Tenecteplase Dosing for Acute Ischemic Stroke
For a 43-year-old patient weighing 96 kg with acute ischemic stroke, administer 24 mg of tenecteplase as a single intravenous bolus (calculated as 0.25 mg/kg, with a maximum dose of 25 mg). 1, 2, 3
Weight-Based Dosing Calculation
The recommended dose of tenecteplase for acute ischemic stroke is 0.25 mg/kg administered as a single intravenous bolus with a maximum dose of 25 mg. 1, 2, 3
For this 96 kg patient: 96 kg × 0.25 mg/kg = 24 mg, which is below the 25 mg maximum. 2
This dose is specifically validated for stroke treatment and differs critically from the myocardial infarction dosing of 0.5 mg/kg—clinicians must not confuse these protocols. 1
Critical Distinction from MI Dosing
The FDA-approved myocardial infarction dosing uses a weight-tiered approach (30 mg for <60 kg, 35 mg for 60-69 kg, 40 mg for 70-79 kg, 45 mg for 80-89 kg, and 50 mg for ≥90 kg), but this is NOT appropriate for stroke. 4
The stroke dose of 0.25 mg/kg (maximum 25 mg) is approximately half the MI dose and was established through trials demonstrating superior recanalization and improved 3-month outcomes in large vessel occlusions. 2, 5
Evidence Supporting 0.25 mg/kg Dose
Meta-analysis demonstrates that tenecteplase 0.25 mg/kg produces significant improvements in early neurological improvement (OR = 1.52), excellent functional outcome at 90 days (mRS 0-1: OR = 1.19), good functional outcome (mRS 0-2: OR = 1.21), and reduced mortality (OR = 0.78). 5
The 0.25 mg/kg dose achieves superior reperfusion rates (22% vs 10% substantial reperfusion) compared to alteplase when used prior to mechanical thrombectomy. 1
Higher doses are unsafe: tenecteplase 0.4 mg/kg significantly increases symptomatic intracranial hemorrhage risk (OR = 2.35) and mortality, particularly in moderate to severe strokes. 5, 6
Administration Guidelines
Administer as a single intravenous bolus over 5-10 seconds, which offers substantial workflow advantages over alteplase's 1-hour infusion. 1, 2, 3
Treatment should be initiated as soon as possible after CT scan, with a target door-to-needle time of less than 60 minutes in 90% of treated patients. 1
The longer half-life of tenecteplase (90-130 minutes) eliminates the need for continuous infusion and reduces nursing time and potential medication errors. 2, 3, 4
Guideline Status and Patient Selection
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
Patients eligible for IV thrombolysis should receive it even if endovascular therapies are being considered (Class I, Level of Evidence A). 1, 3
Both tenecteplase and alteplase share similar contraindications including intracranial hemorrhage, recent significant trauma or surgery, and uncontrolled hypertension. 2, 3
Safety Profile
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. 1, 3
The number needed to treat for favorable outcomes is 8-14, which should be discussed with patients and families during shared decision-making. 1, 3