages over alteplase's 1-hour infusion, particularly beneficial in centers performing endovascular therapy or planning patient transfers 1, 2
Evidence Supporting the 0.25 mg/kg Dose
The 0.25 mg/kg dose is specifically recommended based on trials demonstrating superior recanalization rates and improved 3-month functional outcomes compared to alteplase, particularly in patients with large vessel occlusions 1, 4. Meta-analyses of randomized trials (1585 patients) support tenecteplase superiority in recanalization of large vessel occlusions and noninferiority in disability-free 3-month outcomes, without increases in symptomatic intracranial hemorrhage or mortality 4.
Higher doses (0.40 mg/kg) do not provide additional benefit. The EXTEND-IA TNK Part 2 trial directly compared 0.40 mg/kg versus 0.25 mg/kg in 300 patients with large vessel occlusion and found no significant difference in reperfusion rates (19.3% vs 19.3%), functional outcomes, or mortality 5. The higher dose showed a non-significant trend toward increased symptomatic intracranial hemorrhage (4.7% vs 1.3%) 5.
Critical Dosing Pitfall
Do not confuse stroke dosing with myocardial infarction dosing. Tenecteplase for MI is dosed at 0.5 mg/kg, which is double the stroke dose 3, 4. Using the MI protocol for stroke patients would result in overdosing and potentially increased hemorrhagic complications.
Guideline Recommendations
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) 1, 2, 3. The 0.25 mg/kg dose is specifically recommended for large vessel occlusions based on superior recanalization data 1.
Administration Timing
- Initiate treatment as soon as possible after patient arrival and CT scan 3
- Target door-to-needle time of less than 60 minutes in 90% of treated patients 3
- Treatment window extends to 4.5 hours from symptom onset using standard intravenous thrombolysis eligibility criteria 2, 5
Safety Profile
Both tenecteplase and alteplase share similar contraindications, including intracranial hemorrhage, recent significant trauma or surgery, and uncontrolled hypertension 1, 2. The absolute increase in symptomatic intracranial hemorrhage risk with thrombolysis is approximately 6% (7% with thrombolysis vs 1% without), yielding a number needed to harm of 17 2, 3.