Purposeof review: Tenecteplase has been studied and recommended as an alternative thrombolytic agent in acute stroke patients. A brief review of clinical trials and guidelines pertinent to our clinical decision algorithm is described. This is followed by operational steps that were made to create and implement a clinical pathway based on available evidence in which tenecteplase is used in select stroke patients at our comprehensive stroke center.Recent findings:A number of patients have been treated at our center with IV tenecteplase. A case is presented to illustrate the successful implementation of this new process.Summary:Development of our protocol is discussed in detail in order to enable other centers to create their own clinical pathways for thrombolytic treatment of acute ischemic stroke using tenecteplase.

Introduction As IV tenecteplase (TNK) is becoming an alternative to IV alteplase in acute ischemic stroke (AIS), establishing the incidence of intracranial hemorrhage (ICH) complications is important. Given the higher fibrin specificity of TNK as compared to alteplase, our aim was to distinguish hemorrhage within the stroke burden versus spontaneous ICH in patients with AIS with TNK‐associated ICH. Methods Retrospective chart review of patients presenting from February 2020 to January 2022 with anterior circulation AIS to our comprehensive stroke center who received TNK was performed to evaluate for associated ICH. ECASS‐3 criteria was used to define hemorrhagic transformation and ICH score was used for primary, spontaneous ICH. Fisher exact test statistic was used to evaluate for significant differences in ASPECTS score, medium versus versus large vessel occlusion, angiographic recanalization, IV eptifibatide use, pre‐morbid antiplatelet use, and association with symptomatic versus asymptomatic hemorrhage. A benchmark less than 5% symptomatic ICH incidence was set based on historical alteplase rates within our network. Social science statistics software was used for data analysis. Results Out of 77 subjects who received TNK, 20.7% (n = 16) developed ICH, 9.1% (n = 7) of which were symptomatic ICH with a temporally‐related increase in NIHSS of at least 4 or greater. Seven subjects (43.75%) were male. Mean age was 73.38 (95% CI 65.92, 80.83). Median initial NIHSS was 16, 95% CI [11.74, 21.51]. Median ASPECTS was 9, 95% CI [8.74, 9.89]. Two subjects developed spontaneous, primary ICH (n = 1 symptomatic ICH, n = 1 non‐symptomatic ICH) in the absence of hemorrhagic transformation of ischemic stroke. No significant difference between subjects with asymptomatic hemorrhage versus symptomatic hemorrhage was found when comparing ASPECTS > = 7 versus < 7 (Fisher value = 1), angiographic recanalization (Fisher value = 1), use of IV eptifibatide (Fisher value = 1), pre‐morbid antiplatelet use (Fisher value = 0.13), or medium vessel occlusion (Fisher value = ‐0.63). Conclusions Expected rates of hemorrhagic transformation were higher in tenecteplase than our historical benchmark rate for alteplase. Spontaneous hemorrhage unrelated to ischemic stroke area were seen in 2 subjects without known hematological disorders. Larger, prospective studies are needed to validate safety of tenecteplase in real world settings.

Introduction : The use of IV thrombolytics and concomitant intra‐arterial therapy (IAT) in large artery occlusion (LVO) has become standard of care in acute ischemic strokes. Distal embolization may limit the efficacy of revascularization with IAT. Distal embolization may occur spontaneously or secondary to IV thrombolytics. Our objective was to compare rates of distal embolization in subjects who received IV alteplase (tPA) or IV tenecteplase (TNK) followed by EVT. Methods : Electronic medical records of subjects with acute ischemic stroke secondary to MCA occlusion who received TNK or tPA and underwent IAT therapy were reviewed. Digital subtraction images were reviewed to evaluate for distal embolization prior to revascularization. To confirm distal embolization, pre‐procedure CT angiogram or CT head hyperdense sign were reviewed. Z score for 2 population proportions was used to compare rates of distal embolization in tPA and TNK subjects. Social Science Statistics was used for data analysis. Results : From June 2020 to May 2021, 29 subjects received IV thrombolytics (tPA n = 12; TNK n = 17) followed by IAT. Five subjects were excluded from the TNK group with tandem and/or ICA occlusion. Twelve patients in each group with MCA occlusions (M1 or proximal M2 occlusions were compared). Difference in distal embolization rates had a trend towards statistical significance (z = ‐1.2649; p = 0.10383). Conclusions : The exclusion of tandem and/or ICA occlusions due to small sample size was a significant limitation of the study that affects generalizability to the strokes secondary to LVO. The trend towards statistical significance in higher distal embolization rates in subjects receiving TNK warrants larger, prospective studies to validate results.