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. 2022 Sep 20;6(6):e12795. doi: 10.1002/rth2.12795

Alteplase or tenecteplase for thrombolysis in ischemic stroke: An illustrated review

Annie Zhu 1, Phavalan Rajendram 1, Eric Tseng 2, Shelagh B Coutts 3, Amy Y X Yu 1,✉
PMCID: PMC9487449  PMID: 36186106

Abstract

Intravenous thrombolysis is a standard of care treatment for patients with acute ischemic stroke. Tissue plasminogen activator (tPA) has been the main thrombolytic agent used since the publication of the seminal National Institutes of Neurological Disorders and Stroke trial in 1995. There is now mounting evidence to support the routine use of Tenecteplase (TNK) to treat acute ischemic stroke. TNK is a genetically modified tPA with higher fibrin specificity, longer half‐life, and reduced systemic coagulopathy. In this illustrated review, we compare the indications, doses, mechanisms of action, efficacy and safety of TNK and tPA. We provide an overview of published clinical trials studying TNK in acute ischemic stroke, including dose‐escalation studies and head‐to‐head comparisons with tPA. Finally, we summarize current acute stroke guideline recommendations and suggest treatment algorithms to manage the two main complications of intravenous thrombolysis: symptomatic intracerebral hemorrhage and angioedema.

Keywords: fibrinolytic agents, hemorrhagic stroke, pharmacological mechanisms of action, stroke, treatment outcome

Essentials.

  • Thrombolysis, traditionally with Alteplase, is a standard of care treatment for ischemic stroke.

  • Tenecteplase is a genetically modified version of Alteplase.

  • Tenecteplase has theoretical benefits over Alteplase: better recanalization and reduced bleeding.

  • Growing evidence support the routine use of Tenecteplase 0.25mg/kg for acute ischemic stroke.

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AUTHOR CONTRIBUTIONS

A.Z. contributed to the study design, manuscript drafting, and illustration. P.R. contributed to the study design and manuscript drafting. E.T. contributed to the study design and manuscript revision. S.B.C. contributed to the study design and manuscript revision. A.Y.X.Y. contributed to the study design, manuscript drafting and revision, and supervision.

FUNDING INFORMATION

A.Y. holds a National New Investigator Award from the Heart & Stroke Foundation of Canada.

RELATIONSHIP DISCLOSURE

S.B.C. is the principal investigator of the TEMPO‐2 trial, which is assessing the use of tenecteplase in the treatment of minor stroke. TEMPO‐2 is funded by CIHR and the study drug is provided by Boehringer Ingelheim.

Zhu A, Rajendram P, Tseng E, Coutts SB, Yu AYX. Alteplase or tenecteplase for thrombolysis in ischemic stroke: An illustrated review. Res Pract Thromb Haemost. 2022;6:e12795. doi: 10.1002/rth2.12795

Annie Zhu and Phavalan Rajendram contributed equally to this work

Handling Editor: Dr Suzanne Cannegieter

Contributor Information

Annie Zhu, @cazezhu.

Phavalan Rajendram, @nerdybraindoc.

Eric Tseng, @tsengeric.

Shelagh B. Coutts, @SCouttsMD.

Amy Y. X. Yu, Email: amyyx.yu@utoronto.ca, @amyyu_md.

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