What is the proper administration protocol for tenecteplase (tissue plasminogen activator) in an adult patient with acute ischemic stroke?

How to Administer Tenecteplase for Acute Ischemic Stroke

Administer tenecteplase as a single intravenous bolus at 0.25 mg/kg (maximum 25 mg) over 5-10 seconds after confirming eligibility criteria and achieving blood pressure control below 185/110 mmHg. 1, 2

Pre-Administration Requirements

Blood Pressure Control (Critical First Step)

• Systolic BP must be <185 mmHg and diastolic BP <110 mmHg before giving tenecteplase 3
• If BP exceeds these thresholds, treat aggressively with IV antihypertensives first 3
• Severe uncontrolled hypertension (SBP >180 mmHg or DBP >110 mmHg unresponsive to therapy) is an absolute contraindication 3

Time Window Verification

• Within 0-3 hours of symptom onset: Strong recommendation (Level A evidence) - offer tenecteplase to all eligible patients meeting NINDS criteria 4
• Within 3-4.5 hours of symptom onset: Conditional recommendation (Level B evidence) - consider tenecteplase in carefully selected patients meeting ECASS III criteria 4, 1
• Treatment should be initiated as rapidly as possible, with door-to-needle time <60 minutes in 90% of cases 1, 2

Imaging Requirements

• Obtain non-contrast CT scan to exclude intracranial hemorrhage before administration 4
• Confirm diagnosis of acute ischemic stroke with measurable neurological deficit 4

Dosing Protocol

Weight-Based Single Bolus Administration

Tenecteplase dose: 0.25 mg/kg (maximum 25 mg) given as single IV bolus 1, 2, 5

Critical dosing caveat: The stroke dose (0.25 mg/kg, max 25 mg) differs from the myocardial infarction dose (0.5 mg/kg) - do not confuse these protocols 1

Administration Technique

• Administer as a single intravenous bolus over 5-10 seconds 2
• No infusion pump required (unlike alteplase which requires 10% bolus followed by 60-minute infusion) 4, 1
• The longer half-life (90-130 minutes) of tenecteplase allows single-bolus administration 1, 2

Post-Administration Monitoring Protocol

Blood Pressure Management (First 24 Hours)

• Maintain systolic BP ≤180 mmHg and diastolic BP ≤105 mmHg for at least 24 hours 3
• Monitor BP every 15 minutes for first 2 hours 3
• Monitor BP every 30 minutes for hours 2-8 3
• Monitor BP hourly from hours 8-24 3

Neurological Assessment Schedule

• Perform neurological assessments every 15 minutes during and immediately after bolus 3
• Continue every 30 minutes for 6 hours post-administration 3
• Then hourly from hours 6-24 3

ICU/Stroke Unit Admission

• All patients receiving tenecteplase must be admitted to ICU or stroke unit for intensive monitoring for at least 24 hours 3

Key Contraindications to Verify

Absolute Contraindications

• Any prior intracranial hemorrhage 4, 3
• Ischemic stroke within previous 3 months 4
• Head trauma in previous 3 months 4
• Blood pressure >185/110 mmHg unresponsive to treatment 4, 3
• Evidence of intracranial hemorrhage on CT 2
• Recent significant trauma or surgery 2

Relative Contraindications

• Recent internal bleeding within 2-4 weeks 2
• Noncompressible vascular punctures 2
• Pregnancy 2
• Active peptic ulcer 2
• Current oral anticoagulant use (requires careful assessment of INR, factor Xa levels, or thrombin time) 4

Management of Symptomatic Intracranial Hemorrhage

Recognition and Response

• Symptomatic ICH occurs in approximately 5-6% of properly selected patients 3
• If symptomatic ICH suspected: immediately discontinue any ongoing infusion (not applicable to tenecteplase single bolus), obtain emergent CT, and consider cryoprecipitate for fibrinogen replacement 3
• Neurosurgical consultation should be obtained for large hemorrhages based on size, location, and clinical status 3

Advantages Over Alteplase

Workflow Benefits

• Single-bolus administration reduces nursing time and potential medication errors 1
• Particularly advantageous in centers considering endovascular therapy or patient transfer 1, 2
• No need for infusion pump setup or 60-minute monitoring of infusion 1

Clinical Evidence

• The ORIGINAL trial (2024) demonstrated noninferiority to alteplase with 72.7% achieving mRS 0-1 at 90 days versus 70.3% with alteplase 6
• Similar safety profile with 1.2% symptomatic ICH rate in both groups 6
• Superior reperfusion rates (22% vs 10%) prior to mechanical thrombectomy 1

Guideline Status

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

The benefit of IV fibrinolytic agents other than alteplase and tenecteplase is unproven; streptokinase should never be used due to unacceptably high hemorrhage rates 1, 2