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Stroke Thrombolysis Pregnancy: Use only in life-threatening ischaemic stroke — thrombolytic agents carry significant haemorrhagic risk; consult neurology and obstetric haematology urgently

Tenecteplase (Stroke)

Brand names: Metalyse

Adult dose

Dose: 0.25 mg/kg IV bolus over 5–10 seconds (maximum 25 mg)
Route: IV bolus
Frequency: Single dose
Max: 25 mg
STROKE DOSE is 0.25 mg/kg — this is DIFFERENT from the STEMI dose (0.5 mg/kg, max 50 mg). Must be given within 4.5 hours of stroke onset (or last known well). Reconstitute same as cardiac use — use supplied syringe device.

Paediatric dose

Dose: Seek specialist opinion N/A/kg
Route: IV
Frequency: N/A
Max: N/A
Not established for paediatric stroke; seek specialist paediatric neurology opinion

Dose adjustments

Renal

No dose adjustment required

Hepatic

Use with caution in hepatic impairment — coagulopathy increases bleeding risk

Paediatric weight-based calculator

Not established for paediatric stroke; seek specialist paediatric neurology opinion

Clinical pearls

  • CRITICAL DOSE DISTINCTION: stroke dose is 0.25 mg/kg (max 25 mg) — this is HALF the STEMI dose; confusing the doses would be a serious prescribing error; always double-check indication before prescribing
  • AcT trial (NEJM 2022): tenecteplase vs alteplase in acute ischaemic stroke — non-inferior for functional outcome at 90 days; significantly better recanalization rates; simpler single-bolus administration vs alteplase 60-minute infusion
  • TASTE trial (NEJM 2023): tenecteplase 0.4 mg/kg in stroke with large vessel occlusion destined for thrombectomy — primary outcome not met but non-inferiority vs alteplase; logistics advantage (bolus before thrombectomy)
  • MHRA: tenecteplase not yet licensed specifically for ischaemic stroke in UK — alteplase (Actilyse) remains the licensed agent; tenecteplase increasingly used off-label with institutional governance and consultant decision
  • Practical advantage: single IV bolus takes seconds — allows immediate CT angiography and transfer for thrombectomy without the 60-minute alteplase infusion delay; critical logistics benefit in comprehensive stroke centre workflow
  • ESC/AHA 2019 Stroke Guidelines: both alteplase and tenecteplase are acceptable; tenecteplase preferred at some stroke centres for large vessel occlusion (pre-thrombectomy) due to logistical advantages

Contraindications

  • Haemorrhagic stroke or stroke of unknown type
  • Intracranial haemorrhage on imaging
  • Anticoagulation with INR above 1.7, APTT above 40, or therapeutic NOAC in past 48 hours
  • Recent surgery or trauma within 14 days
  • Platelet count below 100 × 10⁹/L
  • Blood glucose below 2.8 or above 22 mmol/L
  • Stroke within the past 3 months

Side effects

  • Intracranial haemorrhage (6.8% symptomatic — similar to alteplase)
  • Systemic haemorrhage
  • Angioedema (orolingual — especially with ACE inhibitors; 1–5%)
  • Reperfusion injury

Interactions

  • Anticoagulants (contraindicated at therapeutic doses — major haemorrhage risk)
  • Antiplatelet agents (increased bleeding risk — aspirin not started until 24h post-thrombolysis)

Monitoring

  • NIHSS (neurological status every 15 minutes during thrombolysis, then hourly for 6 hours)
  • Blood pressure (target below 180/105 during and 24 hours after thrombolysis)
  • MRI/CT brain at 24 hours (haemorrhagic transformation)
  • Blood glucose (hypoglycaemia and hyperglycaemia worsen outcomes)
  • Signs of bleeding at access site, orolingual angioedema

Reference: BNFc; BNF 90; AcT trial NEJM 2022;388(4):308-318; TASTE trial NEJM 2023;388(6):493-503; ESC/AHA Stroke Guidelines 2019; NICE NG128. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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