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.

We were intrigued by the finding of severe obstructive sleep apnea (OSA) in patients referred to our Sleep Clinic with a history of stroke at a relatively young age, in the setting of a patent foramen ovale (PFO). This prompted us to do a literature search to see the association of OSA with stroke in such a patient population. The correlation of PFOs with cryptogenic strokes is well established, as is that of OSA with stroke. However, not many studies have looked at the correlation between OSA and PFO in patients with cryptogenic strokes.

Introduction Intravenous tenecteplase (TNK) is currently being used as a thrombolytic agent in acute ischemic stroke (AIS) and has has been shown to be non‐inferior to intravenous alteplase according to recent studies. Intracranial hemorrhage (ICH) as a complication of alteplase is approximately at 6%. The aim of our study was to determine the rate of significant ICH in patients receiving TNK indicated for AIS in a real world setting. Methods A network‐wide (3 CSCs, 6 PSCs), multicenter retrospective chart review of patients receiving TNK from February 2020 to January 2022 was performed using the Get With The Guidelines database. TNK bolus dose of 0.25mg/kg was used according to a network‐wide policy. ICH was categorized using ECASS‐3 criteria. Fisher exact test statistic was used to determine if a significant association existed between the presence of ICH and baseline ASPECTS score, endovascular treatment (EVT), and IV eptifibatide use. A benchmark less than 2% PH‐2 incidence was set based on historical alteplase related PH‐2 rates within our network. Social science statistics software was used for data analysis. Results Out of 180 patients who received TNK, 25 subjects (13.89%) developed hemorrhagic transformation. Mean age was 71.88 (95% CI 65.54, 78.22). Forty‐eight percent of subjects were female. Median ASPECTS score was 8 (95% CI 7.54, 8.78). Median 90 day mRS was 3 (95% CI 2.1, 3.9). Hemorrhagic transformation was classified as HI‐1 in 5% (n = 9), HI‐2 in 1.7% (n = 3), PH‐1 in 3.8% (n = 7), and PH‐2 in 3.3% (n = 6) subjects. No significant difference between subjects with other subtypes versus PH‐2 was identified when adjusting for ASPECTS score > = 7 versus < 7 (Fisher value = 1), EVT versus no EVT (Fisher value = 0.65), or use of IV eptifibatide (Fisher value = 0.06). Conclusions Tenecteplase is associated with higher rates of PH‐2 intracranial hemorrhage when compared with our benchmark rates of alteplase‐related PH‐2. This study is significantly limited by small sample size, retrospective nature, and uncontrolled variables. Larger, prospective studies are needed to validate our results.